ABIM's plans to keep certification—and itself—relevant
Faced with competition in measuring physicians, the Board is making landmark changes
From the December 1997 ACP Observer, copyright © 1997 by the American College of Physicians.
By Jennifer Fisher Wilson
From his 17th-floor office at the American Board of Internal Medicine (ABIM), Harry R. Kimball, MACP, has a sweeping view of Philadelphia's medical institutions both old and new. It is from this vantage point that Dr. Kimball, ABIM's president, is guiding the 61-year-old credentialing organization onto a new course.
Besides limiting its certification to 10 years, the Board has recently taken a stance on practice issues such as professionalism and clinical issues like proficiency testing. ABIM has even formed a new group, the Institute for Clinical Evaluation, to test for proficiency in clinical skills and maintain standards.
In the increasingly competitive health care environment, Dr. Kimball said, it's up to venerable organizations like the ABIM to more aggressively promote quality medicine. In doing so, Dr. Kimball is also hoping to provide the Board with an increased leadership role in internal medicine.
Dr. Kimball, an allergy and infectious disease subspecialist, has been president of ABIM since 1991. Before that, he held leadership roles at the National Institutes of Health and the New England Medical Center. He talked with ACP Observer about changes at the Board.
ACP Observer: How is the role of board certification changing?
Dr. Kimball: For many years, Board certification was mostly an accolade, a personal academic achievement that had little relevance to medical practice. For example, when I completed training in the 1960s, only half of my fellow residents expressed an interest in becoming certified, and during 14 years of private practice in the 1960s and 1970s, I was asked only twice by patients whether I was board certified.
Today, the situation is very different. Hospitals and health care systems are keenly interested in a physician's certification status. The Board is aware that certification is being used in some institutions as an entry requirement for employment, despite ABIM's protestations that certification should not be the sole criteria for granting clinical privileges.
Q: How many internists are board certified?
A: We can only track those who apply for certification. At present, in excess of 95% of graduating internists apply to sit for the certifying examination. Last year, the pass rate for first-time takers was about 81%, but ultimate pass rates are in excess of 90% when repeat attempts are factored in. The pass rate for the first group of internists completing the Board's new recertification in 1996 was 93%.
We do not know the precise number of clinically active internists who are not board certified, since we can only track those who have applied at one time or another. Our best estimates are that between 15% and 20% of the nation's 120,000 internists are not currently certified.
Q: What effect will new ABIM programs like recertification have on internists?
A: The Board expects the first big wave of internists to apply for recertification in 1999 or 2000, but thus far reactions have been very positive. The Board anticipates the vast majority of internists will choose to remain certified throughout their careers, meaning that they will interact with the Board on two or three occasions during their professional lifetimes.
Q: Why didn't ABIM require all internists to recertify?
A: For 56 years, the Board issued certificates without any stipulations or limitations whatsoever. In our opinion, it would be neither fair nor appropriate to do so post hoc. The Board recognizes that this creates different rules for internists depending on when they were certified, but this is a transient problem that will disappear over time. The Board anticipates that many internists with non time-limited certification will choose to voluntarily recertify.
Q: How does ABIM fit in with new credentialing programs such as the AMA's American Medical Accreditation Program (AMAP) and the American College of Cardiology's (ACC) proficiency testing?
A: We anticipate there will be confusion about the terms certification and accreditation, and to a lesser extent, proficiency testing. These credentials and processes are very different.
For the purposes of verification, AMAP seeks to consolidate professional credentials in one place and in that respect, I think the program is a step forward. AMAP also plans to accredit individual physicians who earn enough points to complete a series of personal and practice oriented requirements.
The Board has serious concerns about the minimal standards proposed for granting this accreditation status. For example, an internist or cardiologist can be accredited, even in the absence of any formal training in either discipline. It's hard for me to believe that a knowledgeable public or profession will consider this standard credible. The ABIM is still considering what relationship, if any, it should have with this new accreditation program.
Proficiency testing is another matter. Last year, the ACC introduced rigorous proficiency testing and credentialing in ECG interpretation that was open to all physicians. Proficiency testing examinations have been offered by other organizations, but to my knowledge this is the first time that a stand-alone evaluation/credentialing program has been offered by a mainstream professional society in internal medicine. The Board believes the idea deserves serious consideration.
Q: Why are so many organizations getting involved in credentialing?
A: The main reason is that the public is demanding that physicians and health care systems be more accountable. Patients are better educated about how the medical system works and are less tolerant of unexplained variations in clinical outcomes.
A second explanation for the increasing number of credentials is that they provide a competitive advantage to physicians who have them. This is very important in areas of the country where there is a surplus of physicians and competition for clinical positions.
Q: With so many organizations measuring and accessing doctors, what can the Board do to keep relevant?
A: To remain relevant, the Board must work harder to set high standards that improve the quality of care available to our patients. To survive in the 21st century, certification must be more than just a personal accolade, it should be predictive for the potential for higher quality patient care and it must be of acknowledged value both to diplomates and the profession.
There appears to be a growing need for a mechanism to develop and administer skill-specific proficiency examinations in internal medicine that offer clinicians meaningful practice credentials. Several months ago, the ABIM decided to create, through its Foundation, an independent non-profit organization called the Institute for Clinical Evaluation (ICE), which will assess the usefulness of proficiency testing to the profession.
In this context, ICE has the potential to positively influence the development of these standards. At the same time, we can be sure they are compatible with broad-based certification and recertification programs. The Board thinks that ICE can develop collaborative arrangements with professional societies to bundle education and evaluation into a single process. This process would be educationally efficient, credible to patients and acceptable to agencies and institutions responsible for the health and safety of the public.
For the recertification program, the Board is developing a series of practice-assessment modules that allow diplomates to assess their preventive practices, receive feedback from patients and their colleagues about the quality of their professional services and assess the effectiveness efficiency of their clinical practice. The first of these modules is on clinical prevention and will become available this month.
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