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Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Accreditation
  5. Licensure, Certification and Revalidation of Credentials
  6. Conclusions
  7. Contributors
  8. Acknowledgements
  9. Funding
  10. Conflicts of interest
  11. Ethical approval
  12. References

Context

The accreditation of medical school programmes and the licensing and revalidation (or recertification) of doctors are thought to be important for ensuring the quality of health care. Whereas regulation of the medical profession is mandated in most jurisdictions around the world, the processes by which doctors become licensed, and maintain their licences, are quite varied. With respect to educational programmes, there has been a recent push to expand accreditation activities. Here too, the quality standards on which medical schools are judged can vary from one region to another.

Objectives

Given the perceived importance placed by the public and other stakeholders on oversight in medicine, both at the medical school and individual practitioner levels, it is important to document and discuss the regulatory practices employed throughout the world.

Methods

This paper describes current issues in regulation, provides a brief summary of research in the field, and discusses the need for further investigations to better quantify relationships among regulatory activities and improved patient outcomes.

Discussion

Although there is some evidence to support the value of medical school accreditation, the direct impact of this quality assurance initiative on patient care is not yet known. For both licensure and revalidation, some investigations have linked specific processes to quality indicators; however, additional evaluations should be conducted across the medical education and practice continuum to better elucidate the relationships among regulatory activities and patient outcomes. More importantly, the value of accreditation, licensure and revalidation programmes around the world, including the effectiveness of specific protocols employed in these diverse systems, needs to be better quantified and disseminated.

Editor's note: This article has been written in response to the following line from Lasagna's modernisation of the Hippocratic Oath [1]

‘I will prevent disease whenever I can, for prevention is preferable to cure.’

Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Accreditation
  5. Licensure, Certification and Revalidation of Credentials
  6. Conclusions
  7. Contributors
  8. Acknowledgements
  9. Funding
  10. Conflicts of interest
  11. Ethical approval
  12. References

From the perspective of medical regulators, disease can be thought of as a metaphor for poorly functioning doctors. The primary mandate of regulators is to ensure patient safety by restricting professional practice to only those who have demonstrated competence (i.e. are free from ‘disease’). In a similar way, properly functioning accreditation systems should minimise the production of poorly skilled doctors by improving the education process. Prevention, in this context, is certainly preferable to cure. Given the costs associated with poor health care delivery, it is better to produce highly competent practitioners and ensure, through continuing educational activities, that those who care for patients remain competent to do so.

The present article is not a systematic review and nor does it provide a comprehensive historical overview of medical licensure, specialty board certification, revalidation of credentials or accreditation. The interested reader is referred to Dauphinee,[2] and Norcini and van Zanten[3] for more detailed overviews. Instead, we provide a brief synopsis of current issues in recognition and regulation, and outline the potential problems in and benefits of establishing and maintaining quality oversight mechanisms, at both the system (i.e. educational programme) and individual (i.e. doctor) levels. Although we have attempted to provide an international perspective, many of the examples come from a North American or UK context. This, by no means, should be seen as an endorsement of the developed world's perspective on medical regulation and accreditation. Instead, it simply provides a framework for discussing the benefits and, more importantly, the potential drawbacks and consequential impact of current accreditation, licensing, certification and revalidation efforts. In the first part of the manuscript, we provide an overview of accreditation practices for medical education programmes, both undergraduate and graduate, and the many challenges associated with their implementation, administration and validation. A high-quality education system is needed to adequately prepare medical students to become capable patient care providers. In addition to assuring that minimum standards have been met, accreditation encourages quality improvement. In the second part of the paper, we discuss regulation issues (e.g. initial licensure, specialty certification, revalidation of credentials) as they pertain to practising doctors. Regulatory systems ensure that doctors, both at initial licensure and during their careers, have the knowledge, skills and attitudes necessary for safe and effective practice. As many stakeholders, especially the public, have a fundamental interest in the quality of their health care, it is important to know how the regulatory systems for doctors work and where changes, given available resources and evidence to support their efficacy, could potentially lead to more effective and efficient patient care.

Accreditation

  1. Top of page
  2. Abstract
  3. Introduction
  4. Accreditation
  5. Licensure, Certification and Revalidation of Credentials
  6. Conclusions
  7. Contributors
  8. Acknowledgements
  9. Funding
  10. Conflicts of interest
  11. Ethical approval
  12. References

Systems of accreditation are frequently viewed by stakeholders (e.g. the public, health care administrators, policymakers) as effective mechanisms for ensuring the quality of basic medical education curricula and subsequent training programmes across the learning continuum. Accreditation can be defined as a process by which a designated authority reviews and evaluates, on a cyclical basis, an educational programme or institution using clearly specified criteria and procedures. A positive accreditation status is usually a governmental or professional body requirement, although in some instances the review is voluntarily requested by the administrators of the educational programme. To better elucidate the purpose and scope of accreditation activities, this section describes the current state of medical education accreditation in the USA and internationally. Next, literature is presented on the validity of accreditation systems, including associations between accreditation activities and doctor performance. Potential benefits and challenges that must be considered by an institution's administration in deciding whether to pursue an accreditation review are then outlined. Finally, because very little research in this field has been conducted to date, we discuss some of the unanswered questions concerning the value of accreditation, and highlight areas for further investigation.

Various organisations around the world accredit medical education and training programmes. In many countries, such as the majority in South America and some in Africa and Asia, accreditation organisations review higher education institutions as a whole. In other countries (e.g. Australia, Mexico, the UK), specialised agencies accredit specific professional education programmes, such as medicine. In some instances, multiple quality reviews are conducted by both types of agency. Accreditation authorities can be part of a country's government, such as an entity that is directly part of a ministry of education or health, or may be an independent body, the decisions of which are usually officially recognised at government level. Organisations can function at the provincial, national or cross-national (regional) level, and reviews can be mandatory or voluntary. An accreditation organisation's authority can be broad and encompass all medical education programmes in its jurisdiction, or be limited in scope, and cover only either public or private education programmes, institutions with a specific language of instruction, or institutions that meet certain other policy requirements.

Accreditation in the USA

In the USA, the Liaison Committee on Medical Education (LCME) is the nationally recognised accrediting authority for medical education programmes leading to the md degree in US and Canadian1 medical schools, and the Commission on Osteopathic College Accreditation (COCA) accredits schools granting the osteopathic (do) degree. The basic structures of the LCME and the COCA are functionally similar, although the LCME's accreditation standards are more expansive. A comparative analysis across the two sets of standards was conducted to determine if differences might affect the educational quality of md and do education, respectively.[4] The authors found some variations, although they concluded that differences in accreditation standards are unlikely to be associated with any quality issues across the two professional degrees.

Graduate medical education (GME) is an essential part of the continuum of medical education in the USA. Upon graduation from medical school, doctors are eligible to apply for GME positions. Graduate medical education is frequently referred to as residency training, generally lasts 3–4 years depending on the area of specialisation, and is required to obtain a licence to practise medicine. Currently, the Accreditation Council for Graduate Medical Education (ACGME) is the overseeing body responsible for the quality assurance of allopathic GME, and the American Osteopathic Association (AOA) accredits osteopathic residency programmes. These organisations have recently announced that, as of 2015, there will be a single, unified accreditation system for GME programmes in the USA.[5] The ACGME has identified six general competencies deemed essential for residency training: patient care; medical knowledge; practice-based learning and improvement; interpersonal and communication skills; professionalism, and systems-based practice. Since the demarcation of these competencies, and the initiation of requirements for evaluating them, numerous investigations have attempted to measure their effectiveness. A meta-analysis of 56 studies reported mixed results, with the authors concluding that there was little evidence that most of the current measurement tools validly assessed the competencies independently of one another.[6]

Accreditation globally

As of February 2013, the Directory of Organizations that Recognize/Accredit Medical Schools (DORA) maintained by the Foundation for Advancement of International Medical Education and Research (FAIMER) lists 104 countries with active systems of accreditation for basic medical education (out of 177 countries with currently operational medical schools).[7] Of these countries, 42% (n = 44) have accreditation agencies that are specific to medical education, and 58% (n = 60) use agencies that accredit medical programmes as part of higher education institutions. It is important to note that the existence of an accreditation system in a country does not denote that all medical schools in that country are accredited, as the review is sometimes voluntary. In other cases, even where accreditation is mandatory, the system may be newly implemented or not yet fully operational.

Similar data regarding the global prevalence of medical education accreditation systems have been reported. A report based on a 1996 World Health Organization (WHO) survey of ministries of health and deans of medical schools[8] indicated that almost two-thirds of medical schools were accredited by an external body, although detailed data describing these agencies or the various processes employed were not provided. Another global investigation of medical education accreditation found that although over half of all countries with medical schools have a national system of accreditation, the nature of the various authorities and levels of enforcement vary considerably.[9] A study comparing medical education accreditation systems in nine developing countries located throughout the world concluded that the trend towards instituting robust quality assurance procedures was spreading to some developing countries, in which protocols similar to those used in the USA have been developed and implemented.[10] Unfortunately, although the prevalence and characteristics of accreditation systems have been documented, there is relatively little evidence to quantify their utility with respect to improving education practices.

Validity of accreditation

Although there has been a recent worldwide focus on the overseeing of medical education quality assurance, there is limited published research demonstrating that accreditation activities are related to the ultimate goal of producing more highly skilled doctors, who, in turn, provide better patient care. The lack of research related to the value of accreditation is likely to reflect a number of methodological factors applicable across educational fields.[11, 12] For example, in medical education specifically, in many countries all programmes are accredited (usually based on the same criteria), which precludes within-country comparisons of performance of students or graduates from accredited and non-accredited programmes. In terms of the outcomes (e.g. performance on national licensing or specialty board certification examinations) of students who have attended schools in various countries or regions with or without accreditation systems, criteria such as admission standards, resources available to students and curriculum factors may differ widely across schools, making comparisons based solely on isolated accreditation variables difficult, and potentially biased. Here, more qualified students may simply choose to attend accredited institutions that are perceived to offer a better education. Most importantly, valid outcome measures (e.g. test results, disciplinary actions) that are comparable across schools, or practice settings, are not commonly available, or only available for a subset of students or graduates.

Despite these methodological difficulties, some investigations have shown that accreditation activities may improve medical education, at least in terms of the performance of students. In a study of Mexican and Philippine citizens seeking Educational Commission for Foreign Medical Graduates (ECFMG) certification, first-attempt pass rates on all components of the required US Medical Licensing Examination (USMLE) series were higher for individuals who had attended accredited medical schools, compared with their peers who had attended non-accredited schools.[13] In another study of the performance of all graduates of international medical schools who took the USMLE Step 2 clinical skills (CS) examination during the 5-year (2006–2010) study period, accreditation was positively associated with the Step 2 CS first-attempt pass rate. The odds of a student or graduate of an accredited school passing Step 2 CS on his or her first attempt were 2.4 times greater for individuals from Caribbean medical schools, and 1.1 times greater for individuals from all other (non-Caribbean) medical schools, than the odds of a student or graduate from a non-accredited school passing the examination on the first attempt.[14]

Although these studies include some data showing a positive association between accreditation activities and student success on examinations, additional markers of quality, including performance on other examinations taken later in the career (e.g. board certification) and actual patient care data are required. Without these, it is difficult to know whether accreditation processes have an appreciable, long-term impact on education programmes and, hence, the quality of those who graduate and eventually practise medicine. Given the many limitations of cross-sectional investigations, future work in this field should also include longitudinal studies for specific schools pre- and post-accreditation. Schools that can confirm marked increases in student performance on examinations, or other quality measures, after making the improvements required by an accreditation review may yield additional evidence to support the utility of rigorous quality assurance activities such as accreditation.

In addition to gathering data on the effects of the existence of accreditation systems, it is also important to investigate the components of accreditation, such as the specific standards used and protocols employed, that may enhance the quality of the education process.[15] Whereas previous investigations focused on describing the existence and some general characteristics of accreditation systems, only a few studies, to our knowledge, have compared or assessed the effectiveness or appropriateness of the specific medical education standards used to make accreditation decisions.[16-18] Additional data demonstrating best practices in the development and implantation of protocols, and supporting the psychometric characteristics of the tools used to assess the effectiveness of the standards employed, are necessary to support the perceived value of accreditation as a means of assuring the quality of education programmes and fostering continued excellence. Unfortunately, until clear evidence is found linking accreditation activities and outcomes (e.g. patient care), it cannot be assumed that one type of system, mechanism or element of quality assurance is superior to another.

Although there is evidence, albeit limited, to support the value of accreditation of basic medical education programmes, some benefits of these systematic reviews may be manifest despite limited data showing marked improvement in student outcomes. For example, schools that are subject to a review are forced to prepare for the exercise, usually beginning many months, or years, in advance. Schools must examine their own quality assurance systems and determine their compliance with internal rules and regulations. They must ensure that all necessary policies have been created, disseminated and implemented. Even if a school does not ultimately pass the official accreditation assessment, it is likely to have made significant positive efforts to meet the requirements of the external review. Therefore, although this is difficult to quantify, the education programme should improve, thus producing more qualified graduates who are more likely to possess the knowledge and skills required for the delivery of effective patient care.

Accreditation decisions made by agencies around the world are usually considered credible and are accepted by stakeholders as meaningful and trustworthy. Nevertheless, because of a lack of transparency in the process, variability in methodology, or other issues related to a lack of standardisation across schools, the decisions can sometimes appear capricious and arbitrary. In order to address the need for a globally accepted system for ensuring the quality of accreditation systems themselves, the World Federation for Medical Education (WFME), in conjunction with FAIMER, has formulated policies and procedures for the recognition of agencies accrediting medical schools, an endeavour in meta-accreditation.[19] Necessary documents and instruments have been created, and the system of recognition has been piloted with a regional accrediting agency in the Caribbean, the Caribbean Accreditation Authority for Education in Medicine and other Health Professions (CAAM-HP). Given that accreditation standards can vary by region, and can be applied with more or less rigour, it is important that organisations that provide accreditation services are subject to some sort of formal review. Without this, the comparability of accreditation decisions will be difficult to judge, making it even more problematic to ascertain the educational impact of any quality assurance initiatives.

Incentives for accreditation (cost/benefit)

Although accreditation systems do not exist in many countries and regions, and may be voluntary, there are frequently incentives in place to encourage medical education programmes to undergo an accreditation review. In the USA, the accreditation of basic medical education programmes is technically voluntary, but a school must be accredited in order for graduates to enter GME and obtain licensure to practise, a policy that effectively ensures that all schools must be accredited in order to function. In some cases of voluntary accreditation within a specific country that lacks these types of incentives linked to practice, accredited schools can still offer certain advantages to students. For example, in Mexico, students at accredited schools are provided with enhanced clinical clerkship opportunities compared with their peers at non-accredited institutions. For US citizens studying medicine outside the country, in order to be eligible to receive federally funded student loans, any foreign school attended must meet certain requirements, including accreditation by an agency that has met a comparability determination of the accreditation process. The purpose of the US Department of Education National Committee on Foreign Medical Education and Accreditation (NCFMEA) is to review the standards used by foreign countries to accredit medical schools and determine whether those standards are comparable with standards used to accredit medical schools in the USA.[20] Thus, medical schools located outside the USA that seek to attract US citizen students are given incentives to seek accreditation by an agency that has been deemed comparable by the NCFMEA.

In other countries, such as India, obtaining accreditation by a voluntary agency (e.g. the National Assessment and Accreditation Council [NAAC]) in addition to the mandatory accreditation by the Medical Council of India (MCI) carries some prestige in a crowded field of medical education programmes. A school considering voluntary accreditation needs to weigh the direct cost of seeking the accreditation review and the costs associated with making the necessary changes dictated by the standards against the indirect value of obtaining a secondary accreditation status. Unfortunately, because of the programme evaluation difficulties noted earlier, namely the lack of meaningful outcome measures, it is difficult to provide an economic argument to support or discount accreditation activities. In addition, medical schools must consider the resources needed to meet and document standards. Faculty may be required to spend considerable time away from educational activities to fulfil accreditation obligations. Nevertheless, regardless of the specific motivations of institutions to seek accreditation, and the direct and indirect costs involved, there is an expectation that the net effect of meeting defined standards of education is positive, for both the students (in terms of education quality) and the institution.

Doctor mobility

Accreditation of medical education can also aid in doctor mobility, as accreditation of multiple schools by a common agency, or mutual recognition of accreditation decisions across multiple agencies, can enhance options for student mobility between schools, such as the transfer of credits. Students who wish to pursue elective opportunities outside their home institution are often required to verify that the school offering the supplemental educational experience they desire is appropriately accredited. In addition, graduation from an appropriately accredited medical school, or completion of an accredited GME programme, is often a requirement for a country to accept the credentials of and grant licensure to practise to a non-domestically educated candidate.

Licensure, Certification and Revalidation of Credentials

  1. Top of page
  2. Abstract
  3. Introduction
  4. Accreditation
  5. Licensure, Certification and Revalidation of Credentials
  6. Conclusions
  7. Contributors
  8. Acknowledgements
  9. Funding
  10. Conflicts of interest
  11. Ethical approval
  12. References

Most professions throughout the world have some sort of licensure or certification (registration) process. In many respects, licensure and certification define the profession. Individuals must meet certain requirements before they are allowed to practise or ply a trade. If these requirements are meaningfully related to practice, society is provided with some degree of assurance that the individual is competent to provide services or products.

In medicine, at least in most countries and jurisdictions, there are reasonably strict practice regulations. Licensure (or registration), which is generally granted by governments, at either the national or regional level, is necessary for initial entry into the profession. Certification, by contrast, is usually conferred by a non-governmental agency, and typically connotes a higher level of qualification. In many areas of the world, a doctor can obtain an initial licence to practise medicine and then specialise, obtaining a certificate from a specialty society or board. The various practice regulations, which can vary widely from one country to another (or from region to region within a country), help to ensure that only those qualified to practise, either as generalists or specialists, can provide patient services.

Just as licensure and certification processes vary around the world, the criteria upon which licensure and certification decisions are granted can be quite different.[21-23] Moreover, to keep up with advances in medicine and changing patient needs, licensure and certification criteria can, and should, be modified over time.[24] In general, licensure and certification involve some form of credentialing and assessment. For licensing purposes, credentialing can entail, amongst other criteria, confirmation of medical school attendance and graduation, recognition of the medical school (e.g. accreditation), and verification of the medical school diploma. It should be noted that, in many jurisdictions, the licensing criteria for internationally trained doctors can differ from those for locally educated doctors.[25, 26] For certification in a specialty, the society, or board, may want proof of initial licensure and confirmation of postgraduate training experience. In addition to credentialing, most, if not all, licensing and certification (or registration) bodies have some sort of assessment process. In the USA, initial licensure is dependent on successful completion of the USMLE or the Comprehensive Osteopathic Medical Licensing Examination (COMLEX-USA). Subsequent board certification (or registration) may also involve a number of assessments, including in-training examinations (taken during postgraduate training) and specialty board examinations. Both the credentialing and assessment processes are designed to ensure that candidates seeking licensure and certification have achieved specific standards, and thus help to protect the public from unqualified practitioners.

Historically, both licensure and certification (or registration) have been granted for the lifetime of the doctor.[2] Today, there is a general movement towards maintenance of licensure (MoL) and maintenance of certification (MoC) requirements. In the UK and many other countries, this process is typically referred to as revalidation. To continue to practise, licensed doctors need to provide evidence that they have maintained their knowledge and skills. This ‘re-registration’ of doctors, which is typically on a periodic schedule (e.g. every 5 or 10 years), can have many components, including requirements for continuing medical education (CME) or continuous professional development (CPD), peer and patient assessments, and various types of examination. The ‘revalidation’ process is meant to assure patients, employers and other health care professionals that licensed doctors are up-to-date and fit to practise.[27] Recently, there have been discussions of the regulatory challenges associated with doctor re-entry into clinical practice.[23, 28] Here, the impetus is to ensure that doctors who have left the profession, either voluntarily or because of disciplinary action, are fit to return. In some specialties, there is a push for regular performance-based assessments designed to measure what the doctor can do as opposed to what he or she knows. As in other professions in which knowledge and skills can decline over time, MoL, MoC and revalidation are quality assurance initiatives designed to enhance patient safety by ensuring that doctors maintain their skills. However, given an ongoing expectation that doctors maintain some sort of clinical activity and keep abreast of recent developments in their field, the regulatory process, outside of initial licensure and across different specialties and practice domains, can be quite complex.

Although licensing, certification and revalidation of doctors are accepted practice in most nations, there are no globally accepted ‘best practices’. Instead, local governments (or specialty societies) maintain their own standards. Given that the practice of medicine can vary considerably around the globe, this is probably necessary and certainly appropriate. Nevertheless, depending on its implementation and the rigour with which specified criteria are enforced, the application of licensure (or certification or registration or revalidation) processes can have both positive and negative consequences. In the remainder of this section, we will discuss these issues, cite the relevant literature, and make suggestions for future discussions and research.

Validity of licensure and certification (scores and decisions)

Several authors have discussed the process of gathering evidence to support the validity of licensure and certification decisions.[29, 30] Most typically, at least in instances in which assessments are employed, data are obtained to help support inferences that are based on examination scores. Of primary concern is the match between what is assessed and what doctors actually do in practice. Assessments for licensure should clearly reflect competencies that patients expect of their doctors.[31] The assessment needs for regulation can also be informed by the nature and types of problems typically seen in practising doctors.[32] Often, to support content validity, actual practice data are used to help inform the test blueprint (i.e. how examination content is distributed in a test form). From an assessment perspective, this helps ensure that candidates for licensure (or relicensure) are treated fairly and are measured on the competencies essential for practice. Nevertheless, there continue to be various aspects of medical care (e.g. the use of health information technology) that need to be better assessed as part of the regulatory process.[33]

Although much work has been conducted to ensure that licensure assessments contain relevant content, and new simulation-based assessment methods can measure certain competencies that were difficult to measure previously,[34] other validity evidence is often lacking or, at best, discouraging. For example, in the USA, some researchers have questioned the validity of USMLE scores for making medical residency selections.[35] However, the relationship between these licensure assessment scores and postgraduate performance is only one, and probably a relatively weak, link in the validity chain. What is really needed is some indication of the quality of care these individuals provide after receiving an unrestricted licence to practise medicine. Unfortunately, the research evidence linking regulatory interventions and quality of care is sparse, mainly observational and descriptive, and does not, for the most part, allow for causal interpretations.[36] By contrast, with respect to certification (or recertification), there have been several studies to show that advanced standing within the medical profession (i.e. specialisation) is associated with the provision of better patient care.[37-39]

In 2003, New York State instituted graduated driver's licence laws. The new laws increased the supervision of young drivers and limited both time-of-day driven and number of passengers. In many ways, the licensing and certification of doctors also represent a graduated system, which extends from the assessments required for initial licensure through to MoL and MoC, or revalidation, requirements. However, unlike the implementation of graduated driver's licences, in which the longitudinal effect of the policy can be reasonably measured by counting car crashes,[40] it can be difficult to obtain outcome measures to evaluate the impact of changes in patient care models or provider (doctor) qualifications.[41] As a result, building a strong, defensible case for the validity of doctor licensure examinations, and revalidation efforts, can be difficult. For initial licensure, several studies have shown that licensure examination scores are related to future practice performance.[42-44] Although these studies are informative, and provide some evidence to suggest that performance on licensure examinations extrapolates to practice, they are far from complete. From a public protection perspective, the transgressions of practitioners who have had their licences revoked typically have little to do with the specific knowledge and skills measured as part of licensure examinations. With this in mind, current licensure assessments may not adequately screen out those practitioners with inadequate knowledge, skills and attitudes. Fortunately, just as the licensing of drivers has evolved over time (mostly in response to public sentiment concerning safety), thus making the roadways safer, medical regulatory criteria can, and will, change to help yield better practitioners and to adequately sanction those who provide inadequate care.[45]

There is, no doubt, a consequential impact of introducing new assessments as part of the licensure and certification (or registration) process.[46] Provided that the assessments are well constructed and meaningfully related to practice, candidates will prepare, making them better practitioners. This effect, based primarily on CME, is probably more pronounced in revalidation activities.[27, 47] The key, however, remains with constructing licensure and certification assessments, or developing ongoing mandatory educational requirements, that prompt individuals to learn and practise meaningful skill sets.

Costs and benefits

Most licensure, certification and revalidation processes are very expensive, and costs are typically borne by the candidate. As an example, the total cost of the USMLE (Step 1, Step 2 Clinical Knowledge, Step 2 Clinical Skills), necessary for licensure in the USA in all jurisdictions, is approximately US$2320.[48] Although some of the examinations are offered outside the USA, students typically have some additional travel expenses. Moreover, students who fail any of the steps must retake the examination(s) and pay the fees once again. On top of the cost of typical licensure assessments, it is also common to have a recurring fee associated with the granting and maintenance of the licence. For those doctors who seek specialty certification, there are additional expenses associated with obtaining and maintaining this status. Finally, with the possible introduction of simulation-based assessments for the MoC[49] and retraining of doctors for medical licensure,[50] the expense borne by the individual doctor is likely to rise.

Although licensure, certification and revalidation costs can be prohibitive, the costs of oversight must be weighed against the potential cost of its lack to society (e.g. poor patient care). There are some data to show that regulatory (licensure) systems yield better performing doctors,[51, 52] and even more evidence linking specialty board certification or registration to better patient care,[53-55] but there appear to be no comprehensive studies of their costs and benefits. Here, part of the problem may reflect the difficulty of relating the costs of (poor) care with the individually licensed doctor. Although even one preventable death may provide the impetus to implement very elaborate and comprehensive regulatory structures, there remains a need to explore best practices for licensure and certification, including how the specific costs of regulation (i.e. screening assessments), including revalidation, relate to patient safety.[56]

Another issue related to cost rests with the need to maintain accurate databases concerning doctor qualifications. In the USA and elsewhere, efforts have been made to construct national practitioner databases.[57] These types of database, including those maintained by certification agencies, help to ensure that doctors, especially those against whom disciplinary actions have been taken, do not slip through cracks in the regulatory system. To judge the efficacy of any regulatory system, it is imperative to have comprehensive, longitudinal data on all doctors within a jurisdiction, including qualifications and practice characteristics. There is, however, a substantive cost associated with building and maintaining such a database.

Although the cost of licensure and certification can be high, there are certainly some benefits, at least to the doctors who engage in the process. Based on survey results, diplomats of the American Board of Anesthesiology in the USA have attached importance to board certification and consider that it is of value in demonstrating competence.[58] They were, however, concerned with the cost and complexity of the MoC activities. Similarly, general practitioners in the UK reported that it was feasible to collect supporting information for the Royal College of General Practitioners (RCGP) revalidation proposals.[59] Nevertheless, as licensing authorities and certification boards continue to implement additional practice criteria, or revalidation standards, there is certain to be some concern about their overall value[60] and the potential negative impact of taking doctors away from patient care to assemble evidence to support their competence.[61] Moreover, from an administrative perspective, there is very little information available to guide policies concerning when practising doctors, at least those not subject to disciplinary actions, should be recertified or revalidated. Establishing the trajectory for knowledge and skills degradation over time is certainly an area for further investigation.

Finally, the cost of certification and the increasing test requirements associated with MoC may push some doctors into early retirement or motivate them to abandon specialty practice, perhaps creating shortages in some disciplines or geographic areas.

Doctor mobility

For individuals who travel, it is fairly straightforward to arrive at an airport and rent a car. Although international driver's licences can be procured in some parts of the world, rental car companies typically demand only a licence that is valid in the jurisdiction in which the renter resides. This holds true whether drivers commute on the left or right side of the road. Although treating patients is certainly more complex than driving a car, the globalisation of medicine, including the desires of patients to travel across national borders to obtain health care, may one day motivate authorities to establish a common licensure pathway.[62, 63] Many jurisdictions, as part of both their licensure and certification processes, accept some of the qualifications of internationally trained doctors. It can be argued that this enhances mobility and may contribute to the ‘brain drain’ of doctors experienced in some countries. Nevertheless, given the educational and economic needs of some doctors, their movement from one country to another may not necessarily have an overall negative impact on society.

Although mobility can be enhanced by the introduction of centralised regulatory structures (e.g. national or international licensing examinations), there are some potential drawbacks. First and foremost, the practice of medicine can be quite different from one region to another. Based on validity considerations, creating a unified examination (for licensure or certification) that spans a large geographic region, or even a continent, may be quite difficult and, perhaps, not defensible. Even so, it would still be prudent, and efficient, for licensing authorities to share best practices and, when applicable, examination content.[64]

Conclusions

  1. Top of page
  2. Abstract
  3. Introduction
  4. Accreditation
  5. Licensure, Certification and Revalidation of Credentials
  6. Conclusions
  7. Contributors
  8. Acknowledgements
  9. Funding
  10. Conflicts of interest
  11. Ethical approval
  12. References

The assessment of a doctor's fitness to practise medicine is both complex and difficult, and certainly dependent on the practice environment. Providing effective patient care for a multitude of presenting conditions, with variable equipment and medications, incorporating multidisciplinary health care teams, and dealing with various resource constraints can be challenging. Moreover, the education of doctors and specialists is certainly not uniform, and involves differing lengths of training, variable curricula and divergent evaluation processes. However, given ongoing doctor migration, and the increasing numbers of patients who travel for health care, the need for oversight at both the system and individual levels is paramount. Both governments and individuals seeking medical careers need to know that the educational programmes in operation are sound and produce qualified practitioners. Regulators and certifying bodies need to be aware of changes in doctor practices and emerging assessment tools, and how these can be incorporated into both initial and ongoing decisions regarding competence. As patient care evolves, incorporating multidisciplinary teams with shared responsibility, the credentialing of individuals, as opposed to groups of individuals, may not be sufficient for addressing competency to practise. However, regardless of how patient care is delivered in the future, or the evolution of competencies deemed essential for practice, the development of sound regulatory practices can be best accomplished by sharing resources, including research findings and data, and using the available evidence from around the world to develop best practices.

The oath taken by many doctors at the commencement of their medical education emphasises their essential role in preventing disease. Although it could be argued that health systems around the world, including those in the USA and UK, continue to lag behind in direct efforts to deter the onset of diseases in healthy populations, there has been recent focus on ensuring the safety of the patient who is already under a doctor's care. Key components of these safety initiatives centre on rules and regulations aimed at ensuring, through high-quality educational programmes, the production of highly capable doctors, and certifying that practitioners are knowledgeable and competent over the course of their careers. Although these regulatory and quality assurance protocols are generally deemed to be comprehensive, at least in some parts of the world, and involve considerable resources to implement, little systematic research has been conducted to evaluate and quantify the outcomes of these accreditation, licensure, certification and revalidation initiatives. Equally importantly, regulatory processes, at both the institutional and individual levels, can be quite complicated, making it difficult for the public to know the ongoing qualifications of their providers or the criteria by which they were evaluated. Systems to evaluate and quantify the outcomes of accreditation, licensure, certification and revalidation programmes are needed. These should be combined with ongoing efforts to explain the value of these regulatory processes, where the evidence permits, to the many stakeholders who expect high-quality care.

Contributors

  1. Top of page
  2. Abstract
  3. Introduction
  4. Accreditation
  5. Licensure, Certification and Revalidation of Credentials
  6. Conclusions
  7. Contributors
  8. Acknowledgements
  9. Funding
  10. Conflicts of interest
  11. Ethical approval
  12. References

both authors contributed to the interpretation of the literature, and the drafting and revision of the article. Both authors approved the final manuscript for publication.

Note
  1. 1

    Together with the Committee on the Accreditation of Canadian Medical Schools (CACMS)

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Accreditation
  5. Licensure, Certification and Revalidation of Credentials
  6. Conclusions
  7. Contributors
  8. Acknowledgements
  9. Funding
  10. Conflicts of interest
  11. Ethical approval
  12. References
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