The forces driving recertification in internal medicine
By Christine K. Cassel, MACP
It has been eight years since, as President of ACP, I wrote an article for ACP Observer. I appreciate the opportunity to return to these pages in my role as president of the American Board of Internal Medicine (ABIM).
Consistent with my new role, I took the exam that is part of the Continuous Professional Development (CPD) process in geriatric medicine last November, and thankfully, I passed. After completing one more self-evaluation module, I will have renewed my geriatrics certificate. This process has given me first-hand knowledge of internists' experience with the ABIM.
Aside from shoring up my knowledge of geriatrics, I've also learned in my initial months at ABIM that internists don't always fully understand the role of the Board. Perhaps a little history might shed some light.
The ABIM's roots
The ABIM was established in 1936 by ACP and the AMA. It is the only internal medicine board recognized by the American Board of Medical Specialties (ABMS), and only one of 24 specialty boards to be recognized by the ABMS.
Like all boards that belong to the ABMS, the ABIM is a private, not-for-profit standard-setting organization that refers to the physicians we certify as "diplomates." While certifying boards have many stakeholders, we do not have "members," marking a key difference between the ABIM and ACP.
Like the College, however, the ABIM is committed to promoting professional competence and improving quality. Our mission statement spells out this goal clearly: "To assure patients and the profession that certified internists are competent to provide high-quality medical care in a compassionate, humanistic, and ethical manner."
Board certification has always been a voluntary but highly respected credential recognized throughout the world. Certification demonstrates that a physician has completed intensive study, undertaken self-assessment and received good evaluations for practice performance. Although substantial data support the view that certification is a marker of physician quality, it is just one step in physicians' lifelong process of evaluation.
Certification used to be considered an honorific credential. With changes in health care financing and delivery, however, certification is becoming expected—and even required—by some health plans, medical groups and hospitals. Currently, 87% of U.S. physicians are certified.
For most of the ABIM's history, certification was a once-in-a-lifetime event that was connected to completing residency training. But in 1974, the ABIM introduced voluntary recertification. In 1990, consistent with other ABMS boards, we began issuing 10-year certificates. Time-limited certification asserts a philosophical view that physicians have a professional responsibility to demonstrate maintenance of knowledge and skills.
Many other specialties already required diplomates to renew their certificates. The American Board of Family Practice, for instance, has issued seven-year certificates since its inception in 1974, while surgery has had 10-year limited certificates since 1969.
The role of the ABMS
The ABMS is the self-governing federation of recognized certifying boards that sets consistent standards. The ABMS plays significant roles in both certification and maintenance of certification (the phrase we now use for recertification).
A good example of the ABMS' unifying role is reflected in the framework it adopted in 1999 with the Accreditation Council for Graduate Medical Education (ACGME). After working through a five-year process involving many stakeholders, both groups endorsed six general competencies for all specialties. That joint endorsement means that physicians will be expected to demonstrate these competencies in both training and certification.
Those six competencies are in the following areas:
practice-based learning and improvement;
interpersonal and communications skills;
The ABMS framework for recertification
The ABMS has used these competencies as the basis for a "maintenance of certification" framework that consists of four components and is relevant to all the boards. In adopting this framework, each board agreed to promulgate a program suited to its specialty with all components present. (See "How CPD recertification meets the ABMS requirements." )
Here is a closer look at how the CPD program addresses each of the four ABMS components.
Part 1: Professional standing. The ABIM verifies diplomates' credentials by assuring a clean license in the state or states where they practice. We also confirm good standing with local credentialing bodies.
Part 2: Lifelong learning and self-assessment. Traditional ABIM self-evaluation modules consist of 60 multiple-choice questions focused on medical knowledge and judgment. New types of modules have been introduced to allow diplomates to evaluate their clinical skills or focus on recent advances by specialty. We continue to work with professional societies to find new and innovative ways to help diplomates complete self-evaluation.
Part 3: Cognitive expertise. The secure, proctored exam is sometimes perceived as the biggest hurdle in the CPD process. All ABIM examinations are scored using an absolute standard, which means that anyone who answers enough questions correctly will pass. In other words, there is no grading curve.
While I can attest that the exam requires preparation, our data suggest that the vast majority of diplomates are well-prepared. Between 1996 and 2003, 91% of diplomates passed the CPD exam on their first attempt, and 98% succeeded on repeated attempts.
CPD exams are based on the same psychometric standards as ABIM certifying exams, and all meet the highest industry standards for an objective, reliable reproducible test. A national network of practicing internists reviews all potential questions, and only questions that receive very high ratings for relevance to clinical practice appear on exams.
Currently, most ABIM exams are administered on paper at approximately 50 sites, but the Board is converting to computer-based testing. By 2005, all CPD exams will be administered at more than 200 professional centers throughout the United States, saving diplomates travel time and offering more flexibility.
Part 4: Evaluation of performance in practice. This ABMS requirement for CPD represents the first time we are asking physicians to participate in a quality improvement project, an increasing expectation in health care. New ABIM tools will guide diplomates through the study of their own practice.
The first of these tools, practice improvement modules, are now available for preventive cardiology, asthma and diabetes, and other modules are being developed. Because this is a new area, the modules are optional, although they count toward self-evaluation credit.
Diplomates may also select a module that solicits feedback from patients and peers. This module includes materials that are similar to the patient satisfaction surveys that practice groups and Medicare regularly use.
Efforts to improve CPD
To improve the CPD process, we at the ABIM are investing considerable time and effort in the process. To serve on the Board, all directors and committee members must enroll in CPD and work to renew their certificates. This ensures that we understand how CPD functions—and how Board requirements affect practicing internists.
From the beginning, the ABIM has been committed to a process that is efficient and congruent with internists' other quality improvement efforts. We realize that CPD must be credible and rigorous, yet easy to understand, relevant and flexible enough to apply to the entire range of internists' interests and careers.
To help meet these commitments, the Board has sought collaborations with ACP and other specialty societies. We also initiated discussions with national organizations, including the Joint Commission on Accreditation of Healthcare Organizations and the National Committee on Quality Assurance.
We hear diplomates' concerns from internists directly or through their professional society representatives. I encourage you to talk to ABIM representatives at society meetings, visit our Web site, or contact us by e-mail or phone (800-441-2246).
ABIM and medical societies
To facilitate communication with medical societies, the ABIM and ACP established the Liaison Committee on Recertification (LCR) in 2002. This group includes representatives from many of the professional societies that collaborate on the CPD process.
We're also working together to create concrete programs and resources. For instance, five societies last fall offered workshops at their annual meetings, with expert panels leading participants through a self-evaluation module.
Diplomates were able to attend an educational session with CME credit and then submit their answers to the ABIM for CPD credit. Because those sessions were so well-received, they are being expanded in number and frequency.
Medical societies are now providing educational resources to help diplomates complete self-evaluation modules at home, through printed syllabi or electronic resources. (ACP provides CME credit to diplomates who complete modules on their own, as well as to those who pass the exam.) The ABIM and ACP recently received joint approval to use the Board's new practice improvement modules in an AMA pilot study to assess a new type of CME credit. That credit will reward physicians who participate in a formal practice improvement activity.
We're also enthusiastic about an ACP proposal to substitute MKSAP modules for ABIM-developed self-evaluation modules. We're making good progress on developing a process and standards that will enable MKSAP to count for up to two CPD knowledge modules. That credit should be available by the end of this year.
Why maintain certification?
Historically, achieving certification has signaled that a physician has demonstrated a high level of competence.
Demonstrating quality is a critical part of our profession's societal obligation. Achieving and maintaining certification sends a respectful message to our patients about how the profession sets standards and upholds public expectations.
As a standard-setting organization, the ABIM takes its role in advancing physician quality very seriously. At the same time, we recognize that the Board is just one element in a wide network of individuals and organizations, all working toward the same goal of improving quality. My hope is that our collective efforts will help us realize that goal much more effectively than any one of us can achieve alone.
Christine K. Cassel, MACP, is president of the American Board of Internal Medicine.
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