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In order to provide the best possible care for their patients, most physicians devote considerable effort to staying current on developments in their field. But keeping up with the rapid evolution of knowledge and changes in patient expectations and standards of care can be challenging. Electronic resources available at the point of care can help physicians access the latest information, but, given time pressures, such tools aren’t always used. Yet current clinical knowledge remains the foundation of high-quality care.
How do physicians know if they have succeeded in keeping up with changing foundational knowledge? Strong evidence suggests that none of us are good at knowing what we don’t know.1 Performance scores on quality measures provide some feedback on practice, but these measures aren’t always relevant, particularly for specialists, and they tend to reflect overall team performance rather than the abilities of individual physicians. Comprehensive independent assessments provide critical guidance for — and evidence of — staying current. Maintenance of certification (MOC) plays a key role in supporting this important professional responsibility.
Board certification differs from medical licensure in important ways. Administered by state governments, licensure is quite broad: states allow licensed physicians to practice without restrictions, whether they are administering chemotherapy, replacing heart valves, or delivering babies. It is the profession that has created and applied higher standards for physicians who claim to have specialized knowledge. States don’t regulate claims of special expertise, so we rely on board certification to verify that a physician has received specialized training and achieved and maintained knowledge and skills in a particular field. The medical profession has broadly embraced this credential: 79.1% of all licensed physicians in the United States are board certified by an American Board of Medical Specialties (ABMS) organization.2
Despite critics’ claims to the contrary, we believe the evidence is convincing, albeit incomplete, that certain outcomes are better for patients treated by board-certified physicians. Published data show, for example, that the risk of both death and emergency coronary artery bypass grafting is lower when patients undergoing percutaneous coronary interventions are treated by board-certified interventional cardiologists, and the cost of care for Medicare beneficiaries is 2.5% lower among physicians who were obliged to complete MOC than among those who were not.3 Because the vast majority of physicians are board-certified, certification can easily be taken for granted. But in an Internet-based world where anyone can become, for example, an ordained minister online, reliable credentials based on solid standards have become even more valuable.
Founded in 1970, the American Board of Family Medicine became the first board to exclusively issue time-limited certification. By then, it was widely recognized that a certificate issued at the completion of training meant less as physicians progressed in their careers. Other boards eventually moved to time-limited certification. The American Board of Internal Medicine (ABIM) stopped issuing lifetime certificates in 1990. Boards that never issued lifetime certificates have had a smoother path to time-limited continuous certification since they never had lifetime certificate holders.
Over the years, there has been ongoing and spirited debate about how boards could best make the transition to time-limited certification. In 1979, the American Medical Association debated the possibility of imposing a moratorium on recertification in favor of relying on continuing medical education (CME). Arnold Relman, the editor-in-chief of the Journal at the time, wrote in an editorial, “Those who believe that mandatory CME is a better way to assure the maintenance of clinical skills need to recognize why it hasn’t been used as the criterion for initial specialty certification. The reason is, of course, that CME alone, without some kind of test, cannot possibly assure competence.” After citing the many challenges associated with creating a meaningful and valuable recertification program, he added, “The development of an acceptable method of recertification ought to be an achievable goal for any specialty board that commits itself to this task. . . . but for a profession that takes such pride in its self-imposed discipline, total abandonment of the recertification idea would be a mistake.”4
The world has unquestionably changed since 1979, and so must our thinking about certification. We at the ABIM have revised our organizational structure and are reimagining our relationship with practicing physicians to align with these changes.5 We are discussing with 32 different specialty societies the best way to design an MOC program that is relevant and meaningful for a very diverse community of physicians. And we are taking advantage of new tools — for example, by “crowd-sourcing” decisions on what knowledge certified physicians should possess. By asking colleagues in each discipline what knowledge is most important and what knowledge they use most frequently and combining their responses with national data on disease prevalence, we’re able to refine assessments to focus on the areas that are most relevant to practice.
Recognizing that doctors are utilizing a variety of resources to stay current, the ABIM has partnered with the Accreditation Council for Continuing Medical Education to create standards so that many more CME offerings can also confer MOC credit and to streamline the process through which physicians can claim that credit. As of mid-November, more than 4651 activities had been registered through this collaboration, with 45,200 individual physicians earning a total of 2.02 million MOC points.
In consultation with practicing physicians, we have developed a new format for reporting scores on certification exams that provides more detailed feedback, increasing the value of assessment to guide further learning. We are also conducting a study of the effect of making electronic resources available during our assessments.
Perhaps the most dramatic change the ABIM is planning is the creation of a new maintenance pathway through which most certified physicians will be able to demonstrate continuing maintenance of knowledge without having to take the long-form exam every 10 years. We are developing a series of more frequent, less burdensome assessment approaches focused on identifying gaps in knowledge, with escalating consequences for unsatisfactory performance over time. We will also be exploring partnerships with specialty societies, many of which already have programs designed to help physicians integrate assessment and learning into their busy schedules. This process will involve defining expectations for ongoing educational programs with built-in assessment that might serve as alternative maintenance pathways.
Whatever the ultimate outcome, we remain committed to ensuring that an ABIM credential is meaningful and relevant and derived from a fair, transparent, and defensible process based on participation and performance. The 10-year exam will remain as the pathway to recertification for physicians who don’t participate or perform successfully in this alternative maintenance pathway, as well as for those who have lost certification and want to reinstate it.
Internists and subspecialists distinguish themselves every day through their specialized knowledge and commitment to using that knowledge in service of their patients. We believe that protecting the integrity of a peer-defined, discipline-specific credential is not the role of the government, health care delivery systems, or payers — it belongs to those of us who practice the discipline, maintaining highly specialized knowledge and demonstrating that we have done so.