Strategies to help you prepare for recertification
By Jason van Steenburgh
Recertification has been a great source of concern for internists for the last few years. While the College and the American Board of Internal Medicine (ABIM) are working to add flexibility to the recertification process, the current process continues to require patience and a significant investment of time.
Several thousand internists have to recertify this year and the same number will have to do so next year. Internists who have recently recertified shared their strategies to prepare for and survive recertification.
Step one: self-evaluation
The first step of the process involves successfully completing five open-book, take-home self-evaluation process (SEP) modules. (Internists also recertifying in a subspecialty must complete a knowledge module in that subspecialty.) The modules can be completed and returned at any time during the 10-year recertification cycle.
According to ABIM officials, the modules are designed to test internists' clinical judgment and help them stay current. Many SEP questions highlight new and often controversial material, such as new drugs and new clinical approaches.
To get through the SEP modules, physicians offered these tips:
Pace yourself. Physicians who've been through the recertification process agree: It is essential to start early and pace yourself. Not only will you learn more, but you'll also find the process less painful.
Mark J. Mullen, ACP-ASIM Member, who practices in southeastern Pennsylvania, gave himself a year to complete his five SEP modules. He took two months to research and finish each module, waiting for the ABIM to send his graded results before beginning another.
"It was steady, a nice pace, and I didn't feel pressured," he said.
Many physicians set up a specific schedule to work on SEP modules. For instance, Glenn S. Ross, FACP, a general internist in Newport News, Va., set aside Saturday mornings to work in a local community hospital's medical library. (He said he spent about eight Saturday mornings there over several months.)
Jonna L. Schmidt, ACP-ASIM Member, a solo practitioner in Hudson, Mich., also did most of her SEP work on Saturdays. But "if a question required detailed investigation," she said, "I would allow up to 30 minutes of 'information search' each weeknight when I got home." Oncologist Nevena Damjanov, MD, assistant professor of medicine at Philadelphia's Fox Chase-Temple Cancer Center, tried to devote one hour a day to working on the open-book modules.
Work your sources. While seeking answers to SEP questions, physicians say you'll need easy access to colleagues, the Internet and a medical library.
Louis A. Orlando, MD, a general internist with Jackson County Medical Group in Independence, Mo., relied on what he called "the subspecialty bibles": Harrison's "Principles of Internal Medicine," Braunwald's "Heart Disease: A Textbook of Cardiovascular Medicine" and Mandell's "Principles and Practice of Infectious Diseases."
Dr. Damjanov used a chain of references that worked well for her. "If it was a straightforward internal medicine question that I just don't know because I don't face it often, I went to 'The Merck Manual [of Diagnosis and Therapy]' first," she said. "If I didn't see the answers there, I went to Harrison's, and after that, PubMed or MedLine."
Make sure you match the complexity of your source material to the particular module you're working on. Michigan's Dr. Schmidt, for instance, said she tried to answer questions on the infectious diseases subspecialty SEP module with the internal medicine MKSAP, and found it wasn't in depth enough.
Like other recertifying internists, Missouri's Dr. Orlando spent a lot of time trying to get subspecialists' help with tough questions. He recommended that you spread your subspecialist SEP questions around.
"After a while, I felt like they were running away from me," he said. "They couldn't answer a lot of the questions either, even though that was their specialty area."
Join forces. Some physicians prefer the solitary "lockdown" approach to completing modules. Dr. Damjanov, for instance, holed up in a cabin in Kansas for a week's "vacation," working on the required modules for her triple-header recertification in hematology, oncology and internal medicine.
Others, however, find strength in numbers. Mario Littman, FACP, a solo practitioner in Philadelphia, teamed up to do modules with a senior resident who was studying to take the boards for the first time.
"Our strengths on different topics like infectious diseases or cardiology complemented each other," he said.
Dr. Orlando was part of a four-physician study group that met monthly for three hours. He said the group was by far his most valuable resource in getting through the modules. Group members who completed many of the same modules divided up research on tough questions to work through the modules more efficiently.
Julie Taylor, FACP, a hospitalist at Grand Strand Regional Medical Center in Myrtle Beach, S.C., formed a four-physician study group, and said she's glad she didn't try to go it alone. Each group member completed a module alone, then they met to discuss their individual answers.
Dr. Taylor noted that the group approach had one drawback, given the legendarily difficult nature of many of the knowledge-based module questions: conflicting information. For one tough endocrinology question, for instance, each group member asked a different endocrinologist—and each got a different answer. That made it very frustrating when it came time to pool information.
The way ABIM grades the modules also didn't advance the group's education, Dr. Taylor said. "You never find out why your answers were wrong," she said. "They should send a booklet than explains the answers when you finish."
If you don't have other recertifying physicians in your practice or town, try working with former colleagues from residency or medical school via e-mail or Internet chat rooms.
Pick and choose. If you're pressed for time, the following strategies can help you optimize the time you do have.
First, consider doing fewer of the more time-intensive medical knowledge modules. According to the ABIM, physicians report spending an average of 16 hours on each medical knowledge module, but only eight hours each on the clinical skills and practice improvement modules. (Several physicians say those estimates are low, and claim they worked nearly 30 hours on each medical knowledge module.) Since only one of your five modules has to be knowledge-based, you can choose other module types to meet the requirement.
Another approach for those who are under the gun is what ABIM president Harry Kimball, MACP, called the "quick-and-cold" method. Choose your modules and answer the questions with minimal or no research. You may in fact pass the module. If you don't, you can either choose another module that might be easier or re-take the one you failed as many times as you need to.
"This strategy allows you to focus on the questions you missed," Dr. Kimball said, pointing out that the questions you get wrong are a good indication of what you need to study in the time you have left. "The 'quick-and-cold' approach forces you to concentrate on areas where you might not know as much as the Board thinks you should."
You'll get pass/fail feedback even faster from the ABIM if you complete modules on CD-ROM and submit answers electronically. But Philadelphia's Dr. Mullen offers this caveat: If you choose the CD-ROM, you're limited to working in places with computer access. He used the traditional booklets instead—and found he could pull them out whenever he had a few spare minutes.
Of course, physicians can also choose modules to fill in knowledge gaps or to learn more about an area of internal medicine they find intriguing. Michigan's Dr. Schmidt, for instance, is a general internist who chose to complete subspecialty medical knowledge modules in hematology, infectious diseases and cardiology. Those modules not only taught her about less familiar topics, but have also helped her take better care of patients.
"I live in a rural area where there is no infectious diseases expert within 40 miles," she said. "Doing that module prepared me to face problems that have come up since."
Step two: the exam
The second step in the process involves preparing for and passing a six-hour secure exam consisting of three modules, each with 60 multiple-choice questions. The exam is offered twice a year in more than 40 sites across the country. Unlike the SEPs' focus on cutting-edge details, the exam is geared toward general medical principles and a wide variety of medical problems.
Some physicians suggest taking the exam at least six to 12 months before your certification expires. It will not only reduce your stress level, but also gives you a chance to retake the exam if necessary without endangering your hospital privileges or health plan credentials. You won't "lose" years by taking the exam early: Your recertification will begin the year that your original certification expires.
Dr. Taylor voiced what seems to be the general consensus among internists: "The written exam is much easier than the modules," she said. "It was more clinically pertinent, and the questions were more reasonable." To prepare for the exam, Dr. Taylor and members of her SEP study group worked through MKSAP, and they all passed.
Just as with the SEP modules, internists say the key element to exam preparation is time. According to ABIM officials, doctors report spending an average of 32 hours preparing for the exam. Dr. Schmidt, however, recommends more.
"I put in a good 50 hours to make sure that I passed," she said. "I'd hate to put in 30 hours and fail by just five questions."
To get ready for the exam, many physicians opt to take preparatory courses designed specifically for recertification or for the initial board exam. For more information on courses, see "Recertification resources."
Philadelphia's Dr. Littman chose the Johns Hopkins Internal Medicine Board Review course that met seven days, from 7 a.m. to 6 p.m. The course cost "under a $1,000," he recalled, and was so informative that he might take another one soon, even though he doesn't have to recertify again until 2010. (Dr. Littman also took the week off before the exam, going over MKSAP and his Johns Hopkins' review material.)
Janelle A. Rhyne, FACP, Governor for the North Carolina Chapter, also took a board review course. "It gave me a week away to study," she said. "If I'm at home or in my practice, there are so many distractions, it's hard to sit down and do the work that's required."
Taking a course also helps build confidence, said Douglas Paauw, FACP, Governor for the Washington Chapter and professor of medicine at the University of Washington School of Medicine, who directs the College's San Diego recertification course.
"Review courses help people realize that they know a lot of the material," he said. Particularly helpful is the audience response system, where internists use keypads to answer case-based questions. That allows them to see which questions they get right, as well as what they need to study further.
But if taking a review course just isn't in the cards, don't panic. Mahendr S. Kochar, FACP, who runs the College's recertification course in Chicago, recommended MKSAP to help prepare for the exam. "Read the book, do the questions and read the critiques," he said. "If you run out of time, at least do the questions and critiques."
Dr. Paauw urged physicians to pick one good source of material that has plenty of case-based practice questions such as MKSAP or MedStudy. Physicians should also get themselves up-to-date on published guidelines for conditions they see every day.
"A number of exam questions will likely focus on back pain, headaches, hypertension and asthma," Dr. Paauw said. "You should know the agreed-upon guidelines and how to competently treat these conditions."
Finally, once you get word that you've successfully recertified, verify it online at www.abim.org/dp/apps/physdir.htm. The Board doesn't always post results instantly. That delay has led some hospitals to revoke privileges when doctors were no longer listed as certified.
At the end of the long recertification road, do internists feel a sense of satisfaction or accomplishment? Does the process enhance collegiality among peers or give physicians a wealth of new medical insights? For most, the answer was "no." The College and the ABIM are working hard to reshape the process because many feel the SEP material still has a way to go to be relevant to practicing physicians.
In the midst of this "very frustrating process," Missouri's Dr. Orlando said he sees his role as a pioneer.
"We're the first group of internists who can point out the problems in the process so it can change," he said. "By working through it, we can perhaps improve it for the physicians who come after us."
The College now holds four recertification review courses a year, in Philadelphia, Chicago, Orlando, Fla., and San Diego. The cost is $530 for members. For more information, see www.acponline.org/cme/acpcours.htm.
The College also sells "The Core of Internal Medicine: Recertification Preparation Course," a 10-videotape set that covers an Annual Session presession course on recertification. .
MKSAP 12 and MKSAP Prep for Boards remain the College's premiere products for both certification and recertification.
MedStudy provides an internal medicine board review course that many physicians recommend for recertification. See www.medstudy.com.
Stein's "Internal Medicine, 5th edition," a comprehensive internal medicine resource, can be purchased in book or CD-ROM format at www.ramex.com/mo/mo-inte7.html.
"The Merck Manual of Diagnosis and Therapy" is a good resource for finding answers to self-evaluation process modules. See www.merck.com/pubs/mmanual/.
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