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Regents explore recertification concerns, solutions

After hearing the objections of Governors and members, College officials adopted five resolutions

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

By Phyllis Maguire

Atlanta—The contentious issue of recertification dominated much of the discussion at this year’s Annual Session, leading the Regents to adopt five new resolutions designed to address internists’ complaints about the process.

In meetings throughout the week, College leaders turned to the Board of Governors and Annual Session attendees for their feedback on recertification. College officials said they were impressed by members’ insistence that ACP–ASIM take a forceful stand against the current recertification process and the continuing professional development (CPD) program that the American Board of Internal Medicine (ABIM) has proposed.

Young physicians and College Governors voice concerns about the burdens of recertification and the disparities it creates among physicians.

At the Board of Governors meeting just before Annual Session, several Governors said that members support recertification—but only if the process is simplified or reconfigured. “Even if we agree with the need for recertification, much depends on how it is done,” said Faith T. Fitzgerald, MACP, outgoing Governor for the Northern California Chapter. “It can’t proceed by penalizing young physicians and removing them from time spent with patients.”

Dr. Fitzgerald’s comments echoed the sentiments of many members and Governors. At a combined meeting of the Board of Regents and Board of Governors held the day before Annual Session officially began, several Governors explained just how seriously their members take recertification.

“It was clear that the outcry from members is unique in College history,” said Herbert S. Waxman, FACP, the College’s Senior Vice President for Education and staff member on the Joint Committee on Recertification. (The committee includes College and ABIM representatives.)

“This is not an abstract issue,” he said, “but a galvanizing one that affects every member personally.” Dr. Waxman said that College Governors pointed out that even mem­bers who are “grandfathered” and aren’t required to recertify worry that they may end up facing local pressure to get recertified and be caught up in the complex CPD process.

Member feedback

At a session presented on the CPD pro­gram, a panel of ABIM officials tried to explain the rationale behind this next version of recertification. (For more about the CPD process, go to www.acponline.org/journals/news/nov00/recertification.htm#redesign.)

“Can we guarantee that this process will improve the quality of care?” asked panelist and ABIM board member James L. Naughton, ACP–ASIM Member. “No, we can’t. But what we’ve seen over and over again in a variety of settings is if you measure physician performance, it gets better.”

Despite the panelists’ explanations, more than a dozen physicians in the audience sharply criticized the ABIM’s recertification process. Several young physicians who have successfully recertified complained that the self-evaluation questions were ambi­guous, clinically irrelevant and filled with questions about conditions that they would routinely refer to subspecialists.

One physician said that she has had to postpone a research project to devote time to recertification. Another phy­sician claimed that answers to knowledge-based questions were sometimes supported by one medical textbook but not others.

Several physicians who do not work in typical practices—hospitalists, administrators and researchers—said they are worried that they won’t be able to complete the ABIM’s proposed peer and patient review module because they don’t have standard patient groups. Another young physician commented that recertification is leading younger physicians to view their older colleagues “with skepticism as to whether they are giving good care.”

Several College leaders also addressed the ABIM panelists. Yul D. Ejnes, FACP, Governor for the Rhode Island Chapter, said that several of the ABIM’s assessment modules would force him to repeat many of the efforts he has already gone through for local health systems.

He explained that during the last five years, he has been credentialed twice by his hospital, a process that included peer review. He said he has gone through two managed care credentialing processes twice each, and experienced at least one site visit by a health plan.

His use of mammograms and beta blockers has been examined several times, while relicensure proceedings reviewed his CME credits. Insurers and even his own practice have also performed several patient satisfaction surveys.

“Even if CPD has value—and that’s not been proven—does that justify the duplication of effort and utilization of resources that CPD calls for?” Dr. Ejnes asked. “Many of us are not convinced that it does.”

Dr. Naugton explained that the ABIM may accept other credentialing measures to help physicians avoid such duplication of efforts. He noted, however, that the measures used by other organizations do not always use a large enough sample size or the same measurements as some of the ABIM’s assessment modules. As a result, he said, the ABIM may be less willing to accept them as substitutes.

Nathan Erteschik, FACP, Governor for the U.S. Army Chapter, claimed that members of his chapter feel that recertification for internal medicine is more rigorous than for other specialties. He urged the ABIM to work with the American Board of Medical Specialties to develop a standard recertification process.

And C. Scott Smith, FACP, Governor for the Idaho Chapter, said that half of his young chapter members say they are not planning to recertify. While he admitted that several would probably capitulate when faced with the prospect of losing hospital privileges, he noted that he was concerned that many physicians—particularly in the underserved area he represents—will opt out of recertification and be “disenfranchised and decredentialed.”

Regents’ actions

Toward the end of Annual Session, the Regents adopted the following resolutions to address concerns about recertification:

  • The Regents reaffirmed their support of a recertification process that includes an assessment of professional knowledge;

  • The Regents support a recertification process that provides “maximum” choice to physicians to further their continuing medical education and prepare for recertification assessment;

  • The Regents support a policy whereby education and certification are separate processes to be undertaken by different nonprofit organizations;

  • The Regents continue to authorize College representatives on the Joint Committee to negotiate with the ABIM;

  • The Regents want representatives from the Joint Committee to present a recommendation at the Board’s July meeting on whether the College should endorse ABIM’s recertification program.

The Board also directed College staff to undertake several projects related to recertification. The Regents asked staff to conduct a telephone survey of least 600 College mem­bers to poll them about their opinions on recertification and ask what is happening locally on the issue. The Regents heard anecdotal evidence, for instance, in­dicating that some hospitals may maintain privileges of physicians who do not recertify.

The Regents also directed College staff to find out how physicians with “grandfathered” certificates will be listed on the ABIM Web site. Comments made by the ABIM panel at the CPD session gave some College leaders the impression that the ABIM site would claim that internists without time-limited certificates had opted out of recertification, perhaps reflecting negatively on physicians who don’t need to recertify.

College staff was also charged with assessing the implications of discontinuing the continuing medical education credit the College now offers for the certification and recertification processes.

Dr. Waxman said that he believed Annual Session had been an educational experience for ABIM members, as well as for College leaders. “It’s very clear to the ABIM that the College has to respond to its members,” Dr. Waxman said. Before Annual Session, he explained, the ABIM may have been under the impression that the College’s major concern was keeping educational concerns—and potential revenue—separate from the certification process.

“After the Atlanta meeting,” he continued, “they are now very aware that the College’s No. 1 concern is to ensure a recertification process that is beneficial to the professional development of our members and to the quality of care they’re delivering.”

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