Orthopaedists in Europe prepare to meet mandatory recertification requirements

Steps are being taken that will require physicians in Europe, including orthopaedic surgeons, to certify that the medicine they practice is current.

Meeting these requirements may involve regularly earning continuing medical education (CME) credits through appropriate activities or passing knowledge-based or skill-based examinations in a particular area of expertise, or meeting other requirements. In some parts of Europe, a component of the professional appraisal and recertification process may be an exam to determine gaps that exist in a physician’s knowledge base, sources told Orthopaedics Today Europe.

Even as the recertification or revalidation process for orthopaedic surgeons begins in Switzerland, the United Kingdom and other countries, some orthopaedic and medical professionals elsewhere in Europe have not started to address the issue of CME and related requirements. However, sources said that, in time, a planned European Union (EU) directive could mandate that they take action.

The European Federation of National Associations of Orthopaedics and Traumatology (EFORT) seeks to be involved in and support the revalidation of orthopaedic surgeons at the national level across Europe, according to EFORT president Pierre Hoffmeyer, MD.

“EFORT has to make sure there is a certification process that goes on in every country. We can encourage this, but we cannot enforce it,” he said, noting EFORT has made inroads in the revalidation arena with lobbying activities in Brussels.

To date, national or regional orthopaedic and traumatology associations have typically dealt with issues related to certification and recertification of orthopaedic surgeons. For example, in the United Kingdom, the British Orthopaedic Association (BOA) spearheads plans and activities related to the institution of mandatory revalidation of orthopaedic surgeons in Great Britain, which is expected to start in January 2013, according to David Limb, BSc, FRCS-Ed (Orth), chairman of the BOA education committee.

“Once we are sure that all of Europe has a good certification process, we can then go on to revalidation,” Hoffmeyer said. “It has become obvious, because of the various problems that orthopaedists have run into in the last few years, especially [with] the prosthetics, that orthopaedics has come into the limelight of politicians in many countries.”

Resources available

With various government bodies having a say in defining physician recertification, orthopaedic surgeons must be proactive, Hoffmeyer, an Orthopaedics Today Europe Editorial Board member, said. However, once politicians realize that EFORT strives to make improvements in the professional development process and is equipped and qualified to do so, then EFORT can fully support the national orthopaedic associations with needed resources. This might include providing the manpower to identify, recruit and train orthopaedic examiners or revalidators, he said.

“EFORT … can furnish lists of experts who could be consulted for this type of revalidation. Revalidation needs to be painless,” he said.

Hoffmeyer noted EFORT is well-positioned to deliver educational programs that support the revalidation efforts of most orthopaedists in Europe, and it already offers a course to help orthopaedic trainees attain their initial certification.

Eventually, EFORT could tailor courses specifically for physicians who need recertification and play a role in supporting European recertification that way, according to Hoffmeyer.

“[This] would take the onus off of some of the national societies that just do not have the means or the time to act on this,” he said, adding that EFORT could support European recertification by conducting customized orthopaedic and traumatology courses in a given country, in the native language.

“EFORT, if it is serious about revalidation, will go that way. And, we are. We think this is something we need to do because the benefits of revalidation are also for the societies,” Hoffmeyer said.

Everyone — from the national orthopaedic societies, to the physicians and their patients — benefits from recertification of orthopaedic surgeons, because it is essentially a quality measure, he said.

“It is a win-win for everyone,” Hoffmeyer said.

UK revalidation deadline

In keeping with its commitment to assist national orthopaedic associations in meeting recertification goals, Hoffmeyer and EFORT officials met with BOA representatives in September to discuss strategies for including special educational content that supports the revalidation process on the program when both organizations meet jointly in June 2014 in London.

BOA took this approach at its annual congresses last year and in 2011, and it was a success, according to Limb.

A consultant orthopaedic surgeon who has served on the revalidation board of the Royal College of Surgeons, Limb is as integrally involved in the revalidation process at his own National Health Trust in Leeds, United Kingdom, as he is in the broader efforts affecting BOA members. He told Orthopaedics Today Europe that several recertification activities that are expected to become mandatory next year in the United Kingdom were evaluated in pilot studies, including documentation requirements and physician appraisal methods.

After the pilot studies were completed earlier this year, U.K. employers reported their “state of readiness” for revalidation to the U.K. Department of Health using an organization readiness self-assessment tool. Limb said employers have since had the chance to address any weak areas.

Based on the results, “The Secretary of State will declare whether or not revalidation will begin at the beginning of 2013,” Limb said, noting the official announcement is imminent.

Annual appraisals

The start date for U.K. physician revalidation was moved back from Jan. 1, 2010, so the pilot readiness studies could be completed, according to Limb.

“The big thing that is different with the revalidation is the restructured annual appraisal that all doctors will have to have. What is happening at the local level is the appraisers are being properly trained to deliver sufficient standards of appraisal for revalidation, and the data collection processes are being brought up to speed to inform those appraisals,” he said.

An assessment tool that lists the exact elements each health care organization must have in place by Jan. 1, 2013 is available, he said, and it gives those using the form a framework to complete their recertification plans.

At this juncture, to make U.K. physician revalidation work, Limb said it has been “watered down” from what was originally conceived about 6 years ago, particularly the individual outcomes assessment and detailed analyses of performance. But, in some ways, the simpler, more straightforward approach to revalidation that will be adopted will yield a less time consuming process, Limb said.

“It is sensible to start with something that is reasonably sensible and then build on it. But, it will make it, as it is introduced as far as surgical outcomes in orthopaedics, very crude indeed. But the General Medical Council (GMC) is not specifically about mining down to detailed outcomes at the moment, but rather introducing a process that works with the data available,” he said.

The GMC is the government-appointed regulator of U.K. health care, including revalidation efforts.

Practically speaking, Limb expects his 2013 annual appraisal will be similar to this year’s except outcomes will be viewed slightly differently and there will be a patient feedback questionnaire. However, not everyone is prepared for these changes, he said, particularly orthopaedists who do not work in NHS Trusts, including those who work wholly in the private sector, who may have never undergone a formal appraisal and for whom GMC has no record of continuing professional development.

The goal now is to get that sector engaged in the appraisal process, Limb said.

In terms of revalidation by medical specialty, each specialty communicated its ideal standards for surgical outcomes and skills to the U.K. Royal Colleges of Surgeons. The BOA informed the College what the standards should be for traumatology and orthopaedic surgery and theoretically they will be what orthopaedic surgeons in the United Kingdom will need to meet beginning in 2013, he said.

Switzerland’s self-assessment

In June, 105 members of the Swiss Society of Orthopaedic Surgery and Traumatology (SSOST) voluntarily — and anonymously — sat for an orthopaedic surgery knowledge self-assessment test translated into Swiss and German. The Swiss Institute of Medical Education analyzed the scores and reviewed comments about the examination, according to Christian Gerber, MD.

The questions focused on applied knowledge and case-based judgment. He said the test results will help identify areas where surgeons lack knowledge and which questions need to be rewritten.

“These questions were fairly reasonable, were not geared toward students, but toward practicing orthopaedic surgeons,” Gerber said.

Currently, there are no universal methods of recertification and the method that will work best in orthopaedics is open to debate, Gerber, immediate past president of the SSOST, told Orthopaedics Today Europe.

“For Europe, we try to take a leading role in assessing what would be a sensible way to assess the knowledge and skill of an orthopedic surgeon, but how can we assess that somebody is very likely to successfully practice his profession?” he said.

Surgeon success

The fact that the recertification process applies to individual surgeons and not the departments where they practice needs to be emphasized, Gerber said, and noted that knowing one department is good compared to the others is not particularly helpful in this situation.

“We should try to make it clear, we do not want to test people and we do not want to judge people. What we want to do is to provide a possibility [for them] to get better,” he said.

“We need to ascertain that every orthopaedic surgeon who sees patients is competent and documents that they are competent.”

Ultimately, “EFORT can probably play a role so far as it promotes self-assessment and recertification,” Gerber said.

It can make an impact by conveying to EU authorities, in general terms, what the standards in Europe should be, however, “I do not believe we are yet at the point where a standard exam would be appropriate,” he said.

CME in Finland

Finland has not fully embraced the concept of recertification and required orthopaedic surgeons to meet such requirements, according to Ilkka Kiviranta, MD, PhD, president of the Finnish Orthopaedic Association (FOA). But, he said the EU is working on a directive for professional competence that may soon affect recertification requirements in Finland.

“Direct scientific evidence on the effect of recertification is limited, but medical knowledge is renewed so rapidly that CME is a must, also in orthopaedics and traumatology,” Kiviranta said.

CME is voluntary in Finland. About 10% of Finnish physicians or 2,000 physicians nationwide voluntarily enter their CME activities in a database and keep their credits current independently, according to Kiviranta.

The FOA offers its members courses and meetings in which they have been active. Quality outcomes are tracked through the national joint replacement register and other registers, but those data are obtained usually only at a hospital level. In Finnish hospitals, team spirit and friendly competition also motivate orthopaedists to keep their knowledge and skills updated, he said.

“Better knowledge and skills will definitely improve the quality of care,” said Kiviranta, professor in the Department of Orthopaedics and Traumatology at the University of Helsinki.

Finnish physicians in surgical specialties annually spend 9.9 days, on average, completing CME activities, he said, according to results of a Finnish Medical Association survey. Therefore, CME controlled by a recertification process is not critical, Kiviranta said, but he acknowledged this could soon affect Finland and predicted that the format for revalidation will likely be determined by the Finnish health authority and government.

Until then, Kiviranta hopes EU officials will listen to orthopaedic associations and societies, such as EFORT and the Nordic Orthopaedic Federation, as they prepare the new directive.

“The vast majority of Finnish orthopaedic surgeons will update their knowledge even without regulations,” Kiviranta said. “However, all physicians should continue to update their knowledge. Protocols and guidelines will help the decision-making to take part in continued education.”

As Hoffmeyer said, the basic principle of revalidation is this: “To show that you are proactive in your profession, that you can prove that you are keeping on top of it.” – by Susan M. Rapp and Renee Blisard Buddle

Reference:

Helin-Salmivaara A, Kajantie M, Vänskä J, et al. Amount of external CME in groups of specialties: a nation-wide survey among Finnish doctors. BMC Res Notes. 2009;2:265.

For more information:

Christian Gerber, MD, can be reached at Balgrist University Hospital, Forchstr. 340, CH-8008 Zürich, Switzerland; email: christian.gerber@balgrist.ch.

Pierre Hoffmeyer, MD, can be reached at Hospital of the University of Geneva, 25 Avenue de Champel, 1211 Genève 14, Switzerland; email: pierre.hoffmeyer@efort.org.

Ilkka Kiviranta, MD, PhD, can be reached at Helsinki University Hospital, Topeliuksentkatu 5SB, 00260 Helsinki, Finland; email: ilkka.kiviranta@helsinki.fi.

David Limb, BSc, FRCS-Ed (Orth), can be reached at Leeds General Infirmary, Leeds West Yorkshire LS1 3EX, United Kingdom; email: d.limb@leeds.ac.uk.

Disclosures: Gerber, Hoffmeyer, Kiviranta and Limb have no relevant financial disclosures.

Is the recertification of orthopaedic surgeons in Europe a needed process? Why?

Supports recertification in orthopaedics

In the Netherlands, a recertification program was implemented for all medical specialties in 2006. Before 2006, lifelong certification was given at the end of the training as a medical specialist. However, since 2006, recertification is necessary every 5 years. The requirements for recertification are a commitment to lifelong learning, sufficient practice experience and adequate performance in practice.

In the Netherlands, a minimum of 200 hours of continuing medical education (CME) in a 5-year period is required for recertification. The maximum number of CME hours per year is 80. The number of hours granted for attending a congress or training is determined by a Netherlands Orthopaedic Association committee based on the meeting program or the training. There are several other requirements to receive CME hours for a meeting or training.

Sufficient practice experience is defined as an average of 16 hours in clinical practice per week. To evaluate the performance of a medical specialist, every hospital group of medical specialists with the same subspecialty is evaluated as a group every 5 years. The quality of care, the organization and cooperation of the group, and the use of guidelines is evaluated. The requirement for recertification is that a person has been involved in this quality assessment. In the recertification process, there is no formal examination. In the event an orthopaedic surgeon fulfills all these requirements, a 5-year recertification is granted by the Dutch Medical Authority – the KNMG.

This system is fully accepted in the Netherlands and is fully supported by the Netherlands Orthopaedic Association. Driven by increasing societal concerns over the quality and safety of medical care, recertification is a good 5-year check of professionalism, CME participation and medical expertise.

In the United States, recertification evolved to a maintenance of progression program aimed to improve patient safety, stimulate practice improvement and lifelong learning, and enhance physician interpersonal communication and professionalism. In many countries in Europe, orthopaedic surgeons still have a lifelong certificate. Many of them will have a high ambition for the best possible care and personal performance, but not all. Progression and change in our profession is so fast that a regular check of the orthopaedic surgeon’s competence is essential. For the good ones, it will not be a problem to recertify. But, for weaker colleagues, this may become an obstacle. Recertification is a good solution for patients and professionals. Every European orthopaedic association should support the adoption of a recertification process.

Jan A.N. Verhaar, MD, PhD, professor of orthopaedics at Erasmus University Medical Center, Rotterdam, Netherlands, is president of the Netherlands Orthopaedic Association.
Disclosure: Verhaar has no relevant financial disclosures.

Pragmatic process needed

Revalidation is due to be implemented next year in the United Kingdom and most surgeons have been contacted by our regulator, the General Medical Council (GMC), indicating 20% will be revalidated annually. This will be based on an extended appraisal system where five appraisals will form the basis of recommendation from a Responsible Officer from each hospital recommending revalidation. In my hospital, we have piloted this apart from the quinquennial 360° assessment to determine whether the physician has the correct attitude and communicates with patients and staff. An important element is practice-related continuing professional development. Those who do trauma and hip surgery need to ensure CME in both areas, not just a special interest.

Presently, most are unsure of the effectiveness of this process, but surgeons feel it will help them remain up-to-date in our specialty. A system of revalidation by peers is needed to ensure that surgeons remain current and personal development is managed actively and not just left to each surgeon to address. Orthopaedic surgeons tend to be busy as their ratio to the European population is high. It is easy after we are deemed to be trained to then get little additional training, especially for the section of surgeons that does not attend meetings regularly. A formal system ensures everyone remains informed and gets additional skill as techniques evolve or are introduced, and it will ensure our patients get the best possible care because surgeons remain well informed of innovations and the effectiveness of standard operations.

We have recommended, and GMC has accepted, the need to keep this process simple and pragmatic. One of its major flaws is the responsible officer is usually the medical director of each hospital, which gives this manager the capacity to insist on compliance with hospital rules even if this does not improve quality of care. However, my NHS hospital has appointed five of more than 600 medical staff to oversee this, and many of us have had formal training in the extended appraisal which looks at activity, CME, audit of practice and 360° assessment, among other factors.

Joseph J. Dias, MD, FRCS (Edinburgh), FRCS (England), MD, BS, is at the University of Leicester, United Kingdom, and is immediate past president of the British Orthopaedic Association.
Disclosure: Dias has no relevant financial disclosures.