When one has devoted an entire career to the education of anesthesiologists and to improving the accreditation of anesthesiology programs and the certification of anesthesiologists, one would like to answer unequivocally “yes” to the title question. However, when one researches the literature, it provides a paucity of supporting articles.
The safety of anesthesia practice today is at the highest level ever. Death, cardiac arrest, or brain damage associated with anesthesia is, indeed, a rare event. The measurements of quality for all medical specialists remain an inexact science and today is not even an art. Determining efficiency and cost-effectiveness of practices likewise remains elusive. Having personally inserted thousands of Swan-Ganz catheters and frequently making what I thought were tough clinical decisions upon the resultant hemodynamic data, I cringe when pubished data suggest that patient morbidity and mortality have been increased due to the use of these devices.
I am also well aware that the data are sparse linking board certification of physicians with improved outcomes for any medical specialty. However, we also know that the board certification movement has dramatically improved graduate medical education by improving the quality of the residency programs (faculty, organization, facilities, etc.) as well as the education of the residents. Credentialling of physicians must always include more than board certification. The Silber article1 does link board certification of anesthesiologists to better patient outcome. The concept of “failure to rescue” is introduced and is defined as “the probability that the hospital failed to rescue the patient after an adverse occurrence.”1 In 1994, the American Board of Anesthesiology performed a study which linked a positive clinical skills rating by attending anesthesiology faculty to success in the board certification process. It was concluded that “board certification in anesthesiology although still a surrogate for ideal assessment of clinical skills, is truly sensitive to superior competence in an anesthesiologist.”2 Despite the fact that credentialling today is aimed more at “weeding out the bad apple” than documenting quality, such credentialling still improves patient safety. When a peer review group is able to identify a pattern of unsafe practice, a monitoring and education system can be put into place to improve the practitioner’s practice. How to use information from the National Practitioner Data Bank remains an enigma, and yet no one says the data should not be used. However, managed care companies have developed “a black box” system to identify cost-effective providers and to exclude those who are not. This has caused county and state medical societies and the AMA to propose credentialling mechanisms for physicians. The American Medical Accreditation Program (AMAP) would assess physician performance in five areas: 1. Credentials 2. Personal Qualification 3. Environment of Care 4. Clinical Performance 5. Patient Case Results There should be little difficulty in documenting the first two areas. However, meaningful documentation of the last three years with the information systems currently available will be difficult at best. Criteria to help determine cost effectiveness, quality, and safety are in the infant stages of development.
Data obtained from individual state licensing boards regarding restriction, suspension, or revocation of licenses are also used in the credentialling process. However, the licensing boards most often respond to overt acts such as criminal activities, substance abuse, inappropriate prescribing patterns, patient abuse, confidentiality issues, etc. rather than simply to a pattern of poor patient outcomes. Restrictions, probationary actions, etc., need to be managed closely by appropriate physicians to insure patient safety.
There is a substantial body of knowledge relating to the validity of board examinations themselves. However, this validates only the examination process, but does not study any change in patient outcomes that could be attributed to board certification of physicians. Therefore, although we “know quality when we see it, “we have had great difficulty in developing quantitative systems to support our biases. We believe that credentials are important for improving patient safety; we are in the process of proving it.
Dr. Arens, a past President of the American Society of Anesthesiologists, is Vice President for Clinical Affairs, The University of Texas Medical Branch at Galveston.
References
- Silber J, Williams SV, Krakauer H, Schwartz JS: Hospital and patient characteristics associated with death after surgery. Medical Care, 1992;30:615-627.
- Slogoff S, Hughes FP, Hug CC, Longnecker DE, Saidman LJ: A demonstration of validity for certification by the American Board of Anesthesiology. Academic Medicine, 1994;69:740-746.