ABIM: Maintenance of Certification – For the public

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.

ABIM: Maintenance of Certification – For the public 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.

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  • http://www.gruntdoc.com GruntDoc

    Expect “For the Public” to be the ABMS version of “For the Children”; it’s meant to shut down debate about whether the cost of the program has enough merit, and, frankly, whether there’s any evidence it does any good.

  • anonymous

    what about the grandfather issue? it is an embarassment that a generation decided that they would pass on a burden to the young that they were not willing to bear.

    i was under the impression the board certification was something that identified excellence, not competence. if so, why should we as a profession allow insurance companies and hospitals to deny payments or credentials based on presence or absence of board certification. it is easy to say that is none of the abim’s business, but are you working equally hard to defend the certification as a recognition of excellence to those entities?

  • Seve

    Remove proctored examinations and you’d find acceptance goes up. Make it an open-internet home examination. Have each yearly component worth a good amount of CME and acceptance would go up. Remove grandfathering. Do it ‘for the children’. Make all the geezers who are 80, still practicing medicine, and never recertified, recertify and acceptance would go up. Reduce the cost. Do it via cutting personnel at ABMS. Acceptance would go way up. Just a few helpful suggestions.

  • http://thehappyhospitalist.blogspot.com The Happy Hospitalist

    Can I take the nurse practitioner recertification instead, once no clinical difference exists in their practice limitations when compared with MD trained primary care physicians.

    Wait a minute. Is there such a thing?

  • http://www.drjshousecalls.blogspot.com Dr. Mary Johnson

    It always sounds like these guys/gals are trying to convince themselves of their own arguments – albeit with “non-scientific” polls.

    I totally do not mind doing CME (which I already do in order to maintain state licensure & hospital privileges). Likewise, I totally do not mind re-certifying (key prefix RE) . . . IF the process is not stressful (in other words, CAN the timed/closed exams – because baby, I already gave at that office) . . . kind to my schedule (since 30+ million more Americans are going to be on our schedules) . . . and inexpensive (because I’m sick & tired of being bled dry – by everybody – and being told it’s for my own good).

    In short, much like the process that was good enough the first time I re-certified for the ABP.

    But this jump-through-a-half-dozen-hoops-then-start-all-over-again garbage is for the birds.

    And yes anon, the grandfather issue spits in their own wind.

  • http://glasshospital.com John Schumann, M.D.

    “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…”

    She calls it “relevancy”; I call it “revenue.”

  • alex

    Just another tollbooth for forcibly extracting money in order to continue to work as a physician. Another cottage industry that will, in the fashion of true bureaucracy, slowly creep out and add more requirements and more expenses. Add it to the state licensing fees, board certification fees, USMLE step fees and all the others…

  • http://www.healthtrain.blogspot.com Gary Levin

    My comments are all of the above. All PCP and specialty face this conundrum. We pay medical license fees on California that are supposed to go to only medical licensing affairs. These funds are now tapped to make up for the financial incompetence of California’s legislature.

  • http://thehappyhospitalist.blogspot.com The Happy Hospitalist

    Here’s what I don’t get. If certification is “for the patients”, certification should be considered a marker for meeting the standards of excellent. Why then do we have board certified doctors being sued millions of times a year for failure to diagnose and other claims of malpractice.

    If board certification implies competence, should not the ABIM be sued for certifying doctors who are aren’t, when claims of negligence are brought about? Or should certification protect doctors from claims of negligence.

    How can we have a board certified physician also being sued for not practicing up to the standards of their scope of practice, when their board says they are. You just can’t argue both ways. Either the certification should protect physicians from claims of negligence or the certifying board should be sued for certifying negligent physicians when patients sue.

  • tgottsdo

    I’m in the process of recertifying with ABIM… unfortunately I had to let my certification lapse due to the cost. I simply couldn’t afford it. I think the ABIM modules are worthwhile and most importantly can be done on my schedule. Primary Care doctors are getting hammered from every direction… we need help from the Board not more hoops to jump through.

    BTW, 64% of American’s believe that aliens from outer space have visit our planet, 50% believe they have abducted humans and 34% believe they’ve contacted the US government… according to a CNN/Time poll. The point is why should ABIM care about a poll of people who have no concept of what the recertification process is and are just as likely to believe in aliens or that 9/11 was an inside job? The MSNBC poll means nothing other than the fact that the general public is ignorant to the reality of board certification… maybe you should educate THEM.

    If Board Cerfification is such a valuable service to the public why don’t you give it away for free?

  • BobBapaso

    When I have been referred to specialists I have never been told whether or not they were certified. I was just told the locations of their offices and when to be there. I have never asked and never noticed it posted on their walls. Though the walls were nicely decorated. That I am writing this suggests that their treatment has been effective.

    The public certainly wants its doctors to be as up to date as its airline pilots. But Pilots have a more effective and humane system. It is dictated by a federal agency, the FAA. They read books and get lectures, like we get CME, but they prove their ability by actually flying, a plane or simulator, with a certified examiner looking on, ready to save them both if the examinee blunders. And they get paid for their time.

  • Marc S Frager

    It seems very disingenuous for Dr. Cassel to comment that physicians in practice may balk at having to prove their ability to a certifying board. Perhaps the board is balking at proving its worth to those subject to its machinations. Furthermore, while Dr. Cassel feels that $170/yr is reasonable, she does not comment on the huge amount of money ABIM contributed to its foundation, whose only apparent purpose is to define “professionalism” as a physician who recertifies.

  • http://assiany@aol.com Martin

    I have recently recertified in my primary specialty of Internal Medicine to get specialty certification in Hospice and Palliative care. I wound NOT have re certified despite my time limited certification status had it not been for the fact that I could not sit for the hospice specialty board without certification in my primary specialty. I found the process of recertification arduous, expensive and completely irrelevant to my practice of medicine. I have a significant primary care practice, I care for my own hospital patients, I direct and care for patients on an inpatient hospice unit, and I am the Chairman of Medicine in my small urban community hospital. I give a grand rounds morbidity and mortality lecture once monthly, and attend grand rounds regularly. I supervise and train medical students, nurse practitioners and residents. No patient in 12 years of practice has ever asked me if I am Board Certified, and the certificate is not hanging in my office. I agree 100% with the second opinion in the NEJM. The process is flawed and needs to be completely revamped. In these difficult financial times for hospitals and doctors, it is utterly disingenuous that for more that one thousand dollars and countless hours spent studying which comes out of practice and family time that the ABIM cannot prove their case in an evidence based fashion. It clearly displays how out of touch the ABIM is with the realities of the practice of Medicine in 2010. Moreover, that the board can pocket such exorbitant fees at tremendous profit without expending a dime on adding to the literature in an evidence based fashion that the recertification process is worthwhile shows how unfair the ABIM’s monopoly on internal medicine truly is. Given the fact that most quality of care issues in hospitals are dependent on physicians, and the public outcry for better performance, it is time the ABIM took a dose of its own medicine.