College's efforts to streamline the recertification process
From the January/February ACP Observer, copyright © 2004 by the American College of Physicians.
By Phyllis Maguire
ACP's efforts to improve recertification for internal medicine have led to some long- and short-term gains that will help internists recertify.
For years, the College has been working with other internal medicine organizations and the American Board of Internal Medicine (ABIM) to streamline the recertification process. ACP officials say that the pace of negotiations is picking up and point to recent changes in the current recertification process as evidence.
This year, for example, physicians can take the recertification exam at one of nearly 200 computer-based testing centers around the country, instead of the 50 sites that offered the internal medicine paper-based exam. In addition, ACP and other specialty societies are offering learning sessions that allow attendees to come together to complete self-evaluation modules in hours.
Many internists, however, want more substantial changes to be made to the process. As a result, the College is preparing to open discussions on several modifications called for by a number of internists. Those changes include allowing physicians to apply programs like CME and MKSAP to recertification and crafting alternative recertification pathways.
In July 2002, both organizations signed a "memorandum of understanding" that laid the groundwork for negotiating changes in the recertification process. First, the memorandum established a new timetable for the ABIM's Continuing Professional Development (CPD) recertification process. It pushed back until January 2010 the date when several CPD modules—such as patient-peer assessments—would become mandatory, giving the board the opportunity to work with member organizations to refine those modules.
The agreement noted that both organizations were committed to computer-based testing. It also endorsed in principle the idea of letting internists substitute self-assessment material from specialty societies for the recertification process's self-evaluation modules.
And the memorandum created a body known as the Liaison Committee for Recertification. This advisory group of representatives from the College, the ABIM and subspecialty societies meets twice a year to bring recommendations about recertification to the ABIM. (The committee will meet again in March.) Comments and recommendations made during committee meetings are sent to the ABIM's recertification committee, which then reports to the ABIM board of directors.
The good news is that progress has already been made on several fronts. Several societies including the College, for instance, offer "learning sessions" that allow attendees to complete one knowledge-based self-evaluation module at each session.
While those sessions will help internists complete individual modules, the liaison committee wanted to open up the courses to all internists, not just those who have enrolled in the recertification process. During their first two meetings, committee members lobbied for—and won ABIM approval for—a provision to do just that.
Even more important, representatives on the liaison committee convinced the ABIM to change the course format from six to four hours. That means that attendees will be able to complete two self-evaluation modules in one eight-hour day session, not one. The College, which has one-module sessions scheduled for this year, will assess members' interest in the two-module sessions.
"We initiated the learning sessions as quickly as possible to help members with what they're going through right now," said Lynne M. Kirk, FACP, one of the College's representatives on the liaison committee. She is also a member of the College's Board of Regents and past Chair of the Board of Governors. "CME was the quickest way to offer something to our members."
Most recently, the liaison committee proposed a broader recommendation that would allow changes to the CPD process to be considered. The ABIM agreed to a process that would allow proposals—including those for substitutions for CPD elements and alternative recertification pathways—to be submitted at any time to the ABIM's recertification committee.
While this development itself has not yet led to any changes, it is significant. The board has made it clear that proposals to change the recertification process can now be submitted at any time, not just during the formal meetings.
"In our first two meetings, we solidified progress in areas that we saw as probably easier to do," said Lawrence G. Smith, FACP, one of the College's three representatives on the group and former Governor for the New York Downstate I Chapter. "We are now starting to tackle issues that will be more difficult."
With that new mechanism in place, the College is working on the following proposals to improve the recertification process:
Credit for MKSAP. College representatives to the liaison committee plan to submit a proposal that would formally bring MKSAP into the CPD process. The memorandum of understanding addresses the possibility that internists can substitute MKSAP questions for up to two knowledge-based self-evaluation modules, and the ACP and ABIM are working together to make sure that any substitute MKSAP materials would meet ABIM criteria.
However, there are concerns about exactly how such a process would work. Taking questions from the MKSAP program and packaging them without answers would be a difficult process, explained Theresa Kanya, the College's Vice President of Medical Knowledge and Education. At the same time, the answers to MKSAP questions are an important part of the learning process.
"We would rather have the entire program proposed as a substitute," said Ms. Kanya. ACP officials plan to propose this change soon so the liaison committee can discuss it at its March meeting.
Literature-based pathway. Another proposal to be made before the next committee meeting will represent a fundamental paradigm shift in the recertification program. At its October meeting, the Regents approved a Board of Governors' recommendation supporting the development of an accountable, literature-based recertification pathway.
The College proposal will be modeled after the literature-based recertification pathway currently used by the American Board of Obstetrics and Gynecology (ABOG). To recertify, ob/gyns currently "can do either/or," said Cathy Cash, the ABOG's executive secretary, speaking of that board's two recertification pathways: taking a written exam every six years or meeting literature-based criteria every year to get a one-year certificate extension. "A large amount of our applications [to the literature- based pathway] are voluntary."
According to Ms. Cash, more than 95% of ABOG's recertifying diplomates last year chose the literature-based pathway. (At the same time, the "either/or" status of the two ob/gyn recertification pathways is likely to change in the next few years, with ob/gyns likely to have a required exam as well.)
"This will be a substantial test of the liaison committee process," said Regent William E. Golden, FACP, who is Chair of the College's representatives to the committee, "as to whether or not the ABIM leadership will recognize alternative modules or pathways."
Pathways for subspecialists. Another issue that has already been raised in the liaison committee will continue to receive serious discussion. Subspecialty representatives have made it clear that their members may not be able to recertify in general internal medicine.
The problem? The written internal medicine exam doesn't reflect the practice of many subspecialists. If they let their certificate lapse, however, some subspecialists fear they'll lose hospital privileges and access to health plan panels.
The committee will continue to discuss with the ABIM representatives whether the board should create a core internal medicine exam that would apply to both generalists and subspecialists. General internists might then take a separate "subspecialty" exam that could be further tailored to either an office-based or a hospitalist practice.
"The core training in internal medicine has not kept up with all the changes in internal medicine practice," said Christine K. Cassel, MACP, president and chief executive officer of the ABIM. "The board has started a process to examine this question, to make an active internal medicine certificate more accessible to generalists and subspecialists alike."
Areas of debate
One important issue already raised in liaison committee meetings pertains to the ABIM's role in the growing quality improvement and performance measure movements. ABIM leaders have indicated that they see a strong role for the board in assessing physician quality and performance, but not everyone agrees with that vision.
"To complete a quality improvement module every 10 years is not consistent with the current vision of what quality improvement and professional self-assessment is all about," said Dr. Golden, who is also a member of the National Quality Forum.
In the meantime, the College and the ABIM are jointly sponsoring research that will begin later this month to ask internists with time-limited certificates why they are choosing to recertify—and why those who choose not to have taken that option.
The College's liaison committee representatives say they—and the other representatives—know there is a sense of urgency to assure the relevance of the recertification process, reduce redundancy and accommodate different learning styles. They also say that the ability to come together with subspecialty groups gives their recommendations much greater weight.
"We are able to accomplish," Dr. Kirk said, "much more than each organization communicating with the board independently."
Beginning this month, College members enrolled in the recertification program will have access to a new, free member benefit.
The College will give those members links to educational material to help answer every question in all five general internal medicine self-evaluation process (SEP) modules.
Members will be only a click away—via the Web or CD-ROM—from support materials that can help them answer each of the 300 SEP-module questions. (There are 60 questions in each of the five modules.)
"This will save members time," said Patrick Alguire, FACP, the College's Director of Education and Career Development and one of the internists who identified answers to the questions. "We've done the preliminary screening of materials to find those directly related to each question. Members will also have access to many Colleges resources that they may not have on hand."
In researching the questions on the self-evaluation modules, Dr. Alguire drew on the entire body of College products, from articles in Annals of Internal Medicine and College books to modules from the Physicians' Information and Education Resource (PIER) and MKSAP materials.
Dr. Alguire said he was able to find the answers to more than 90% of all the self-evaluation questions in College materials. For those questions not covered by College resources, he said, the College will link internists to articles through PubMed that will provide the answer.
Here is how the benefit will work: A link on ACP Online will direct members to a member-restricted section of the College's Web site. Once members enter their College user name and password, they will have free access to an index of the SEP-module questions.
Selecting a question from one of the five modules will bring up links to relevant sections of ACP resources that provide the necessary information to answer the question.
(A link to the site will also be included in the ABIM's CD-ROM for each general internal medicine SEP module.)
But, Dr. Alguire explained, don't expect the materials to just hand you the answer. Instead of providing a sentence that spells out the answer, the links will take members to an appropriate Annals article, for instance, or a section of a PIER module.
That should make the links more educational, he said, while dramatically cutting the time members will have to spend chasing down resources to answer questions for recertification.
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