This post is presented in conjunction with the March 2020 issue of the American Journal of Bioethics. You can read the full article and commentaries here.
by Armand H. Matheny Antommaria, Chris Feudtner, Mary Beth Benner, Felicia Cohn & on Behalf of the Healthcare Ethics Consultant Certification Commission
In June 2018, the Healthcare Ethics Consultant (HCEC) Certification Commission (the Commission) began accepting applications, and since then three candidate cohorts have received the Healthcare Ethics Consultant-Certified (HEC-C) designation. While these individuals have reported favorable experiences, concerns about the HEC-C program—both the certification process and what the designation represents—exist.
As members of the Commission, we welcome dialogue about these concerns and wish to enhance understanding of the Commission’s reasoning behind key aspects of the HEC-C program. This program is part of an evolving system of professional structures, for which much work remains. In developing the HEC-C program, we were guided by well-established standards. The HEC-C program is not set in stone, but instead will evolve over time. We hope that transparency will encourage productive dialogue, improving the practice of, and access to, healthcare ethics consultation.
CERTIFICATION AS PART OF A SYSTEM OF PROFESSIONAL STRUCTURES
In healthcare, certification is part of a system of professional structures, each with roles to play and standards to uphold. Certification is never, for any profession, self-sufficient. Certification is often complemented by state licensure, and organizational credentialing, along with ongoing managerial oversight. Certification is not licensure. In some disciplines, licensure requires certification. Licensing rules and regulations, however, extend beyond certification. While licensing bodies have the authority to designate who may practice, certification authorities have no such authority.
Certification has limitations. Certification does not assure expertise for any professional. Certification is also insufficient to make hiring decisions. Healthcare organizations, each with its own particular needs and specific job requirements, still need to assess whether a particular applicant has the requisite knowledge, skills, and attitudes. Certification status should be supplemented by other resources such as personal interviews and references. Certification cannot assure that individuals do not practice above their skill level. This is a matter of personal adherence to professional codes of ethics (in our case, the first statement of the Code of Ethics and Professional Responsibilities for Healthcare Ethics Consultants—namely, “Be competent”). This is also a matter of organizations living up to their ethical obligation to provide ongoing managerial supervision of staff.
Certification, lastly, is not a substitute for the accreditation of training programs. Work on accreditation is beginning in our field. The Association for Bioethics Program Directors, for example, has articulated standards for clinical ethics fellowship programs. More work is needed regarding evaluating formal training programs and assessing the quality of trainees. The HEC-C program may catalyze training program accreditation, as certification has in other fields.
CERTIFICATION IS IMPORTANT
Although certification alone is not a complete professional structure, certification is an important component of professionalization. Certification allows HCECs to demonstrate a standardized level of achievement while supporting other efforts to professionalize the field. The Commission recognizes concerns about not overstating what the HEC-C designation signifies, and desires to increase the standardized level of achievement. The Commission will assess our marketing materials to assure a clear message and will continue to examine the skills assessed and the passing standard.
CERTIFICATION STANDARDS
Establishing the HEC-C program has entailed innumerable decisions. When making them, the Commission has been guided by key standards: valid, reliable, defensible, just, fair, feasible, and sustainable. Importantly, these standards are not unique or even unusual among certification programs; they are consistent with the standards set forth by the National Commission for Certifying Agencies (NCCA). The NCCA has accredited approximately 330 certification programs from more than 130 organizations over the past 43 years and the Commission is pursuing NCCA accreditation of the HEC-C program in 2020.
QUALIFICATIONS
One of the decisions the Commission had to make was who should be eligible for certification? More specifically, what measurable and potentially auditable metrics should be used? Addressing these questions required accounting for the diversity of settings in which HCECs practice, variation in the patient volume and type (such as children, pregnant women, and patients with cancer), and differences in the number of healthcare ethics consultations. Establishing a certification process that would likely emphasize one clinical setting, such as academic, tertiary care medical centers, would not do justice to patients or HCECs in other settings.
Eligibility decisions included what level of degree should be required and how much experience should the consultant have? There is a relative paucity of evidence regarding any potential associations between HCECs’ characteristics, such as the consultants’ degree or number of degrees, or their volume of consultative experience, and the quality of their healthcare ethics consultations. In order to better understand actual practice, in 2016–2017 the American Society for Bioethics and Humanities (ASBH) conducted a HCEC workforce survey. The survey found that the majority of respondents had bachelor’s, but not higher, degrees. Given this information, the Commission set the minimum requirement at a bachelor’s degree.
Regarding healthcare ethics consultation experience, the workforce survey found about 75% of respondents devoted 25% or less of their time to consultation. Given this data and the need to encompass the range of practice locations, the Commission established the currently required 400 hours of healthcare ethics consultation experience. Furthermore, given the broad range of the annual number of “formal” healthcare ethics consultations respondents performed (58% reported 10 or less per year), and the variety of ways such consultations are currently conducted and documented, the Commission chose not to define what constitutes a healthcare ethics consultation or to require a specific minimum number of consults. Like many of our decisions, we may revisit this one as we gain a better understanding of potential candidates.
To safeguard the integrity of the HEC-C program, applicants are required to provide contact details of a supervisor or peer who can attest to their experience. The Commission staff reviews all applications and randomly audits 10% of all applications. Suggestions of ways to improve this important task are welcome.
EXAMINATION SCOPE AND FOCUS
What should be the examination’s scope and focus? Given the diversity of HCECs’ disciplinary training, and debates regarding the merits of ethical judgments or the basis of ethical expertise, this question—not surprisingly—persists. To address it, the Commission followed well-established standards. The content outline was based on a role delineation study which identified pertinent knowledge and skills. HCECs subsequently rated the domains in terms of importance and frequency of occurrence. The number of questions addressing a specific domain are in proportion to that domain’s combined importance and frequency.
One of the domains is, broadly speaking, to evaluate and improve the quality of ethics-relevant policies, programmatic ethics education, and other offerings. Although some have questioned the inclusion of this domain, about 75% of all respondents to the workforce survey indicated that they performed all nine of this domain’s tasks, and overall highly rated the importance of this work. The examination specifications blueprint afforded 13% of the total examination content to this domain. In comparison, 11–13% of United States Medical Licensing Examination (USMLE) Step 3 focuses on Practice-based Learning and Improvement.
EXAMINATION FORMAT
Some commentators have questioned the adequacy of, or otherwise objected to the use of, multiple-choice-questions for the HEC-C examination. Nevertheless, compared to alternative evaluation formats, this modality has proven to be the most valid, reliable, and defensible. Other options, while seeming to be more nuanced or probing, are troubled by difficulties of assuring that candidates are tested on the same content, answers are graded in reliable and reproducible manner, and direct and indirect costs are fair and reasonable. Any decision regarding the evaluation format inevitably confronts tradeoffs.
Consider the proposed analogy to the USMLE Step 2 Clinical Skills examination. Critics have pointed out, however, that this examination lacks an evidence-base and is not cost-effective. Objective Structured Clinical Examinations (OSCE), a method used to evaluate a range of skills, are also not optimal, as the psychometric properties of OSCE rating scales have been found to be of intermediate quality. While efforts to develop OSCE for HCECs are encouraged, current evaluation tools have inconsistent rater agreement across the ability spectrum.
The Commission, nevertheless, would welcome better testing modalities, capable of assessing, for example, interpersonal skills, communication abilities, and reasoning. The challenge in certification (which, while related to education, is distinct) is assuring that these modalities are valid, fair, feasible, and defensible.
EXAMINATION QUESTIONS
In the development, internal evaluation, and deployment of the examination, the Commission utilized an established testing company with substantial expertise in psychometrics in general and certification in particular. Individual questions were written and underwent review and validation by multiple subject matter experts. The testing company performed a psychometric review of all questions regarding “best practices” for standardized test questions, such as assuring that incorrect answers were similar in length, complexity, vocabulary, and grammatical construction compared to correct answers.
Each answer required justification by reference to a standard work in the field. Some have expressed concern about the core reference list, specifically that this list was not developed via a formal consensus-based process. As the certification process evolves, the Commission may consider improved ways for identifying core references.
Importantly, after each examination administration, the testing company performs a statistical analysis of each question, regarding issues such as its ability to discriminate between those who scored high and low on the whole test. Content experts reviewed poorly performing questions (questions that people who otherwise answered most questions correctly answered incorrectly). The content experts decided whether to maintain the question unaltered (because there is a clear correct answer), discard the question (because the question is ambiguous), or (if two answers are, in retrospect, deemed correct) add an additional correct answer. The Commission has heard complaints regarding questions posed in a particular “what would you do first” format. Even though this is an established question format, if questions with this format are found to perform poorly, the Commission will act accordingly. Lastly, examinees should keep in mind that each examination includes new questions that are not scored, but are evaluated for use in future examinations.
CERTIFICATION COSTS AND SUSTAINABILITY
How much should certification cost and is the process sustainable? Answering these questions requires balancing the quality and accessibility of the HEC-C program. In terms of the costs borne by the candidate, the Commission considered both direct costs (fees payed for certification, including taking the test) and indirect costs (expenses incurred for traveling and lodging). Both direct and indirect costs to candidates would be substantially higher for more complex, in-person assessments. At the same time, the HEC-C program needs to be financially viable in the long-term. The costs of the administering the program cannot exceed its revenue (fees) and other sources of support (funds from ASBH).
THE HEC-C PROGRAM IS A WORK-IN-PROGRESS
The Commission continuously seeks to improve the HEC-C program. To this end, all comments, suggestions, and criticisms are welcome. The Commission proactively seeks feedback from individuals who pursue the HEC-C designation. Based on this ongoing dialogue and new knowledge, the Commission may change the program, for example, the initial qualifications or the requirements for recertification. The examination itself will certainly change, with new questions written and evaluated. We encourage individuals to participate in developing questions or join the Commission. We hope that these and other improvements in the HEC-C program will be supplemented by the development of other professional structures, and that jointly these developments not only will enhance the value of certification but also will improve the quality of healthcare ethics consultation.
DISCLOSURE STATEMENT
All authors are members of the HCEC Certification Commission, one (MBB) as paid staff, the others as volunteers. They have no other financial or other conflicts to disclose.