By Tom Granatir, Senior Vice-President, Policy and External Affairs, American Board of Medical Specialties

In 2018, 30 bills were introduced in 20 states that would have prevented hospitals or health plans from requiring certified physician specialists to participate in “Maintenance of Certification,” a recertification program developed in the early 2000s by the 24 specialty boards of the American Board of Medical Specialties (ABMS). Almost all of these bills were promoted by physicians and supported by state medical associations.

Imagine: physicians organizing across the country to prevent the adoption of a process designed by physicians to assure up-to-date medical practice through certification. What was behind this movement, and how did the ABMS boards respond?

Historical Milestones

ABMS boards began developing standards for training and certifying physician specialists over a century ago. Recertification was introduced by the American Board of Family Medicine when it was created in the late 1960s, on the basis of growing evidence that knowledge and clinical skills decline with time away from practice and that it takes a decade and a half for new evidence to work its way into practice. Over the next 30 years, the boards adopted similar recertification programs that required high-stakes examination at least every 10 years.

In 2000, in recognition of new thinking about quality improvement in health care, the ABMS Member Boards adopted a new “Maintenance of Certification” (MOC) program that required a mix of education, quality improvement and high-stakes examination. This revised recertification program was implemented by the 24 boards over the following decade.

By 2012, physicians were beginning to voice their concerns about the new program — some said it was burdensome, time consuming, and because they got so little feedback from the examination, the process offered little in the way of learning value. Plus, because each physician’s practice tended to narrow after training, many of the items on exams were not relevant to each physician’s scope of practice a decade or more later. What they wanted was something convenient and practice-relevant that delivered learning value.

ABMS Response

The ABMS, in consultation with the Council on Medical Specialty Societies, created an independent, external commission to examine recertification programs and make recommendations for the future of continuing certification. The “Vision Initiative – Commission on the Future of Continuing Certification” (the Commission) consisted of 27 members. This included seven public members representing the public, hospitals and other users of board certification, and 20 physicians from a variety of specialties and settings.

After hearing wide-ranging testimony about the current program from physicians, medical and specialty societies, hospitals, other regulators and public/consumer representatives, the Commission delivered a report to the ABMS in February 2019. The ABMS board accepted the report as a road map for change over the next five years.

The Commission’s recommendations entail a radical repositioning of continuing certification from a single, high-stakes event to a formative process that supports physician learning over time. The Commission acknowledged that the boards need to continue to deliver a certification process capable of validating that certified physicians continue to meet the board’s standards for knowledge, clinical judgement and behavior. This is what patients, hospitals and other stakeholders expect and depend upon.

The Commission’s consensus was that member boards must enhance the learning value with a program of assessment directing certificant learning and promoting professional development. Member boards were encouraged to collaborate with their physician professional organizations to create these new programs, since it is the professional organizations that traditionally take responsibility for developing continuing education and helping physicians fill gaps in knowledge or skill.

Practical implications of these recommendations have been significant. First, recertification programs are being reviewed to assure that all elements are coherent and linked to desired outcomes. Assessments have been transitioning to new formats to achieve the following goals:

• More convenient, online delivery that can be more easily integrated with the workflow of busy practitioners
• Multiple, frequent, low-stakes assessments in place of single point-in-time exams
• Customizable content that is tailored to recognize the variation in clinical practices
• Exploration of new technologies to address issues of security, authentication and scoring
• New item formats that simulate decision situations in practice
• Immediate feedback on each item to support learning and improvement

Achieving these goals requires member boards to develop new skills that enhance positive engagement with certificate holders, plus new relationships with professional organizations and other stakeholders.

Certification decisions are made based on a portfolio of performance and participation requirements to ascertain whether knowledge and skill standards continue to be met. In the process, the experience of the participating physician diplomates is transformed.

Summary

Over the past five years, legislation has been passed in 15 states. In 10 of these states, the legislation only prohibits the use of certification by state medical boards as a condition for a license to practice. Such legislation is a solution without a problem, as no medical board has ever made certification in a physician specialty a requirement for a general license to practice. Five states regulate the use of certification by health plans or hospitals, but none of the legislation has yet had a material effect.  As the boards have implemented these new programs and engaged their stakeholders more directly in conversations about the future of recertification, the pace of legislation has slowed. The specialty boards are hopeful that they can put the political battles behind them and focus on charting a new path in collaboration with their stakeholders.

The challenges to the member boards — to develop new skills, adopt new technologies and forge new relationships — are enormous. However, the effect — better engagement of physicians and enhanced learning — will be truer to the goals the boards set for themselves, which are higher standards and better care.