Maintenance of skills, competencies, and performance in allergy and clinical immunology: time to lay the foundation for a universal approach.

Allergist/clinical immunologist maintenance of certification and training program reaccreditation are mandatory in some countries. The World Allergy Organization conducted surveys in 2009 and 2011 to assess where such programs were available and to promote the establishment of such programs on a global level. This was done with the presumption that after such an "inventory," World Allergy Organization could offer guidance to its Member Societies on the promotion of such programs to assure the highest standards of practice in the field of allergy and clinical immunology. This review draws on the experience of countries where successful programs are in place and makes recommendations for those wishing to implement such programs for the specialty.

Medical science and the practice of medicine are continuously evolving at an ever-increasing rate. The public expects the medical profession to deliver the highest quality of care to patients. Development and maintenance of professional standards through maintenance of certification (MOC) is one method to do so. This is a self-sustaining process promoted by different entities in various parts of the world. The purpose of MOC is to make sure that the physicians adhere to updated standards in the specialty and to ensure cost-effectiveness in their practice. In addition, the same process indirectly influences and discourages unacceptable medical practices.1 Medical specialty certification, in the field of allergy/immunology, begins the process of assuring quality medical care.2,3 Beyond initial certification, MOC is mandatory to guarantee that the process of learning and staying current with medical advancements is a lifelong process.4,5 Six core competencies are identified by the American Board of Medical Specialties to be important in the process. They include patient care, professionalism, practice improvement, medical knowledge, communications, and systems-based practice.6

The World Allergy Organization (WAO) is an international umbrella organization whose members consist of 89 regional and national allergy and clinical immunology societies from around the world. By collaborating with its member societies, WAO provides direct educational outreach programs, symposia, and lectures to members in 100 countries.7 The WAO Board of Directors initiated this project to make an inventory of MOC practices in the national member society countries. In 2009 and 2011, a survey was conducted among the members of the Education Council, the Specialty and Training Council, and other WAO bodies having rapport with the existing national systems for the MOC and for accreditation and reaccreditation of training programs and schemes. The aim of the survey was to ascertain whether such programs were well established at a global level, or if there is a need for WAO to offer guidance to its membership on the introduction and maintenance of programs to promote high standards in the practice of allergy and clinical immunology. The responses received from different geographical regions suggested that although some countries had systems in place to conduct one or both of these processes in the field of allergy and clinical immunology (Table 1), the global coverage was far from universal. This review draws on the experience of countries where successful systems are in place to make recommendations for those wishing to implement a national system for allergy and clinical immunology specialists.

TABLE 1

MOC/Accreditation of training programs

A system to ensure continuous professional development (CPD) of medical specialists requires 2 complementary components:

A defined process for MOC for specialists. This includes specific procedures, goals, and time intervals.

Approved training programs to cover key specialist competencies and their continuous upgrading and revalidation—accreditation and reaccreditation of training programs.

The WAO Position Paper, “Requirements for physician competencies in allergy: key clinical competencies appropriate for the care of patients with allergic or immunologic diseases,”8 outlined the optimal level of knowledge, technical and skills objectives, and desirable attitudes for the allergy/clinical immunology specialist. Depending on the local needs and circumstances, such lists may provide a useful foundation for the development of MOC and training program reaccreditation in the field of allergy and clinical immunology (see Appendix). Training programs presently in use, in countries where such procedures are mandatory, could also provide useful models for countries where such programs do not exist.

The 2 components, MOC of individuals and reaccreditation of training programs, should derive from and complement the continuous process of graduate and postgraduate education. They should provide a vehicle to achieve smooth transition to maturity of medical specialists and thus ensure the growth of manpower resources in allergy and clinical immunology. Their structure and function at a national level may differ depending on the relationships between the specialist community, academia, and the physician-licensing authorities (Table 2).

TABLE 2

A Successful System—MOC in Australia

FRAMEWORK FOR MOC/REACCREDITATION OF TRAINING PROGRAM MODELS

The MOC/reaccreditation of training program models in allergy and clinical immunology should take into account the specific features of allergic diseases, recognizing that these are systemic diseases with underlying immunological mechanisms and with a wide variety of organ manifestations.9,10 They need to address the wide-ranging skills, knowledge, and competencies required for a specialist (ie, the allergist/clinical immunologist). However, there are conceptual differences between MOC of specialists and accreditation/reaccreditation of training programs, which necessitate separate assessment programs for each of these 2 entities. Ideally, the MOC or recertification of specialists should be based on the same standards of achievement as the ones that regulate the first time certification. Such standards should be decided by the leaders of the specialty, or the corresponding government medical authorization body (as in several countries, it is not the society that gives the certification but a medical council or relevant government authority in medicine), and the standards should be periodically updated in line with the most current medical literature and the needed care of the population served. Although the first time certification is the starting point of an independent specialist career and should therefore require particular scrutiny on the part of a certification authority, the subsequent MOC time points should provide for evidence of incorporation of novel diagnostic and treatment modalities into an individual's clinical practice. Therefore, the MOC procedures should make use of continuous medical education (CME) and CPD systems for life-long learning at the regional level, national level, and where available, international level. The time points for MOC should reflect the evolution of new information in the specialty. The process should not be punitive. Typically, 3 or 4 MOC cycles would be appropriate for a lifetime specialist career of 30 to 35 years. The oversight of MOC of specialists preferably should be exercised by the professional authority issuing the initial certification and not by the governmental institutions and agencies.

At a national level, the process of accreditation/reaccreditation of training programs should involve the participation of a broad circle of experts, specialty organizations, and training program directors or their designees, and it should be driven “on demand” by practice-changing innovations. Such programs should be required to provide evidence of graduating a certain number of students to specialist status over a given period (eg, a 5-year period) as a measure of their effectiveness.

WAO can contribute to the establishment of globally recognized standards in allergy and clinical immunology practice in 2 ways. First, by establishing and regularly updating the recommendations for physician training in allergy and clinical immunology to provide the following:

A model of required and desirable specialist knowledge, technical and skill objectives, and desirable attitudes for the initial certification and MOC of individuals, which will in turn provide a benchmark for training program content for accreditation/reaccreditation purposes (Appendix);

A self-assessment tool for allergists who are considering their individual educational needs and CME requirements, for example, accreditation programs that involve reading online lectures and updates and answering multiple choice questions and awarding “knowledge” accreditation points, which local allergy training councils will accept for the purposes of recertification. In addition, there could be recommended mechanisms of assessing clinical competence and procedures by the local medical councils/bodies.

Second, by recommending the global introduction of MOC standards to help national societies provide a lobby for a challenging, cost-effective, mostly nonpunitive educational process and also to propose how it should be implemented. The national societies of allergy and clinical immunology, and training program directors or their designees, should be the natural interface for the adoption of new practices for the existing programs, and it should maintain a dialogue with allergy/clinical immunology specialists and appropriate health care organizations. This cross talk should allow both specialists and institutions to have a say in incorporating their respective needs into the training program accreditation/reaccreditation process. At the same time, precautions should be in place to prevent commercial bias and self-serving behavior.

Understandably, variations are expected between countries, depending upon the maturity of the specialty and whether allergy and/or allergy/clinical immunology is recognized as a separate specialty or a subspecialty. This fact probably accounts for the poor rate of response to the WAO survey because in countries where allergy/clinical immunology is not recognized as a specialty, individuals refrained from answering the questionnaire. This limitation could be overcome further down the road by adding data through personal contacts and telephone calls. Where allergy and/or allergy/clinical immunology does not currently have specialty recognition, the WAO recommendations for the competencies required to treat patients with allergic and immunologic diseases may be particularly helpful for the individual specialist seeking to identify appropriate CPD and CME educational activities. This review article should be a benchmark for societies and national medical bodies around the globe to help them establish such programs, setting up their own time frame for achieving it.

ADMINISTRATIVE AND LEGAL ASPECTS

The concept of MOC presumes the existence of a recognized certifying authority. It would be advisable to have a national administrative nongovernmental authority responsible for enunciating the national standard and hosting the process of certification and MOC of allergy/clinical immunology specialists and also for vetting the process at regular intervals. The scientific content and logistic structure and functions should be defined by a legal document issued by the governing institution or a legislative body.

The organization of the procedure for accreditation and reaccreditation of training programs should be the joint task of the national societies of allergy/clinical immunology and the national training programs, or corresponding national medical government bodies who are authorized to provide such certification. This procedure may be sanctioned by the administrative body, under whose jurisdiction the certification and MOC of medical specialists occurs.

SUMMARY

Systems that support the need for allergists/clinical immunologists to pursue lifelong education to maintain and update their clinical competency and to ensure that training programs are up-to-date and effective will lead to improved patient care and enhance recognition of the specialty of Allergy and Clinical Immunology.

For those countries wishing to implement such systems, WAO offers the following recommendations for the institution and standardization of programs designed to ensure the development and maintenance of skills and competencies for the allergist/clinical immunologist:

The guiding factor in the development of a program is that it will benefit both patients and physicians

The program should be nonpunitive to the physician for whom it is intended

The program should contain a didactic element; the process to implement it should be a learning experience ending in an examination, which demonstrates increased medical knowledge

Multiple sources of information are necessary to demonstrate the competency of the physician seeking MOC, including patients, ancillary staff, fellow specialists, and other physicians and health professionals. Multiple assessment tools are necessary, including open-book testing of knowledge, proctored examinations, practice assessment, patient care outcomes, and quality improvement

The process should be flexible and adaptable to changes in medicine, science, and the practice of allergy and clinical immunology, and it should recognize local needs, availability of medications and diagnostic tests, and service capabilities

Outcomes should be identified that can be monitored and quantified to verify that the process is beneficial

If problems appear in the MOC for individuals, or in the procedures for revalidation of training programs, which have the potential to jeopardize patient care or the education of physicians, a remediation process to rectify the problems and processes is necessary. If these problems cannot be rectified, then the physician or the training program in question should not be recertified/reaccredited.