Medical advances ranging from brain scans to Viagra have revolutionized the way doctors practice medicine. And that's the problem.

Patients expect their doctors to stay on the cutting edge of medical technology. But procedures doctors learned in medical school just a few years ago are rapidly becoming outdated as new treatments and new drugs reach the field, and the changes keep coming. Medical knowledge is doubling every 3 1/2 years.

Critics say the current system of continuing medical education, or CME, is not enforced rigorously enough to keep doctors up to date. Moreover, they say, doctors are not continually required to demonstrate their competence.

"Everyone assumes that we're regularly tested, and that's just not true. There is more regulation of plumbers in the U.S. than psychiatrists," said Dr. E. Fuller Torrey, a research psychiatrist and president of the Treatment Advocacy Center in Arlington.

David Swankin, president of the Citizen Advocacy Center here in Washington, said, "The great majority of licensed doctors are never seen by the state medical board after they get their initial license."

"If doctors pass their initial exam and continue paying their dues, they're licensed for life."

Continuing education also is subject to abuses, Dr. Torrey said. For example, the Northern California Psychiatric Society sponsored a trip to the Santa Fe Opera as part of its continuing education program. Psychiatrists then attended lectures such as "The Psychotherapeutic implications of Puccini's 'La Boheme' " and "Reality in Art: Mozart and Puccini and Their Works."

"Psychiatrists are undoubtedly the only professionals who can go to the opera, get credit as 'continuing medical education,' and write it off their taxes," Dr. Torrey said.

Dr. Murray Kopelow, executive director of the Accrediting Commission for Continuing Medical Education in Chicago, said he was not familiar with these "operatic" courses but said his organization regularly investigates complaints about courses.

"The task of making this information available to doctors in the field is huge, because the amount of change is accelerating," said Dr. Kopelow, whose organization evaluates and approves continuing medical education courses.

"That's what CME is all about," he said. "It's not just a matter of doctors affirming, 'Yes, I can still do it, and I'm wonderful.' It's become culturally appropriate for doctors to say, 'I don't know, but I'll find out.' "

Dale L. Austin, deputy executive vice president of the Federation of State Medical Boards, said, "The vast majority of physicians stay very current and competent" through both CME and peer review in their hospitals.

"The medical profession prides itself on keeping up. It's very much a part of medical discipline to stay current. Those who don't tend to be the exception, rather than the rule."

Each state's legislature sets guidelines on how doctors in their state keep current. In most cases, competency guidelines require that doctors complete a specified number of continuing education credits in a given time, usually every two or three years.

Just 31 states require a minimum number of continuing education credits for doctors, according to Dr. Kopelow. Maryland requires at least 50 hours of continuing education every two years, while Virginia and the District have no minimum requirements.

But Mr. Swankin doubts that continuing education alone can guarantee that doctors keep up with advances in their field. "Nothing makes you take courses in your particular field or prove that you did anything except go to it."

Moreover, it is up to the doctor to decide what CME courses to take. "It's not based on any deficiency he might have - it's more what he's interested in," Mr. Swankin said.

Consider, for example, a course on physician ethics.

"It's certainly a timely topic with the growth in managed care, and it might be a great course," said Mr. Swankin. "But if you're a brain surgeon, so what if it's a great course? It doesn't help you provide better care for your patients.

"The bottom line is that just mandating that a physician take a certain number of hours isn't enough. To think that CME offers protection for the public just doesn't hold up."

In fact, the Federation of State Medical Boards recently recommended evaluating not only the quantity, but the quality and the appropriateness of continuing education courses.

But Dr. James W. Thompson, deputy medical director of the American Psychiatric Association and head of its office of education, said this flexibility actually serves a useful purpose.

"Everything is so interconnected. For example, if I'm treating a patient for depression, I also need to know about thyroid disease, which is often a cause of depression, so you don't want to put too many limitations on it."

Dr. Thompson said he believes the current continuing education system provides adequate opportunities and incentives for doctors to stay current. "CME makes you keep up," he said.

Still, when asked about psychiatrists attending an opera performance and seminars on opera in psychotherapy, Dr. Thompson was aghast.

"Oh, no! ACCME would have a fit," he said, referring to the group that accredits continuing education courses. "Those people should be reported."

Other colorful CME brochures tout trips to Europe or the Orient, climbing Mount Kilimanjaro in Tanzania or river rafting in Chile, under the guise of "international medical studies" or "wilderness medicine." All offer participants credit for continuing medical education, not to mention a tax write-off.

"Of course, there are some excellent courses out there, too," Dr. Torrey acknowledged. "That's the main way all of us keep up to date."

Nevertheless, he believes doctors should not only be required to take continuing education, but also regularly demonstrate their competence.

Mr. Austin acknowledged that problem areas do exist. "The concern increases the longer a physician is away from formal education and initial licensure, and the more isolated the physician is."

The Federation of State Medical Boards has coined the term "dyscompetent" to describe physicians who fail to maintain acceptable standards in at least one professional skill.

"In this town, a lot of psychiatrists are 'dyscompetent,' " Dr. Torrey said. "Fifteen years ago, they were fine. But they're still prescribing old medications because they don't know how to use the newer medications. We see that all the time."

In October, the Pew Health Professions Commission recommended major changes in competence requirements for health professionals. Former Senate Majority Leader George Mitchell, Maine Democrat, who headed the review, said the current system is enforcing only minimal professional standards and could well be placing patients at risk.

"These minimal standards have served only to make certain that the most egregiously incompetent health professionals are prohibited from practicing. This is not enough," Mr. Mitchell said in releasing the commission's report.

Other health professionals, such as physician assistants and emergency medical technicians, are required to demonstrate periodically their competence in order to keep their licenses, the Pew commission noted. But doctors, nurses and pharmacists are not.

Mr. Swankin, a commission member, said, "The key is protecting the public by forcing the doctor to prove he can do the job."

The Pew commission also recommended that a national set of competency standards for doctors be developed, while leaving the job of administering and enforcing those standards to the states.

The commission suggested that competence testing could be triggered by factors such as the number of medical procedures performed, the length of time in practice, the number of disciplinary actions, or random peer reviews by other doctors.

In fact, last year the Federation of State Medical Boards published a series of indicators that may signal that a doctor is having problems. Mr. Austin favors this approach over the universal testing recommended by the Pew commission.

"It doesn't seem like a good use of limited resources every, say, 10 years to give physicians the same exam they took when they were initially licensed," Mr. Austin said.

"Some tend to believe there is an easy, quick fix: Just test everyone. But if physicians are specialized, the question is, What are you going to test them on?

Moreover, Mr. Austin questions whether testing would address the problem of doctors' competence. "So much of the practice of medicine involves 'the art of medicine,' which includes listening skills and communication skills.

"It's hard to measure those skills with tests, which tend to measure the 'regurgitation of knowledge.' "

The APA's Dr. Thompson noted that most medical specialties are beginning to take a more active role in competence testing.

About 85 percent of licensed physicians are certified by one of the 24 medical specialty boards, according to Dr. Stephen H. Miller, executive vice president of the American Board of Medical Specialties.

However, he said only about 15 of those boards have current re-certification programs, which may include voluntary tests of medical knowledge in that specialty.

Dr. Wm. James Howard, medical director of the Washington Hospital Center, thinks requiring such competence testing for every doctor is "probably excessive," because the current system already forces doctors to maintain their proficiency.

For example, before he re-credentials a physician to practice at the hospital, a doctor must submit documentation to show he has completed 60 hours of accredited CME. Such education can be acquired through in-hospital seminars, reading medical journals, or attending outside professional seminars, he said.

"It's a practice that's becoming far more common," he said. "Quality begins with who you admit to your medical staff."

Dr. Howard contends the marketplace is forcing such changes. "Hospitals are now being held to a higher standard for credentialing." He has testified as an expert witness in several medical malpractice cases, often in suits involving whether a hospital should have allowed a doctor to practice.

The Washington Hospital Center, like many other hospitals, regularly reviews its physicians' practices. A panel of doctors reviews patient charts, watching for problem areas.

"It's not uncommon for additional CME hours to be prescribed if there seems to be a weakness in a certain area," Dr. Howard said. "That's probably better than re-testing, anyway, because this is in the real world."

Dr. Torrey agreed that the best city and university hospitals can use such peer review systems because of the competition for staff appointments. But in rural hospitals, or less desirable hospitals, "peer review has some real flaws."