Who Is Maintaining Certification in Internal Medicine—and Why? A National Survey 10 Years after Initial Certification

To the Editor:

Roughly 6,000 first time candidates take a $1000 annual ABIM certification process and, to date, about half as many MOC candidates [curiously], so revenues are nearby $9,000,000 annually [1]. Review and preparation materials provide additional revenues for the ABIM and others organizations. Studies about ABIM processes are often funded by the ABIM. Thus well funded and after decades of study, evidence for the ABIM's processes should be clear and widely understood, especially in academia [2].

The rate-limiting step of ABIM certification is the written examination. As an idea born from academia, the value of an examination would ideally find unity within academia. My survey of one academic general internal medicine group reveals that the use of the ABIM examination as a measure of clinical quality is far from universal, Table 1. It remains to be shown whether other academic groups perceive the examination similarly. Other sentiments echoed are similar to Lipner et al.[3].

Without concrete evidence of the fact, many employers and payers often mandate ABIM certification as a marker of higher clinical quality. In an era of evidence-based medicine, such policy is clearly unwarranted.

Table 1: Survey of 27 General Medicine Full Time Faculty

Passing the written examination of the American Board of Internal Medicine, ABIM, is a marker of higher quality care as compared against an Internist who did not pass the examination.

YES 52.4%

NO 47.6%

Certification and recertification fees are well spent in studying the ABIM certification process to practicing quality Internal Medicine.

YES 28.6%

NO 71.4%

Periodic written ABIM examinations is a necessary part of providing quality care by Internists to patients.

YES 38.1%

NO 61.9%

My ABIM certification status is:

Time Limited Certification 57.1%

Unlimited Certification 33.3%

Not Certified 9.5%

Total Respondents 21/27 [78%]

References:

1.https://www.abim.org/resources/statcert.shtm

2.Brennan TA, Horwitz RI, Duffy FD, Cassel CK, Goode LD, Lipner RS. The role of physician specialty board certification status in the quality movement. JAMA. 2004 Sep 1;292(9):1038-43.

3.Lipner RS, Bylsma WH, Arnold GK, Fortna GS, Tooker J, Cassel CK. Who is maintaining certification in internal medicine--and why? A national survey 10 years after initial certification. Ann Intern Med. 2006 Jan 3;144(1):29-36.

Conflict of Interest:

None declared

To the Editor:

One might have imagined that in the post-Vioxx (1) and cloning (2) scandal era, Lipner and her co-authors would have been more circumspect in providing support for their position that Maintenance of Certification (MOC) enhances patient safety. Unfortunately, the authors have chosen to be rather cavalier with their facts and suppositions.

The authors start with the always suspect statement that ""¦there is no denying that state-of-the-art knowledge on the part of the individual physician remains a key factor in ensuring quality care." The authors reference Troyen Brenan's 2004 JAMA article (3) to substantiate their position. However a casual persual of said article does not substantiate the author's statement, In fact, the author's of the referenced article admit (page 1042, paragraph 1) that "no empirical studies are available on this point". The authors of the Annals article further justify MOC "to protect the public and patients". Protecting the proverbial public has been the goal of saints and, more often, tyrants for time immemorial. The issue left entirely devoid of validation in this article and the referenced papers is whether , in an era of instant computer-based up to date medical information, the retesting of previously board certified physicians enhances the quality of care.

As to the issue of satisfying the public's demand for competence, said public has been demanding such from its lawyers, accountants and clergy as well as physicians. These other professions have manifested a sufficient sense of self-worth to resist the misguided pressures for "proof" of competence by maintaining a once"“in-a-life-time demonstration of performance by acceptance to the bar and achievement of Certified Public Accountant status. The authors conveniently fail to mention that Brennan's referenced paper in JAMA reports that the public is not satisfied with a once per 6-10 year validation of certification credentials but rather would prefer more frequent retesting (page 1042, paragraph 4).

Initial testing for board certification has always made sense to validate scholarship and the ability, at a given point in time, to acquire information. Beyond that, the public must rely upon their own judgment to determine if the care they are receiving is provided in a competent and caring fashion. The availability of tort histories in the various states further enhances an engaged public's ability to choose their physicians and hospitals wisely. The act of MOC is, in many respects, inimical to adult education in that it promotes activity designed only to pass the next set of exam questions and discourages independent inquiry which can yield expertise in a particular specific area of knowledge. In the computer age a physician's competence is not measured by the ability to pass a periodic exam but rather by the diligence needed to pursue an accurate patient history, a good physical exam and near- compulsive follow up of a patient's status. For the more cynical observer the one thing that MOC certainly does accomplish is to provide a steady, coerced and abundant revenue stream to ABMS regardless of the very dubious public good that it may or may not achieve.

Sincerely yours,

Barry Kisloff, M.D., F.A.C.P

Nobody likes to be evaluated on his or her performance but the public must have a way to ensure that physicians are providing high quality care. The American Board of Medical Specialties established a standard approach called maintenance of certification (MOC) whose goal is to assure the public that physicians do so. The program requires that physicians possess an unrestricted license to practice medicine, and that they demonstrate life-long learning, practice improvement, current medical knowledge, and clinical judgment/diagnostic skill.

This approach, based on Miller's four-stage pyramid for assessing clinical competence, requires that physicians demonstrate that they know the material, know how to apply the knowledge, show how they apply it, and actually do apply it (1). The secure examination is used to demonstrate knowledge and clinical decision-making, and is a highly reliable and valid high-stakes assessment (2). Considerable research establishes that certified physicians have better patient outcomes than those not certified (2, 3). Demonstrating knowledge is not sufficient for proving adequate day-to-day performance, but it is necessary.

The MOC program includes tools that measure practice performance, survey patients and peers, and assess knowledge of recent advances in the field; in the future, we hope to assess skills using simulation methodologies. The fee for this broad-based evaluation is about $1000 every ten years (that is, about $100 a year). This fee provides virtually unlimited access to a wide spectrum of self-assessment tools, and permits choices that reduce redundancy for the individual physician. ABIM coordinates with CME-granting organizations to give credit for medical society self-assessment products (e.g., American College of Physician's MKSAP product), and an AMA Physician Recognition Award for completing a practice improvement chart audit. These offer additional value to physicians (and, of course, require additional organizational resources).

Certification is valued, by physicians and by others. Our survey on a nationally representative sample of certified internists found that, in general, physicians value certification as a way of improving their professional image, updating knowledge, and improving the quality of patient care. Perhaps even more to the point, both physicians themselves (4), and patients (5), consider board certification of major importance when choosing a doctor to whom to refer, or whom to see.

1. Miller G. The assessment of clinical skills/competence/performance. Acad Med 1990; 65: S63-7. 2. Brennan TA, Horwitz RI, Duffy FD, Cassel CK, Goode LD, Lipner RS. The role of physician specialty board certification status in the quality movement. JAMA. 2004;292(9):1038-43. 3. Pham HH, Schrag D, Hargraves JL, Bach PB. Delivery of preventive services to older adults by primary care physicians. JAMA. 2005 Jul 27;294(4):473-81. 4. Kinchen KS, Cooper LA, Levine D, Wand NY, Powe NR. Referral of patients to specialists: factors affecting choice of specialist by primary care physicians. Ann Fam Med. 2004;2:245-252. 5. Bornstein BH, Marcus D, Cassidy W. Choosing a doctor: an exploratory study of factors influencing patients' choice of a primary care doctor. J of Eval in Clin Prac. 2000;6(3):255-262.

Conflict of Interest:

None declared

I agree with the author's response. In particular, his phrasing of how pressure to re-certify "promotes activity designed only to pass the next set of exam questions" singles out one of the biggest flaws of the recertification process.

I have been in family practice for over thirty years and have maintained certification during that time. Recently I did not pass the exam on two consecutive occasions. I did not prepare with any special studies or board review courses. I simply took the test "cold" as I have done for all my career including my initial certification.

I failed the test because a significant amount of it focused on information that I do not need or use in my practice. Like many family doctors (and general internists) my practice has been shaped by the kinds of diseases I see most, the number of specialists in my community, and my clinical abilities. But the family medicine boards maintain that candidates must demonstrate a certain core base of knowledge of what it arbitrarily considers family medicine. Thus even though I no longer do pediatrics, gynecology or hospital medicine I did poorly on those aspects.

The point is that most primary care doctors, general internists and family doctors tailor their practices over time. As the author pointed out initial certification does demonstrate some scholastic skills and is worthwhile; but after that each doctor refines his own knowledge base and tailors it to the needs of his particular practice. It is unbelievable that those who administer the boards do not acknowledge this, though I think that some of them have their doubts about the value of their dogmatic approach.

Finally, the mention of the lawyers and accountants is correct. They only pass a one-time bar exam and their CPA exams. One wonders why physicians accepted a recertification process that was flawed and limited and potentially harmful to their their careers and reputations.

I think our own leadership, in response to the Institute of Medicine's (IOM) misleading report on hospital errors in 1999,promoted recertification as guarantee of physician competence. Also, in 1969 when the Family Medicine Boards were created, in order to increase their credibility within the medical hierarchy, they actually started the whole recertification requirement for their boards, and soon others including the ABIM, followed suit. Worse, HMOs wrongfully use it as an advertising tool.

Perhaps the greatest deficiency of the recertification exam is that it does not take into account all of the qualities that make up a "complete doctor". Nothing is learned of a candidate's character, his ability to connect with patients, the timeliness of his consultations, the opinon his patients have of him, how quickly he answers phone calls, participation in medical politics, and many other attributes that contribute to the totality of a good physician.

This predicament makes one wonder about the ability of our top leadership to make good decisions.

Conflict of Interest:

None declared