Leadership Interview with Lois Nora

Group editor Marty Kauchak had an opportunity to speak with Lois Margaret Nora, MD, JD, MBA, president and chief executive officer of the American Board of Medical Specialties (ABMS).

Group editor Marty Kauchak had an opportunity to speak with Lois Margaret Nora, MD, JD, MBA, president and chief executive officer of the American Board of Medical Specialties (ABMS). The Chicago, Illinois-based community leader provided insights on her organization’s many efforts to improve healthcare in the US.

MEdSim: Thank you for taking time to speak with MEdSim about ABMS. There are many activities in your organization’s portfolio. First, let’s start with an overview of the ABMS mission.

Lois Margaret Nora, MD, JD, MBA: Thank you. I appreciate the opportunity to speak with you on this important topic. The American Board of Medical Specialties (ABMS) is a professional medical organization that works with our 24 Member Boards to improve America’s health care by establishing professional standards for lifelong certification of medical and surgical specialists in our country. We set these standards and then certify when individual physicians (or others, as two ABMS boards certify PhDs) meet them.

Board Certification is an important tool used by the public when selecting their physician. In addition, health systems, insurers and others view certification as an important demonstration that the physician has met the high standards established for training and assessment in a particular specialty. We take our role as an organization that serves the public trust through rigorous, professional self-regulation very seriously.

MEdSim: You mentioned board certification. Lifelong learning is an important element of board certification. How do you evaluate the effectiveness of lifelong learning programs in the US medical community?

LN: In general, medical education across the continuum of a physician’s career is conducted extraordinarily well in our country. We have an established system of accredited medical schools, residency programs and continuing education in place. There is a professional commitment to lifelong learning in the physician community that is embedded across a number of organizations. Accredited Continuing Medical Education (CME) plays an important role in offering continuous learning opportunities. Medical specialty societies do a great deal to foster lifelong learning. We have the emergence of accredited simulation centers – part of your industry – that is also doing its part to encourage lifelong learning. Many things are being done well. That being said, there are still areas in which we can improve.

MEdSim: Such as?

LN: There are opportunities to maximize technology to increase just-in-time learning, and make it more convenient for physicians and health professionals. We need to focus more attention on team learning at the patient’s bed side. In general, we do an extraordinarily good job with discipline-specific learning, but sometimes we don’t do as good a job developing learning opportunities with other core competencies that are not quite so discipline specific, for example team-based care, communications and systems-based practice. And we need to improve the use of technology and other strategies to help individual learners identify their personal learning needs as well as help the medical profession to identify community learning needs.

MEdSim: You noted communications, team learning and such – training scenario attributes emphasized for decades by the military and civil aviation communities as we report in our other Halldale Media publications. It appears the medical community is also emphasizing these “sweet spots” to bolster their training.

LN: I think they are. The military and civil aviation have long been leaders in this area. But the health professions community is increasingly looking at how it can employ a variety of low fidelity and increasingly high fidelity formats for training and education. Where these tools are being used, we are looking at better ways to employ them.

MEdSim: ABMS values patient safety as an element of increased community professionalism. What’s your evaluation of the state of patient safety in the US?

LN: We have made dramatic improvements since the To Err is Human report [1999]. Checklists, “time outs” and other practices that are being employed have reduced error and improved patient safety. But we know we are not where we need to be. There are still steps to be taken to make our environments as safe as we want them to be. For example, The Institute of Medicine report on medical diagnosis will come out sometime this fall [2015], and I think our profession will be challenged with some work to be done in this area.

MEdSim: And it appears there are opportunities for learning technologies – ranging from simulators to distributed learning – to further improve US patient safety.

LN: Learning technologies can play a critically important role in patient safety. More accessible and realistic training models that help encourage healthcare team learning and engagement are especially impactful in improving patient safety. What’s exciting is the question of how best to bring that technology closer to the bedside and make it more just-in-time, both to improve health care, while at the same time, reduce the burden on, and increase the relevance, to physicians and other health professionals.

MEdSim: I want to jump ahead slightly and follow up on your comments regarding bringing the technologies closer to the bedside and other innovative ways to learn. Your other suggestions, please, on how the simulation and training (S&T) industry can better respond to the evolving demands and requirements of today’s healthcare professions.

LN: We need innovations that improve access and relevance, reduce costs, foster continuous improvement and help us address some of the issues we’re talking about today. For instance, how do we reduce the time between the emergence of a new public health issue and the subsequent learning that needs to happen? I was impressed with one of our Member Board’s - the American Board of Anesthesiology - response to the recent [Spring 2015] Ebola crisis. The Board recognized the need to ensure anesthesiologists were up to date on infectious disease protocols. Thus, the Board asked the American Society of Anesthesiologists, the national association with education expertise, to develop a cost-effective, online learning module. Within weeks, the module was available online.

MEdSim: We have also noticed another trend – cases of reductions in insurance companies’ premiums for physicians who complete learning technology-enabled courses or programs. How is that industry also responding to the rigor that ABMS is inserting into board certification and related processes?

LN: ABMS Board Certification is almost a century old and has been long recognized as a quality indicator by insurers, hospital and health systems. Many of them inform their insured population whether or not a physician is board certified by an ABMS Member Board. When Maintenance of Certification (MOC) was introduced, it offered additional information to these groups about a physician’s engagement in ongoing professional development.

MOC is a rigorous framework for continuing assessment and learning throughout a physician’s career, which can span 35 to 45 years. While still a relatively young program, many insurers, health systems and others are beginning to encourage participation in MOC, and to indicate whether or not a physician is participating on their respective consumer websites and enrollment collateral materials.

MEdSim: We have heard much about board certification today. Are there opportunities to increase the use of learning technologies in board certification processes?

LN: ABMS Board Certification occurs after a long and very rigorous process of learning and assessments throughout and after medical school education, residency and fellowship. We know that many of those programs are using simulation and other related technologies as core teaching elements. We recognize that some of the most powerful lifelong learning occurs through the use of both low fidelity and high fidelity formats, and believe these will be of increasing importance in ongoing certification through MOC.

MEdSim: Your thoughts please on how procedural competencies can be assessed?

LN: The practice of medicine is continually changing. Physicians, like other health professionals, are at various stages in their practice, moving along a continuum of learning from being a novice to being an expert. Simulation programs are being used very effectively in residency programs to help novices to hone their technical skills. As those residents become more and more experienced, the simulations help prepare them for patient care and work in a team setting. Simulation allows the learner to experience and practice their skills during routine and unexpected situations. Simulations help them anticipate problems that they would never otherwise see, develop mastery, and become an expert in a variety of competencies.

We also realize that many physicians, years into his or her practice, will encounter a new technology, and suddenly become a novice. It is one of the reasons why participating in MOC and continuous quality improvement in one’s practice is so important throughout the physician’s entire career. You have to work hard to obtain mastery of skills and equally hard to keep them. All physicians should anticipate that at any point in time there will be new competencies and/or procedures that have to be learned and mastered.

MEdSim: And for your many member boards, do they have requirements for their members to demonstrate different competencies within their area of professional oversight.

LN: They absolutely do. ABMS worked closely with the Accreditation Council for Graduate Medical Education (ACGME) to jointly define the following core competencies:

Within these six core competencies, milestones have been identified for every medical and surgical specialty. We and our Member Boards have incorporated these into our requirements for Board Certification and MOC.

MEdSim: Much like other high risk communities (military, civil aviation, nuclear, others), ABMS also focuses on organization quality improvement. Tell us about some of the challenges and impediments to improving quality in the field – at medical facilities and in other organizations.

LN: The good news is there’s tremendous recognition throughout the medical community about the importance and power of continuous quality improvement. We see that commitment in our own world with the more than 40 health systems that are participating in our Multi-Specialty Portfolio Approval Program, which allows physicians to receive MOC credits for participating in cross-specialty, interdisciplinary quality improvement activities in their own health system. That said there are still challenges. One in particular, is that in many health systems, the quality improvement area of the organization is distinct from the continuing professional development or CME arm of the organization and there is insufficient engagement across these areas. If we can help departments encourage greater cross-talk and interaction between our quality improvement and continuing education offices, it would have a high impact on improving quality of care in the field.

MEdSim: It certainly appears ABMS is building a strong linkage between quality improvement and learning – training and education – for physicians.

LN: Absolutely. That is what ABMS and its Member Boards are all about – assessment and learning. And when you look at quality improvement, it is all about those same two elements. You assess, you identify the gaps, you learn how to address those gaps and do so, and assess again; it becomes an ongoing process.

MEdSim: Any other thoughts or messages for the S&T industry on how it can better meet the medical profession’s dynamic needs?

LN: First, my compliments and thanks to the S&T industry for all it is doing. You have helped transform education and that is critically important. I hope that you will continue to innovate. Increased attention to how we can bring some of these important tools out of large simulation centers and to patients’ bedside will have a tremendous impact and could help facilitate other physicians’ accessing those tools. In addition, it will be important to harness the power of simulation to enhance areas like patient-physician communication and informing people of health risks and concerns, among others.

MEdSim: Finally, some would opine that studying for the MOC does not really show competence except for the ability to pass a rigorous test. What would you change to improve the MOC?

LN: The first thing I would point out is that MOC is much more than a single exam - it is a framework that includes assessment of a physician’s professionalism, lifelong learning, self-assessment and Board-based assessment and participation in quality improvement activities. The Board’s assessment is what some call “the exam”, but that is only one component of the framework.

MOC signifies to the public that a physician is Board Certified and is involved in a process that ensures lifelong learning, self-assessment, external assessment, quality improvement and professionalism. Now, can we improve? As with any process, there are opportunities for enhancement and improvement. We recently went through a very intensive year-and-a-half long exercise looking at our MOC program. We developed updated standards that are encouraging innovation and ongoing improvements to our programs that have had a direct and positive impact on a physician’s practice.

Moving forward, the ABMS Boards will continue to engage in our own continuous quality improvement process to ensure that we are serving our patients and physicians alike.

MEdSim: Thank you once again for providing your very insightful and informative insights!