A guest column by the American Board of Internal Medicine, exclusive to KevinMD.com.
by Christine Cassel, MD, MACP
The debate about recertification recently in the New England Journal of Medicine and highlighted earlier this week on KevinMD.com and in an Associated Press article brings to light some of the real challenges facing the future of the Maintenance of Certification (MOC) program.
I have been through the program – recertifying in geriatric medicine in 2005 – and I think it was worthwhile, but I agree that the program can still be improved. Many of the thoughtful comments by physicians in the Journal will help the American Board of Internal Medicine (ABIM) to improve and increase the relevancy of the program for physicians.
But left out of the debate is a key issue. The Journal posed the question — should a 55- year old physician – board certified in endocrinology – and practicing for the last 24 years – participate in ABIM’s MOC program? In an online vote 63% voted against the physician recertifying. MSNBC, in response to the AP story issued its own web survey. A large majority – 80% said yes, all doctors should be required to take tests to renew their certifications.
How do you explain the difference? Well, the respondents in the Journal poll were primarily doctors; the majority in the MSNBC poll, were the general public and non-physicians. Of course, neither poll is scientific, but the results reflect a challenge that those of us at the certifying boards face on a daily basis: while we are of the profession, we are for the public. Board certification and MOC is a marker for the public to know that their physician has met a standard in a particular subspecialty of care. And it is this process that allows the profession to self-regulate – rather than having an outside governmental body determine physician standards, as is the case in many countries.
As we know, medical licensure focuses on general medical knowledge – and does not address competence in a particular specialty and does not differentiate between subspecialties. Any physician in the U.S. can call themselves an endocrinologist and treat diabetic patients. However, not every physician can say they are “board certified” in endocrinology. Only those who have met – and are maintaining – a standard of knowledge in the field are able to do so.
Following the example set by other certifying boards, such as family medicine, surgery and emergency medicine, internal medicine established an MOC process in 1990. Recognizing that what was standard treatment a decade ago may have changed, and that the public needs a process to know if their physicians have kept up to date in their field internists and its subspecialists are now required to maintain their certification every ten years.
The process to maintain certification is labor-intensive and requires physicians to not only take and pass an exam but complete a self-assessment of their practice data, and develop and implement an improvement plan. Physicians are already very busy and this adds to the significant reporting they already need to do for Medicare, insurers and others. So we continue to look for ways to reduce redundancy. For example, we are making progress in MOC being part of PQRI and we have begun to give credit, through our Approved Quality Improvement (AQI) Pathway to give physicians MOC credit for work they are already doing.
While maintaining certification does take time and costs about $170 a year, it is an important marker of physician competency for the public. And a good deal of research not only makes the case for regular recertification, it links the process to improved patient care.
Of course some physicians who have been in practice for a long time may balk at “proving” to a certifying board what they feel they do every day in practice. The commentators in the New England Journal also argued that recertification requirements do not reflect physician’s practice and the exams are just about memorizing facts. Our exams, developed by physicians in practice and in academic medicine and validated through research studies by a staff of psychometricians, assess essential diagnostic reasoning skills: evaluating whether a doctor can put together the patient’s story and symptoms, make the right diagnosis, and provide the right care. Can the process be improved? Absolutely. But MOC is a critically important self-regulatory program that gives the public vital information about their physician.
While it is true that the majority of physicians in practice are knowledgeable and skilled, it is an unfortunate fact that some are not. There are some who may say they are cardiologists, but have not been board certified in that field; there are others who have not kept up with the latest treatment advances in their subspecialty; and still others who don’t have the knowledge and judgment to effectively practice. MOC is the signal for patients that their doctors have kept up to date, understand the current medical advances and have met a standard for knowledge in a particular subspecialty. The ABIM MOC program lets patients know which physicians have maintained professional standards of knowledge and judgment over time – and those who have not.
Christine Cassel is President and CEO of the American Board of Internal Medicine.