In the past decade, the measurement of physician actions has increased drastically. Insurers have launched pay-for-performance programs designed to reward physicians for demonstrating measurable value. Specialty boards have instituted requirements to size up physicians' skills with more frequent recertifications. The latest development in physician measurement comes from the Joint Commission.

The Joint Commission revised its medical staff criteria for 2008 based on ongoing monitoring. Previously, to be reappointed to a medical staff, a physician would be subject only to a periodic assessment, usually every two years. The thinking in the Joint Commission's new Ongoing Physician Performance Evaluation standard is this: Medical staffs (in the modern, automated world) should be able to measure and evaluate the care given to inpatients on an ongoing basis. Daily, monthly or quarterly, the medical staff should assess the quality of care of each medical staff member. Most medical staff leaders are up in arms, trying to determine how they will accomplish this feat.

The Genesis of Measurement
As I see it, the measurement craze started with the desire of some physicians to elevate themselves above others by denoting their special knowledge or skills. Hence these physicians spawned the specialty movement and established criteria to be called specialists.

In order to preserve the autonomy of specialists, specialty boards were developed to assess and measure the skills of an individual applying to become that particular kind of specialist. As these specialty boards gained prominence and independence, their criteria evolved. Eventually, most physicians needed to belong to one specialty or another. Specialty societies representing the economic and political interests of their members did not always agree with the criteria of the specialty boards, and severe conflicts have occurred.

Because doctors faced increasing difficulty in meeting the criteria for a specialty board, splinter groups established their own organizations and labeled themselves specialists in a specific disease or condition separate from the specialty board. Now many of us belong to multiple quasi-organizations for which we need to meet education requirements to maintain membership.

Further, the specialty boards again increased the ante by following the lead of the American Board of Family Medicine and requiring recertification periodically (usually every 10 years). Now the ABFM requires maintenance of certification by online examinations annually. What's next? A daily quiz to maintain your specialty status? Imagine sitting at Starbucks, having your latte and getting your daily quiz question on your BlackBerry. Where will it end?

Physician Monitoring in Hospitals
Thanks to California Medical Association advocacy, California requires that physician applicants to hospital membership be assessed for competence prior to being granted privileges. The Joint Commission adopted the California requirement as a national standard effective 2008. However, the "proctoring" of an applicant for privileges plagues many hospitals. The current system requires a volunteer, untrained proctor to assess the skills of an applicant and send a report to the medical staff office. Usually the applicant must satisfactorily complete a certain number of proctored cases to be granted unrestricted privileges.

This process needs an overhaul. Proctors should be trained. They should develop consistent observation skills and apply them evenly to all applicants. They should be compensated for their time. They should assess the total care given by the applicant through the whole hospital stay, not just individual procedures. Well-trained, experienced proctors could assess physician competence in a variety of skills. For example, a general surgeon could assess specialty surgeons.

Specialty boards pre-establish a passing grade. Similarly, medical staffs should pre-establish proctoring expectations for applicants. Applicants should be advised that, to be granted full privileges, they are expected to receive "very good" or better ratings on five of six evaluations. We should end the current common practice of proctoring a physician applicant until he achieves five satisfactory proctoring reports.

This overhaul creates a fair and measurable approach to assessing applicants to any medical staff. We physicians established the hierarchy of specialties. Now let's apply it consistently in our hospital practice.

Lytton W. Smith, MD, editor for the OCMA, is a physician practicing family medicine with the St. Jude Heritage Medical Group in Yorba Linda. Dr. Smith welcomes feedback on his articles and can be reached at editor@socalphys.com.