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Endurance test: Quest for quality leads to a never-ending road to board recertification
Internists hope their specialty board can reduce some of the curves along the way. Other groups will likely follow its lead.
By Jay Greene, AMNews staff. March 11, 2002. Additional information
Theodore Li, MD, a general internist in Washington, D.C., is getting an early start on the circuitous road toward board recertification. Like thousands of other internists, Dr. Li wants to pace himself over the next few years to avoid having to cram all required recertification tasks into the last year or two. Internal medicine now requires five mini-tests or assessments and a final general knowledge examination that most likely contains medical problems he won't have faced in practice.
"I have completed [four of five] modules" of the American Board of Internal Medicine's new recertification system, Dr. Li said. "The questions were challenging -- none of them were the type you could answer cold. They all required some research into texts or review articles. Although the topics were often niche areas and somewhat esoteric, the point was not for me to acquire medical minutiae. Rather, the questions propelled me to examine my methods of information retrieval. I wasn't so much picking up clinical pearls; I was learning how better to pearl dive."
Nearly 12,000 internists like Dr. Li are in ABIM's recertification process -- now called "continuous professional development," or CPD. Thousands of other physicians face recertification in their specialties. But even for competent physicians, general medical knowledge tests are a challenge. Failure rates vary, depending on the year and specialty. For example, 8% of family physicians failed on their first attempt in 1999, and 13% of internists initially failed in 2000.
The stakes are high, because those who lose certification may be barred from managed care contracts or lose job opportunities. Some 66% of active physicians are board certified, the AMA said.
While not mandatory until 2010, internists will be required to take at least one self-evaluation process, or SEP, module in each of four categories -- clinical skills, medical knowledge, practice improvement, and peer and patient assessment.
ABIM requires only those internists certified since 1990 (1987 for critical care and 1988 for geriatric medicine) to complete the recertification program.
8% of family physicians failed on their first recertification attempt in 1999.
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Dr. Li prepares by reading medical journals, taking continuing medical education courses, subscribing to Internet-based medical information services and talking with peers.
But the best advice Harry Kimball, MD, ABIM's president, can give is to prepare early. He should know. Stimulated in part by public demand for greater physician accountability, the ABIM is leading the charge into the brave new world of CPD recertification. Internists with 10-year certificates are encouraged to start taking the five required modules in the fourth year so they have the ninth and 10th years to pass the final exam, which is given twice a year at 54 national test locations.
Christopher Boni, MD, an internist in Livingston, N.J., has completed two internal medicine modules and one for pulmonary disease. Each module consists of 60 questions.
"Sometimes I am reminded of things I have forgotten; sometimes it reinforces things that I already know," Dr. Boni said. "I believe there should be an explanation of the answers or a reference bibliography."
Dr. Kimball said the ABIM was working with medical societies to integrate Internet hyperlinks into the SEP modules. The links will lead doctors to medical education Web sites.
"We believe the process is stronger if diplomates have access to relevant information without having to search all over the world for it," Dr. Kimball said. "One concern is they didn't know where to get the answers. They tried textbooks and that didn't work. We want to make that information available to them in real time."
13% of internists failed on their first recertification attempt in 2000.
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Elizabeth Gabay, MD, an internist in Bellingham, Wash., said the process had helped her with patients. But she sees little value in some of the other optional modules that will become required in 2010 for clinical internists such as peer and patient assessment.
"I am not convinced of the value of this type of review," Dr. Gabay said. "Practice management skills are important, but I can't see how they relate to certifying a person's competence as a physician, especially nowadays when many of us work in large organizations and do not have strong control over the details of our work situation."
Still under construction
Originally, ABIM wanted to phase in the peer and patient module by 2004. But an outcry from internists and the American College of Physicians--American Society of Internal Medicine led the board to push back implementation to 2010.
"We are supportive of the recertification process, but clearly there are differences in how we would approach the process and how the board has proceeded," said Bernard Rosof, MD, chair of ACP-ASIM's board of regents. "Some of our initial concerns have been addressed, and several other changes have been proposed. We will have to wait and see. The devil is in the details."
66% of active physicians are board certified.
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Dr. Rosof said ABIM was moving to address concerns that include relevancy to practice, duplication and redundancy.
"The main point is does the [CPD] process help patients and medical outcomes?" he said.
While several doctors told AMNews they thought the recertification process would indirectly help improve outcomes, some doctors question its current value.
Making some modifications
Tomás Aragón, MD, an infectious disease specialist and deputy county health officer in San Francisco County, completed the entire recertification process last fall.
"They are changing the process because of all the complaints," said Dr. Aragón, who is raising three children and moonlights to make financial ends meet. "I did the five modules, and for the most part they were a waste of time. Most are not relevant to what I do. I felt like I was a resident again."
Dr. Aragón said he was happy the ABIM was developing alternative modules for physicians who don't see patients or those who conduct research.
"Next time I will start in year six to avoid lumping everything together like I did last year," Dr. Aragón said. "When you work 60- to 80-hour weeks, raise a family and use the time after you put the kids to bed to keep up with your own field, it is not practical for people who are so busy to study for general exams."
While ABIM has more than three dozen modules available and more under development, Dr. Kimball said the board cannot tailor tests to every internal medicine practice. "It is impossible to design a process relevant to everyone's practice. We go as far as we can."
Dr. Kimball said each question is reviewed by 200 internists -- some practicing physicians -- who give feedback on such issues as accuracy and relevancy.
"For public health officers and other doctors out of the mainstream, it doesn't surprise me that some of these questions are a bit unusual. It is very tough for internal medicine, because we have such a diversity of practices," Dr. Kimball said.
Last year the ABIM surveyed 1,760 diplomates who went through recertification from 1996 to 1999. Some 71% viewed the estimated 70-hour process as professionally valuable. Some 10% did not value recertification and 19% were neutral.
But an ACP-ASIM telephone survey last year found "little confidence that the ABIM's recertification process would improve the practice of internists." The majority of those respondents also said they had little information about the new process.
Responding to physician concerns about recertification, the AMA House of Delegates in June 2001 asked the Board of Trustees to study issues surrounding it. The board is expected to look at issues that include relevancy to practicing doctors, duplication, cost effectiveness and impact on doctors with multiple certificates. A report is due in June.
But Dr. Kimball said CPD recertification was the best evaluation tool available to boards. "We are a learning organization, and we have constantly learned more and more about the environment physicians practice in these days. We try to make the process compatible. But we have a responsibility to assure the public that doctors are really competent and can practice high quality care."
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A work in progress
Changes in the recertification process will be phased in over time. More information is available from the American Board of Internal Medicine; its CPD Hotline is (800) 441-2246, ext. 3593.
RECERTIFICATION REQUIREMENTS
Self-evaluation: Five modules required. Four categories offered: clinical skills, medical knowledge, practice improvement, and patient and peer assessment.
Multiple specialties: One additional self-evaluation module as well as an additional exam is required for those recertifying in more than one specialty.
Verification of credentials: Alternative available for diplomates who are not credentialed by a managed care organization or by a hospital medical staff.
Time frame: All modules may be completed at any time during the 10-year cycle, but it is recommended that internists complete one self-evaluation module per year. Postponed until 2010 is a requirement that at least one module in each category be completed.
APPROVED CHANGES
Substitution of up to two self-evaluation process modules from other medical groups will be allowed under a strict approval process.
Flexibility for physicians who do not see patients.
Coordination of practice improvement modules with specialty recognition certificates.
Inclusion of practice improvement modules.
Source: American Board of Internal Medicine
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Recertification becomes a continuous process
Many of the 24 members of the American Board of Medical Specialties are changing their recertification process.
Under the rubric of "continuous professional development," physicians complete periodic clinical and professional assessments during the seven- or 10-year term of their board certificates. Recertification still includes a pass/fail final exam.
First to change was the American Board of Internal Medicine. The American Board of Pediatrics and the American Board of Obstetrics and Gynecology also are adopting a new approach.
But the grandparent of recertification is the American Board of Family Practice. Formed in 1969, the ABFP immediately adopted seven-year certificates.
"We have started discussions on where we should go from here," said Robert Avant, MD, ABFP's executive director. Changes in 2003 call for ABFP to offer patient simulated technology on a computer- administered exam as a practice assessment tool.
"Not everybody has the appropriate hardware to do the exam at home," Dr. Avant said. "For the first several years we will do it at test centers."
In 2003, the American Board of Pediatrics will begin assessing pediatricians on a continuous basis instead of once every seven years.
The new program requires evidence of professional standing, lifelong learning, self-assessment, medical knowledge and practice skills.
For example, pediatricians now will be required to take a closed-book examination instead of the at-home computer test. Evidence of lifelong learning, self-assessment and practice skills will be phased in over the next several years.
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Weblink
American Board of Internal Medicine CPD page, on the recertification Program for Continuous Development (http://www.abim.org/cpd/cpdhome/index.htm)
American Board of Family Practice Recertification Examination page (http://www.abfp.org/recertification1.htm)
Article, "College leaders give update on recertification," ACP-ASIM Observer, March 2001 (http://www.acponline.org/journals/news/mar01/recertification.htm)
American Board of Pediatrics PRCP page, on the Program for Renewal of Certification in Pediatrics (http://www.abp.org/prcpinfo/prcpinfo.htm )
American Board of Obstetrics and Gynecology Maintenance of Certification page (http://www.abog.org/main/main.html)
American Board of Medical Specialties (http://www.abms.org/)
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Copyright 2002 American Medical Association. All rights reserved.
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