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A look at ABIM, recertification and quality measures

The Board's new leader says the specialty needs to take the lead in measuring physicians before someone else does

From the October ACP Observer, copyright © 2003 by the American College of Physicians.

By Phyllis Maguire

In her 25-plus year career in medicine, Christine K. Cassel, MACP, has worked as a geriatrician, an academic administrator and a policy-maker in advancing the national push for quality improvement. In her newest role as president and chief executive officer of the American Board of Internal Medicine (ABIM) and the ABIM Foundation, she plans to tap into all of those experiences.

Dr. Cassel has taken the helm of the ABIM at a time when American medicine is struggling with how to measure—and reward—physicians for the quality of care they provide. As the single most important body certifying internists, the ABIM has a unique opportunity to influence exactly how internists are measured. The ABIM is also the largest of the 24 boards that are part of the American Board of Medical Specialties (ABMS), an organization that itself is looking to play a key role in the growing movement for quality standards and measurements.

The ABIM's role in measuring physicians, however, does not come without risks. The Board has already, for example, felt internists' frustration over its wide-ranging recertification process. Known as continuous professional development (CPD), that process attempts to not only evaluate internists' knowledge, but also engage physicians in quality improvement activities.

The organization is now working with internal medicine specialty societies to broaden the educational appeal of its recertification process. And while Dr. Cassel acknowledged that internists who feel overwhelmed by growing paperwork and waning reimbursements may not welcome new performance measures, she argued that medicine needs to get involved in the process. Doing nothing, she said, will simply open the door for other organizations to monitor physicians' performance.

Dr. Cassel spoke with ACP Observer about her new position with the ABIM, and how she envisions the board's certification programs fitting into the growing demand for quality standards.

Q: How has your past career prepared you for some of the challenges that lie ahead?

A: I initially looked at quality from my perspective in medical ethics, but it's increasingly become a much broader issue of professional accountability. At the ABIM, I have an opportunity to work with other medical organizations to help shape how physicians respond to the consumer demand for accountability.

One of the reasons I was so pleased to take this role was because it seemed to be a convergence of all the things I care the most about. Those include the profession of medicine and the important challenge to professionalism that we all face.

The ABIM and the ABIM Foundation have made a concerted effort to promote those fundamental values. We have also tried to modernize those values, largely through the international charter we created with the ACP Foundation and the European Federation of Internal Medicine. (More on the charter is online.)

Q: What link do you see between professionalism and recertification and quality measures?

A: We expect our recertification process to allow physicians to meet the requirements for maintenance of certification. At the same time, however, physicians need to be able to say to patients, purchasers and regulators, "Look, here's the evidence that I'm a capable physician."

If our measurements are robust and evidence-based and clearly meet the demands of the consumers, physicians won't be faced with external demands for multiple quality measurements to such a degree.

Unfortunately, this is coming at a time when physicians are feeling so beleaguered that they just want everybody to go away and leave them alone. But the reality is, that's not going to happen. Health care is too expensive and the demands for quality are too unremitting.

That's why we need to have our own people—internists—developing those standards. If we don't, we're going to face what I call "the regulators"—Medicare, state licensing boards and everybody else—coming in with their own requirements.

Q: With so many groups gearing up to measure physician quality, do you think there will eventually be just one accepted standard?

A: I think it's inevitable, and that's the explicit goal of the National Quality Forum. I was part of the group of eight people that wrote the initial strategic framework for that forum, so I'm very committed to its goals.

It's critical that we have something credible that we can say, "Look, this is a good standard." Because of the twists and turns my own career has taken, I have relationships with these other organizations and with Medicare. I think I can work with them to help get to a single standard.

Q: Whom do you see emerging over the next 10 years to take the lead in deciding which quality standards are used?

A: I think the ABMS is becoming a much stronger player. That's good for all of us in medicine, because we have partners in all the other specialties sitting next to us while we're pursuing this effort. That makes us much stronger, of course.

Q: Speaking of other specialties, internists have pointed out that there is a great deal of variability across the different boards for recertification. Is it possible to standardize recertification across different specialties?

A: I think it's quite possible, but whether it's likely or not I don't know. On the one hand, we want to emphasize measurement for quality improvement, but there is also a fair amount of pressure within ABMS to create certain kinds of standards. The ABMS has public members who say, "If you don't have something that's saleable, if you don't have a secure exam or some piece that really tests what the doctor can do and knows, than it becomes less credible with the public."

Q: How important do you think it is to preserve recertification in general internal medicine for subspecialists?

A: I've actually been surprised at how many subspecialists have elected for dual recertification already. Eighty five percent have already enrolled to recertify in their subspecialty, but 60% have enrolled to recertify in general medicine. Because they're not required to do so, I think that's impressive.

It's early yet, and those numbers will likely go up. It's important for physicians like cardiologists and rheumatologists, who provide general medical care for their patients, because they manage people with chronic illness.

For people in the more narrowly based, highly technical areas, I think recertification in internal medicine may be less important. I think you're going to see some choices being made along those lines.

I'm actually enrolled in recertification for geriatrics right now and taking the exam in November. After that, I will be enrolling for my general medicine certificate. Geriatrics is an obvious place where you really need certification in both areas.

Q: About 25% of general internists are not entering the recertification process, with varying numbers of subspecialists choosing to not recertify in their field. How is the ABIM planning to deal with that?

A: First, we're going to work with the College to research why. We're going to ask people who aren't yet enrolled why they haven't signed up, and we're going to ask the people who are enrolled why they are. We want to learn from both sides.

I suspect some of the internists who are not enrolling are no longer working in clinical practice, or they have entered careers in administration or are working in nonclinical jobs. We have a commitment with our colleagues in the ABMS to develop a pathway for nonpracticing physicians for recertification, and we're working on having something to offer those folks within the next two to three years, at least as a pilot.

But internists working in clinical medicine are the larger group, and I expect we can get almost everyone in clinical practice to enter the recertification pathway. Some physicians may not be enrolling because they're worried about the pass rate, so we need to get the word out that the eventual pass rate is close to 95%, which should be reassuring. Many people take the exam the first time without really studying or preparing, just to see how they do. Then when they go back and do a little homework, a lot of those people who didn't pass the first time will pass the second time.

Q: In the last year or two, the ABIM has forged partnerships with the College and other specialty societies to create materials for the self-assessment portion of recertification. What are your goals as far as society partnerships?

A: To continue those collaborations and forge new ones. It's a positive model and one that we need going forward.

Quality improvement means linking evaluation to education. Gone are the days when we could have a neat and tidy separation between the two, so we really need to work together. I plan to devote a lot of my personal time to working with the leadership of subspecialty organizations where we don't yet have agreement.

Q: This year for the first time, the ABIM offered computer-based testing for recertification in six different pilot sites. What is the Board's timetable for making computer-based testing available nationwide?

A: We plan to offer all exams electronically in 2005. One of the great advantages of computer-based tests is being able to offer exams in many more locations much more frequently, making scheduling much easier.

Because we use commercial testing centers, we could offer a test in every reasonably sized city. Computerized tests make the process much more flexible for candidates.

Q: What are your goals for making certification and recertification as relevant as possible?

A: I'm fortunate to inherit a process that's well under way and very robust. Just as we want physicians to continually evaluate what they do in practice, we will continually evaluate what we do in testing, and that philosophy permeates this organization. It's something that attracted me to this job, the commitment to always be examining ourselves and seeing how can we get better.

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Christine K. Cassel, MACP: A closer look

A former ACP President, Christine K. Cassel, MACP, comes to the American Board of Internal Medicine after a stint as dean of the school of medicine at Portland's Oregon Health & Science University. She previously served as chair of geriatrics at New York's Mount Sinai Medical Center, as well as director of geriatrics research, education and clinical care at the Bronx Veterans Affairs Medical Center.

Dr. Cassel was elected to the Institute of Medicine in 1992 and also serves on the advisory committee to the director of the National Institutes of Health. A former member of the president's advisory commission on consumer protection and quality in the health care industry, she continues to serve on several editorial boards. Her latest book, "Medicare Matters: Older Americans and the Future of Medicine," is due out in 2004.

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