When Do Physicians Have to Take Boards Again

• Journal List
• Trans Am Clin Climatol Assoc
• v.119; 2008
• PMC2394686

Trans Am Clin Climatol Assoc. 2008; 119: 295–304.

Professionalism and Accountability: The Function of Specialty Board Certification

Brief History of Lath Certification in the United states

Board certification began in 1917 with the American Board of Ophthalmology equally the beginning specialty lath. The American Board of Internal Medicine (ABIM) was incorporated in 1936; and by 2002, the core grouping of the 24 member boards of the American Lath of Medical Specialties (ABMS) had a firm fix of shared guidelines and requirements for lath certification (Table i). The specialty boards were created in the start part of the 20^th century every bit medical scientific discipline was kickoff to advance, and physicians were beginning to gain specialty knowledge. The primary reason for specialty boards was to identify the boundaries and the content areas that defined specific specialties. It was a time, presently after the Flexner written report, when American medicine was beginning to try to distinguish itself from the proprietary physicians trained by apprenticeship, many of whom had fiddling science base and were often considered "ophidian oil salesmen."^one

TABLE one

Fellow member boards of the American Lath of Medical Specialties (ABMS)

• Allergy & Immunology

• Anesthesiology

• Colon/Rectal Surgery

• Dermatology

• Emergency Medicine

• Family Medicine

• Internal Medicine

• Medical Genetics

• Neurological Surgery

• Nuclear Medicine

• Obstetrics & Gynecology

• Ophthalmology

• Orthopedic Surgery

• Otolaryngology

• Pathology

• Pediatrics

• Physical Medicine & Rehabilitation

• Plastic Surgery

• Preventive Medicine

• Psychiatry & Neurology

• Radiology

• Surgery

• Thoracic Surgery

• Urology

Importantly, in contrast with the Regal Colleges in the Great britain and Canada, the specialty boards were established to be independent of the membership societies. The parent bodies that created the ABIM in 1936, the American Medical Association (AMA) and the American College of Physicians (ACP), felt it was important for the certifying boards to be independent of membership societies in order to be able to set high standards that would exist credible with the public. Thus, the true constituency of the certification boards is the public. This cistron has indeed led board certification to have the potential for leadership in advancing quality of physician exercise consistent with growing contemporary pressures for transparency and public accountability.

For the first several decades of the U.s. board certification process, it was a truly voluntary organization and was considered a marker of excellence and actress professional achievement. Indeed, many early leaders in the field were not board certified and near patients would non have considered inquiring about a physician'south certification status. During the latter decades in the twenty^thursday century, a number of of import changes occurred. One was the growing consumer movement in healthcare and the more widespread recognition that a "lath certified physician" was a expert thing, even though nigh members of the public did non really know what that meant. With the growth of hospital-based and more highly technical intendance, hospitals were looking for credentials for infirmary privileges. In the surgical specialties, in particular, board certification began to be considered a highly desired and sometimes required credential. The 2d major modify was the rapid growth of managed care in the wellness insurance manufacture in the 1980'southward. Looking for ways to distinguish themselves, the managed care plans began to prefer board certified physicians for their networks. These two changes caused a big proportion of previously uncertified physicians to seek certification in the late 1980s and early 1990s. The third major modify was the beginning of express duration for lath certification and the consequent incentive for recertification. For example, the American Board of Family unit Medicine (formerly Family unit Practice) required recertification every 7 years from its first in 1972. The American Lath of Surgery changed its standards to crave recertification in 1976. Internal Medicine certificates became fourth dimension-limited in 1990. In 2002, all of the ABMS boards agreed on comparable standards for board certification, including recertification requirements and a new component that requires evaluation of performance in exercise.

Maintenance of Certification

The understanding of the 24 specialty boards to a procedure chosen "Maintenance of Certification (MOC)" marked a new era in the importance of specialty boards for public accountability and the potential for the boards to strengthen public trust in physicians as leaders with a strong ethical responsibility for maintaining their competence and standards of patient care. About 87% of American physicians are certified.

MOC requires all of the boards to limit the elapsing of their certificates. Currently, certificates are required to exist renewed within 6- to 10-yr cycles, depending on the different specialties. All specialties, still, require four components to the MOC process:

• An agile and unrestricted license in the state where the md is practicing.

• Self-evaluation of knowledge, to increase and strengthen the standards for continuing medical education, including the ability to demonstrate significant learning.

• A secure, airtight-book examination of knowledge.

• Assessment of performance in practice.

For most boards, the quaternary component, the practice assessment, is a new and challenging aspect of the MOC process, leading to the demand for boards to interface with physicians' clinical or claims data at a time when such data sources are becoming more bachelor. The investments in enquiry and evolution of new products and approaches to new relationships with the medical societies, health plans, hospitals and healthcare organizations, have energized certified physicians in an important fashion.

The concept of MOC suggests the goal that physicians should be continuously engaged in cocky-evaluation and improvement of knowledge and practice performance over the grade of a career. Boards are developing approaches and products that are more than relevant to clinical practise, reduce burdens of redundant data collection and will create incentives for physicians who complete cocky-evaluation of noesis and practice functioning on a frequent basis, mayhap as oftentimes as every year; but at this betoken, that has not been required by most.

For the self-evaluation of knowledge component, some boards have developed their own education materials with examination-like questions that encourage the apply of educational resources, provide links to key educational information, and may use video and sound recordings.^two This more than active type of CME has been shown to exist more effective in promoting improvement.³

The cognition test is the component of MOC that is probably the most rigorous, well-nigh linked to bear witness of better outcomes but the most anxiety-provoking aspect of MOC.^4–9 Information technology is not hard to see why a periodic secure exam is a core component of public expectation for board certification.¹⁰ Scientific discipline is advancing ever more rapidly, and the noesis base that whatever physician needs is dramatically increasing. The Institute of Medicine pointed out that some 10,000 clinical trials are published every yr, and no physician could be expected to keep up with that volume of cognition. For this reason, many physicians cite the importance of decision support and information resources available to physicians rather than physician memory. However, state-of-the-art question evolution on knowledge exams is not and then much to test rote memory, but more to evaluate the synthesis of data and clinical judgment. The exams are rigorously adult and tested using strict psychometric standards; and at the ABIM, they are reviewed past a national network of practicing physicians and graded for clinical relevance. Only those questions with meaning relevance to practice are used in the MOC examinations.

A comprehensive meta-analysis of the literature on md capability over the grade of a career found a dramatic and significant reject in physician knowledge and compliance with national guidelines for diagnosis and treatment, and in some cases, with actual patient outcomes.^xi Data like these farther support the need for ongoing stimulus for doc learning and self-evaluation. As operation cess becomes more rigorous and more widespread, many people fence that cognition exams are non necessary if performance is existence evaluated in do. Medical cognition, however, consists of so many circuitous areas that the ability to evaluate a physician solely based on a limited number of patients cannot possibly truly evaluate the depth of specialty cognition. In internal medicine, for case, one can fairly reliably gather enough patients with diabetes, asthma or congestive heart failure to test one'south operation in these areas. But no internist would have a large plenty volume of patients with meningitis or tuberculosis to be able to evaluate functioning in those patients; and nonetheless, one would want to expect a board certified internist to be able to consider the possibility of meningitis in a patient with a headache and a fever or of tuberculosis in a patient with a cough and weight loss. Xx years of research in cognitive psychology has confirmed the importance of possessing a certain "cadre" of medical noesis.¹² First, without this cadre noesis one cannot recognize what i does non know and therefore needs to "look up." Second, as shown in Effigy i, this core cognition is a critical component of the clinical reasoning process.¹³ Thus, it is diagnostic acumen that is probably best evaluated by the cognition exam, whereas the treatment and management of mutual weather condition may exist evaluated likewise or improve by practice functioning cess.

Role of Medico Knowledge and Patient Care Adapted from Gruppen and Frohna. International Handbook on Medical Didactics and Research. Kluwer. 2002. (Reference ⁸)

Evaluation of Performance in Practice

The evaluation of practice performance component for ABIM consists of either ABIM-developed tools -the ABIM PIM^SM Practice Improvement Modules (PIMs) - or other data gathered effectually the doc's practice from other sources. The PIM is an internet-based tool, using nationally accepted guidelines for specific atmospheric condition or patient groups, allowing a physician to review nautical chart data, both manually or electronically, survey their patients, and examine the office systems. Physicians send these information to ABIM over a secure link to be analyzed and and so returned to the physician as a summary performance study. To get credit for that component, a physician must spell out goals for improvement; and at a later fourth dimension (perhaps six months to a year), reevaluate a comparable group of patients and resubmit the data. Early research piece of work by the ABIM constitute the vast majority of physicians rated the condition-specific PIMs to be a valuable experience. In a pilot study of the diabetes PIM, the participating physicians discovered deficiencies in care processes among their diabetic patients that surprised them. As a result, all but one md made a modify in their practice habits.¹⁴ Physicians can likewise use modules that specifically ask patients and/or peers to evaluate the physician and that have been shown to discriminate betwixt levels of physician performance.^xv PIMs are being used and tested in more than than 50 residency programs, involving over 700 residents across the U.s..¹⁶

Some physicians receive practise-related data either from their health system, such as those belonging to the Veterans Assistants, or from a large multi-specialty integrated group practice, such as the Kaiser Permanente or Mayo Clinic groups. However, over 50% of practices in the US consisting of v or fewer physicians may receive very little useful clinical data and have no way of identifying their patient denominator base of operations to do a reliable evaluation of practice performance. For those physicians, the PIM is an extremely useful and new tool. Some physicians do receive useful clinical data from insurance companies which collect some data based on individual payment claims submitted by the medico for each patient visit and treatment. Increasingly, the desire is that more straight clinical data (such every bit laboratory values and clinical exams) are nerveless by these physicians for the purposes of public accountability and, increasingly, pay for operation. But in the current world, this is not possible for about physicians to practise, except through something like the ABIM's PIM. ABIM will, nevertheless, requite credit to physicians who have robust enough information from some other source so that they are non so required to engage in redundant measurement in guild to maintain their certification. This reduction of redundancy and reducing the burden of measurement is a major commitment of the ABIM Board of Directors, and the flexibility around meeting the functioning assessment component of MOC is prove of that attempt. Some wellness plans, however, are seeing that the PIMs may be useful to them in pay-for-performance models and are exploring ideas of using these clinical measures for pay for performance. While ABIM would also requite credit for MOC, it is important to understand that the certifying boards are not in whatever mode involved in determining the amount or issuing payment for services.

Certification Boards and Physicians

These are a lot of changes and new requirements at a time when American physicians are feeling increasingly beleaguered by the growing bureaucratic requirements of the fragmented healthcare arrangement and, in the instance of primary care and generalist physicians, reduced payment for their services. How are they responding to these new rules for board certification? When the new requirements were initially announced, there was understandable opposition from physicians who see this as added, and possibly unnecessary, requirements. Over time, however, information technology appears that acceptance is growing as many of the boards - and ABIM, in item - accept fabricated a concerted effort to reach out and communicate to physicians, to behave research to improve the products and to demonstrate the relevance to practice.

For one thing, lath certification is no longer equally discretionary as information technology in one case was. Equally consumers and payers get increasingly interested in evidence of physician competence and quality of intendance, board certification, especially in its new manifestations, has growing relevance to that world. Thus, many physicians really feel that board certification is not optional. For many in the surgical specialties, hospital privileges depend on certification standards; and increasingly, hospitals are looking to lath certification even in not-surgical areas.¹⁷ Widely accustomed quality measures for health plans in the US include a pct of doctors with lath certification as 1 of their quality measures.¹⁸ Thus, lath certification exams come with higher stakes; and physicians are more motivated to maintain their certification. Since internal medicine certificates became fourth dimension-limited in 1990, the beginning wave expired in 2000. Thus, in the concluding five years of experience, information bear witness that 88% of specialists and lxxx% of general internists are enrolling for recertification. The findings of a contempo survey conducted jointly by the ACP and ABIM examined md attitudes about certification.^nineteen It showed a number of interesting things; the most common reasons physicians gave for enrolling in certification were professional image and quality of care rather than employment requirements or payment, suggesting that professional motivation yet is the primary commuter. Secondly, it too showed that physicians were much more likely to exist critical of the process -complaining that it was besides time consuming and not relevant to their practice - before they had gone through the process. More physicians agreed that the process was relevant to their practice afterwards they had completed MOC. The major complaint was still, nonetheless, the amount of time that it takes, an outcome that leads the boards to look increasingly toward ways to streamline data drove and strengthen the ability to recognize activities that physicians are doing with their societies or their grouping practices.

Conclusion

In summary, a combination of knowledge and do is required to maintain board certification in the Us. The boards are independent entities of peer review, without legal or regulatory status but with meaning bear upon in the market place. Given the legitimate public interest in rigorous doctor qualifications, it will be ideal if the profession itself can provide trusted and meaningful oversight.

Word

Billings, Billy Rouge: Chris, I enjoyed that. Nigh fifteen years ago equally a lifelong certificate holder I approached the lath to see what my liability was for recertification, and I was told that if I attempted the examination and was unsuccessful, that non only would I no longer exist certified, just I would have to retake the exam, and if I became successful, I would accept to then once again have to recertify.

Cassel, Philadelphia: I am really glad you asked that question. That is not true and is a common misconception among "grandfathers." The lifetime document will announced on the website as a lifetime document, and you never lose that. If you recertify, then you get an additional piece of information on the website that says recertified, such and such a date. We are actually moving with some of the public members of our board to talk well-nigh displaying, at the physician'southward asking, individual data most which quality or expanse the physician worked in for example. But it is very important that the lifetime certificate holders realize that they don't lose that lifetime certificate, which may behave meaning over time. I think one thing that is happening with the health plans is that they recognize that it is a unlike kind of certificate. Then for health program recognition, yous do have to enroll in maintenance of certification in order to get credit from them.

Billings, Baton Rouge: The other trouble that I call up a number of us confront is that I take a document in internal medicine, hematology and medical oncology, and I am not sure I have the muster to recertify for all three every ten years.

Cassel, Philadelphia: You are actually not required to do all three and that is why I showed y'all those data. A number of people voluntarily do recertify in the underlying certificate, but ABIM does not require that y'all recertify in the underlying internal medicine certificate in club to recertify in your subspecialty. Those exams actually include a off-white amount of specialty-relevant internal medicine in them, then at this bespeak, at least, that is non a requirement.

Billings, Baton Rouge: Thank you.

Cassel, Philadelphia: And so you lot should try information technology. It doesn't hurt.

Billings, Baton Rouge: I'm afraid to.

Ludmerer, St. Louis: Thank you, Chris, for that first-class presentation and very important work that you take been doing and are standing to practise. Information technology struck me that there could be a way out of the big dilemma that faces medicine, and it has to do with properly preparation physicians and making certain that they continue to do well, which is what you lot are doing now. The quality exercise of medicine has always been a thinking practice. You evaluate patients advisedly, and so you do things because they are indicated from the patient's circumstances rather than considering they are there to practise, and it is extraordinary reviewing doctor practice over fourth dimension how seldom we have accomplished that goal. Nosotros get things because they are in that location, non considering they are needed, and we see what the data evidence, and the merely difference in this regard betwixt medical exercise today and 1937 is that nosotros take a larger menu of things to choose from, and the things that we choose from toll more. I have always viewed this every bit a failure of medical education. Bob Brooks' work, which y'all very nicely cited today, confirms this. I would be interested in your view of what we can do in medical education to promote internists, or physicians in any field who truly perform in a cost-effective fashion, getting things considering they are needed without any harm to the patient. If you do less, you are doing more. Reducing costs, bringing uninsured people into it and what might be possible for boards to practice in measuring this aspect of physician performance, as I was very struck by your comments that the board is moving to evaluate non simply noesis, but operation. Is there any technical possibility of measuring this aspect of functioning? Certainly, if nosotros can measure information technology will be an incentive to people to practice more thoughtfully.

Cassel, Philadelphia: Well Ken, I have an reply that I hope volition please you as an educator, which is that we have some preliminary data in a collaboration that nosotros have with Elliott Fisher at Dartmouth, that now has really been funded past NIH for a major national report, suggesting that the people who perform at a college level on our exams accept better resources use and meliorate outcomes. Because of the kind of information that we are collecting, we will, of course, exist able to monitor that over fourth dimension. As you know, Elliott has these maps of geographic variation that are downwards to the Medicare neighborhoods now and the private dr., and and then he is able to lucifer that up with our data on doc functioning on the exams. So when you call up almost it, people who know more are much more probable to club the right test offset, go to the diagnosis start. Now they nonetheless are influenced by their regional pressures and payment policy and things similar that, simply at that place seems to be a remarkably rigorous consistency with noesis and efficiency of care. And so hopefully that written report volition exist published some time inside this twelvemonth. They are doing a whole range of studies with some of the inquiry staff at the Board. So stay tuned.

The other thing related to the question that someone asked earlier about the caring function that Abraham mentioned, and Abraham is a fellow member of our Board, is that nosotros use the CAHPS studies, which is the nationally recognized Consumer Assessment Health Plan Survey Assessment, every bit part of all of our exercise assessment; and at present all of the ABMS boards are using that tool. It is a pretty sophisticated tool of the patient's perception of the quality of their care, not just was the waiting room nice and did you go seen promptly, but did your questions go answered and did y'all feel respected, etc. So I recall we are going to have some pretty robust and consequent data beyond all of the boards very soon. Thank y'all.

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2394686/

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