In the battle to restore the public’s trust in healthcare and ensure physicians truly have the knowledge they need to help patients, board certification—and maintaining that certification—is essential.
That’s the case the American Board of Internal Medicine (ABIM) made before its customers at the recent American College of Physicians annual conference in New Orleans.
Walking a crowd of about 50 internists through the advent of medical societies dating back to the 1700s, Richard J. Baron, MD, president and chief executive officer for the ABIM, noted the need to ensure qualified physicians are identified to the public.
“Part of where certification comes from historically is us, as a profession, coming together and saying there are set of people with special skills … and we have a process for being able to distinguish ourselves from people who may not have those skills,” he said.
Fast forward to the future, where data from Gallup indicates a drop in trust in the medical system from 80 percent in 1975 to 37 percent in 2015. Baron said it is important to both patients and peers to have an indicator of quality healthcare.
“Professional self-regulation is as important now as it ever was,” Baron said.” As a profession, we need to come together institutionally and have credible processes and credible institutions that do that and that’s the work the [ABIM] is trying to do.”
But in the past five years, the ABIM has come under criticism for its maintenance of certification (MOC) process, from the cost of the test and related preparatory materials to frustration with the rigid testing process.
Baron admitted his organization “didn’t do a good job explaining MOC” to internists, but it is truly about keeping pace with medical changes and staying on top of the most recent information.
That theme was echoed by ABIM’s Board Chair Patricia Conolly, MD, who noted the exam was never designed “for learning” but designed as tests “of learning.” Conolly recognized feedback from internists about the testing procedure, but defended it as essential to increase clinical knowledge, adhere more to treatment guidelines, and improve performance on measures of healthcare quality.
And this should be done by the type of summative assessment the ABIM presents, rather than self-assessment or just by attaining continuing medical education (CME) credits, she said. Doctors do not tend to accurately self-assess, Conolly said pointing to research, and CME is typically self-selected, leaning to a doctor’s “comfort zone” and perhaps not as challenging as it should be.
Changes to MOC process
This year marks the first the ABIM will roll out its new “knowledge check-in,” a shorter, lower-stakes exam than the current 10-year MOC test. The 90-question exam allows internists and nephrologists to take the exam at home, in their office, or at a designated testing site and use UpTo Date, an online, evidence-based clinical decision support tool, essentially creating an “open-book” exam.
Marianne Green, MD, board chair-elect for the ABIM, said the organization heard from members that the current 10-year format was “no longer relevant or meaningful,” hence development of this more flexible alternative.
Green said 2018 and 2019 will serve as “no consequence years” for physicians taking the new test. If they fail the exam, they can take it again in 2020 without losing certification. After that grace period, if a physician fails two subsequent knowledge check-ins, they must take the 10-year exam to maintain board certification.
“What isn’t changing,” Green said, was “that board certification matters to many physicians ... It’s a credential people are proud to hold and it has real performance standards behind it. That should mean something to you and mean something to your patients.”
That notion was challenged by internist Charles Cutler, MD, of Philadelphia, who said the ABIM is “stuck” in a summative assessment, when what it should do—and many other specialty boards are doing—is a more formative process, providing ongoing feedback to improve skills.
“I can’t believe [internists] want a test or want to take a test,” Cutler said. “I just don’t get that.”
Baron said the claim other specialty boards were going away from a process like ABIM was “simply not accurate,” and that the organization considers the knowledge check-in their “formative experience” for physicians.