Certifying Competence Among Health Professionals Is a Public Good

Since the late 20th and 21st centuries, the advancement of medicine and surgery has increasingly accelerated, scientific knowledge has consolidated, technology has been increasingly applied, therapeutic methods have been created and increasingly bold surgical procedures have been used, while knowledge and techniques have changed in a short time. On the other hand, society is increasingly informed and, therefore, demanding in the preparation and assertiveness of the attending physician and all related health personnel.

The 1999 Institute of Medicine report, To Err is Human: Building a Safer Health System, highlights the prevalence of medical errors in the health systems. A key feature of the report is to shift blame from individuals making errors to a focus on preventing future errors by learning from medical mistakes and then designing safety into the system. Individuals must be vigilant and accountable for their actions. But when an error occurs, individual blame does little to make the system safer and prevent others from committing the same error. Patient safety demands a competent physician. Physician competence, therefore, should be and is a major concern. It follows that the issues of competence and competency must be at the heart of certification efforts.

Since 2008, AMFEM has published its "Competencies of the Mexican General Practitioner,” with which conceptually it surpasses the vision of labor competence, which only looks at the immediate and focuses on utilitarianism, and which is oriented only to satisfy a labor market. AMFEM has considered competencies as open capacities that prepare us to make decisions in dynamic and complex environments. The statements of competences are visualized as "Fuzzy learning outcomes," which is the challenge to express, through specific statements, the living and complex processes involved in professional practice.

Given the definition of competence, it follows that a competency profile is a document that captures and identifies the competencies for a given work function. The aim of a competency profile is to identify the skills, knowledge, and abilities required to be able to perform the job, role, or occupation and to organize it in an easily accessible and useful way. The skills within a competency profile are defined in performance terms, which means that the skills describe what the person “must be able to do” to effectively perform the job, role, or function.  

Physician and health professionals’ education has shifted from a model based on how long a physician trains to one that emphasizes assessing and encouraging measurable competence. There needs to be a similar shift to ensuring competency for physicians who have completed their training, with an emphasis on maintaining knowledge and clinical skills to ensure patient safety. This leads to several questions. Who must be competent in what? Who decides? Does experience count? How does aging affect competence? In medicine, an expansive range of competencies are considered important and not every physician maintains every competency.

Who better to assess the ability and updating of the doctor than his own peers?

Physician certification gives certainty to the population that the physician meets national standards of competencies to provide high-quality healthcare in a specific medical specialty or subspecialty. The purpose of the boards/councils is to help the public and institutions distinguish physicians who are qualified for specialized work in each branch; there is a national agency, and only one, for each specialty that designs exams for certification candidates and evaluation systems for recertification.

The concept of a "Specialty Board" was introduced in the US in 1908 by Dr. Derrick Vail, president of the Academy of Ophthalmology and Otolaryngology, as an effort to increase the quality of specialty medicine. In 1933, the American Board of Medical Specialties was established. The example spread to other countries; for example, in England and its domains through the Royal Colleges. In Mexico, in 1963, the process began with the foundation of the Mexican Council of Anatomo-pathologists Doctors and by 1974, 15 councils of other medical specialties had been established, which looked to the National Academy of Medicine for support and guidance. It agreed to act as a coordinating and normative entity and began to grant suitability. In 1995, the Mexican Academy of Surgery, also a consultative body of the federal government and with a member of the General Health Council, joined this work and the Councils of Medical Specialties were convened on Feb. 15, 1995, to form the National Normative Committee of Councils of Medical Specialties (CONACEM) A.C.. This committee has the nature of an auxiliary body of the Federal Public Administration to supervise the knowledge, skills, abilities, aptitudes and qualifications in the expertise that is required for the certification and renewal of the validity of the same or recertification in the different specialties of medicine that, for the purposes of its object, recognize CONACEM.

The councils/boards are bodies created by the specialists themselves to regulate their performance based on the necessary requirements of preparation and training in each field of medical practice and in the demonstration of competence in certification and recertification exams. Councils are autonomous associations in their organization and procedures, free from political, gender, doctrinal or regional influences.

Certification is the act by which a council with recognition of suitability, through a pre-established and transparent evaluation process, confirms that a professional has the knowledge, skills and abilities of a medical specialty, defined as a limited part of science, recognized and scientifically validated. Recertification is the evaluation process carried out by the councils to ensure that a previously certified specialist keeps their knowledge and skills up to date, according to the progress made in their specialty during a certain period, which was set at five years.

The purpose of the certification of the specialist doctor is to give the patient the certainty that he has the skills, abilities, aptitudes and is up to date in the scientific and technological knowledge of the medical branch of his specialty. Therefore, the legal good to be protected with the certification is the healthcare of the population. There is scientific evidence validating the association between professional certification and quality of healthcare. This requirement of law, since it is obligatory, has allowed the certification or recertification of 148,688 medical specialists. Certifications in force for the last five years total 111,569 (Jan. 8, 2020). Of the total specialists, 69 percent had current specialty certification by the medical council of the respective specialty, with some specialties obtaining rates above 95 percent of valid certification, while others were occupational, with percentages below 20 percent.

The certification of specialists is one of the great challenges of modern medicine. The professionalization of the various actors involved in the process is required. We need to continue to develop more effective and efficient medical certification processes. To address shortcomings in evaluating medical practitioners, many medical leaders are proposing a more rigorous framework to evaluate competence and to couple this evaluation with the concept of maintenance of certification. The American Board of Medical Specialists has adopted the concept of “maintenance of competency,” which would be an ongoing evaluation and certification of professional competence. Rather than spot-checking cognitive expertise at defined intervals, practitioners would have to maintain their certification through a process of ongoing evaluation(s).

The needs and expectations of society should motivate us in the medical community to take the necessary measures to provide a solid process based on the best evidence of medical education.