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ABIM responds to concerns about recertification

From the January 2001 ACP-ASIM Observer, copyright 2001 by the American College of Physicians-American Society of Internal Medicine.

David R. Dantzker, FACP

Competence and accountability are critical components of the social contract within which medicine functions as a profession. In this context, the article on recertification in the November issue of ACP-ASIM Observer was disappointing. ("As recertification deadline nears, concerns keep growing," November ACP-ASIM Observer, page 1.) It sends the message to an already skeptical public that internists support assessment processes only if they are fast, easy and have negligible consequences for poor performance.

I would like to address some of the points made in the article.

Recertification today

  • Inconvenience. The Board is sensitive to concerns about inconvenience, particularly for diplomates in smaller communities who must travel to distant examination centers. Currently, the Board administers two recertification exams and one certification exam a year in 54 centers nationwide at a cost of $1.3 million. To maintain security and minimize costs, we use testing centers that will draw large numbers of candidates.

    The best solution to concerns about inconvenience would be to administer computer-based testing in smaller centers. While today's testing centers can not yet handle the Board's sophisticated examinations, rapid advances will make computer-based testing a reality in the not-too-distant future.

  • Relevance. Relevance is essential for any recertification program. Instead of relying on anecdotes from individual internists, however, it is more helpful to review the anonymous responses of diplomates who have completed recertification. (See below table)

    More than two-thirds of diplomates who went through recertification between 1996 and 1999 said they regard the program (and the self-evaluation process, also known as the SEP) as having personal and professional value. This result is not unexpected when you consider that more than 2,000 diplomates helped develop the questions and that an independent panel of practitioners vetted the material for relevance.


ABIM data on how internists view recertification
The following data come from a survey of 1,760 ABIM diplomates who went through recertification between 1996 and 1999.

Agree / strongly agree Neither agree / disagree Disagree / strongly disagree

The self-evaluation process was a valuable overall learning experience.
80% 12% 8%
Self-evaluation questions were reflective of clinical advances during the past decade. 74% 18% 8%
Self-evaluation questions were appropriate for assessing up-to-date clinical knowledge. 68% 21% 11%
Recertification was important in terms of personal value. 78% 13% 9%
Recertification was important in terms of professional value. 71% 19% 10%

  • Time. The ABIM understands that the time required to complete recertification is an important issue for busy internists. Diplomates who have gone through the process reported that they spent an average of 15 hours to complete each SEP module. Assuming that internists spend 40 hours preparing for the examination, the recertification process requires about 100 hours to complete.

    Is this too much time to devote to a process that can be spread over 10 years? The Board doesn't think so, given the importance of certification to health care organizations and the ABIM's obligation to publicly attest to the qualifications of diplomates. In fact, some may question whether 10 hours a year is too little, given growing concerns about quality, and patient safety.

  • Pass rates, CME and cost. In the May 2000 examinations, 94% of first-time takers passed the test (out of 1,135 diplomates). This high pass rate is testimony to how well internists are trained and how well they keep up with new medical knowledge.

    The Board has steadfastly resisted requests to provide a syllabus, references or rationales for answers to SEP questions because we acknowledge that such CME is the responsibility of specialty societies and other institutions. The ABIM has made available all 3,240 SEP questions to organizations to guide their CME development.

    ABIM diplomates have consistently asked to receive CME credit for recertification. Although the AMA's Physician's Recognition Award has always been available to diplomates who complete the process, ABIM last year worked with the College to provide up to 102 hours of category 1 CME credit for recertification. The Board has absorbed the substantial cost of this option ($165,000 in 2000).

    ABIM recertification fees ($895 in 2001) compare favorably with other large specialty boards. In 1999, recertification cost $725 for family practice, $1,080 for pediatrics, $1,125 for psychiatry and neurology, and $1,450 for ob/gyn. (Certificates remain valid for seven years for family practice and pediatrics, and for six years for ob/gyn.) High-stakes programs demand high-quality evaluations that are expensive to develop and administer.

The future of recertification

In January 2000, the Board announced its revamped recertification program, Continuous Professional Development (CPD), which will be phased in over the next five years. It has three main features: a multidimensional approach to assess competence, a more continuous process and the inclusion of continuous quality improvement principles in the self-evaluation process.

The Board made these changes because of public concern about physician quality, as well as diplomates' requests for a more relevant process. Recently, the American Board of Medical Specialties, the umbrella organization of the nation's 24 certifying boards, also mandated the following components for recertification: evidence of professional standing; cognitive expertise; lifelong learning and periodic self-assessment; and evaluation of practice performance.

  • Education vs. evaluation. The multidimensional nature of CPD has led some to question whether the ABIM has exceeded its mandate to evaluate the competence of internists and internal medicine subspecialists. In the Board's view, competence requires evidence that medical knowledge and clinical and communication skills are consistently applied in patient care.

    While these elements are difficult to evaluate, the quality improvement model industry has adopted can help accomplish this task. Inherent to this model is the notion that constant feedback about individual performance, paired with appropriate norms, will lead to better overall performance.

    Quality improvement processes cannot be neatly separated into traditional education or evaluation paradigms. Recognizing this, the Board has invited societies to help in develop clinical performance components of the CPD program. The result should be better educational materials linking medical knowledge with clinical performance.

  • Self-evaluation. At first glance, the CPD program may seem daunting, but it is more efficient and less time-consuming than the current self-evaluation process. CPD has been designed to be completed at two-year intervals. The goal is to help diplomates avoid the stress of having everything pile up at the end of their 10-year certificate.

    The Board estimates that the five required modules will take an average of five to 15 hours each to complete. Once multimedia and Internet technology are incorporated into the process, we will be able to provide nearly instantaneous, confidential feedback.

    The ABIM recognizes that redundancy is a serious concern and is meeting with the Joint Commission on Accreditation of Healthcare Organizations, the National Commission on Quality Assurance, third-party payers, medical societies and large health care systems to determine how CPD evaluations can be coordinated with the requirements of other organizations. The Board expects to make significant headway in achieving the ultimate goal of a universal evaluation system.

Conclusion

Our profession is in the midst of great change. The information revolution, combined with a national commitment to improve health care quality, presents a serious challenge to the profession, one that we ignore at our peril. Now is a time for leadership and a time for the specialty to embrace, not resist, the public's call for greater accountability and quality improvement. Continued scholarship and self-evaluation are key to our growth as physicians and to our responsibilities as professionals. n

Dr. Dantzker is the 2000-2001 chair of the ABIM and professor of medicine at Albert Einstein College of Medicine in New York.

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