Editorial
Considering Recertification
N Engl J Med 2010; 362:946-947March 11, 2010
- Article
In this issue of the Journal, Clinical Decisions presents a fictitious vignette involving a 55-year-old physician who practices internal medicine with a subspecialty in endocrinology.1 On completion of his training, the physician took and passed the “board exams,” and he holds time-unlimited certificates from the American Board of Internal Medicine (ABIM) in both internal medicine and endocrinology. The holding of time-unlimited certification is often called “grandfather” status, because it means that participation in the ABIM's maintenance of certification (MOC) program is not required to maintain board certification, whereas participation in the MOC program is required for physicians whose certificates are time-limited. In the vignette, the subspecialist wrestles with whether he should enroll in the ABIM's MOC program voluntarily and become recertified. (Please go to NEJM.org to vote on whether this physician should enroll.)
To highlight the issues involved in this decision, we present two essays. The first is authored by two chairs of departments of medicine at major medical centers who are directors of the ABIM. They argue that physicians with time-unlimited certification should voluntarily become recertified because it will enhance their knowledge base, provide a reason to systematically examine their practice, and set an example for their younger colleagues. The authors of the second essay — the dean of a major medical school, a professor involved in the practice and teaching of primary care, and a physician in active daily practice — argue that the MOC program, as currently constituted, is not relevant to physicians' practice, emphasizes the recall of facts rather than the use of available information, and takes time and money that are better spent elsewhere.
The recertification process is of interest not only to “grandfathers” and “grandmothers” facing a decision about whether to become recertified, but also to thousands of physicians who were certified after the late 1980s and therefore have time-limited, rather than time-unlimited, certificates and must become recertified to maintain board-certification status. In time, all “grandparents” will retire and all physicians certified by a specialty board will hold time-limited certificates from the ABIM or other boards within the American Board of Medical Specialties (ABMS). The experts for and against MOC agree that the concept of recertification is sound — what they disagree about is the process.
Recertification has two potential benefits. First, by reflecting that a given physician has kept abreast of his or her field, recertification can provide the type of “quality” measure of care that health care institutions, insurers, and the general public are seeking. Second, physicians could actually improve the care they provide by participating in the recertification process. Both potential benefits are important goals — so why are so few physicians with grandfather status undertaking MOC?
Among the many reasons that such physicians do not voluntarily undertake MOC, two stand out. First is a concern about the relevance of the program. The MOC examination does not accommodate the large number of physicians with a narrow scope of practice, such as an endocrinologist who focuses solely on thyroid disease or a gastroenterologist practicing only hepatology. The program's relevance is also undermined because the assessment of some key competencies — professionalism and procedural skills — is notably absent. Second, the ongoing requirement that the examination be secure and completed without access to outside sources of information flies in the face of what we teach today's medical students and residents: always use the best sources of information rather than relying on your memory alone.
Admittedly, our views on this topic may be influenced by personal experience. One of us has not pursued recertification because the examination doesn't relate to her narrow scope of practice that emphasizes procedural skills. The other recently became recertified in critical care medicine, but the recertification was not voluntary, since all certificates issued in this subspecialty are time-limited. Despite the ABIM's claims of relevance, much of the secure examination was based on cases that this test taker had never encountered in more than 30 years of practice, and it emphasized factual recall rather than diagnostic reasoning.
How can the MOC process be improved? There should be a method to ensure that the process is relevant to each physician's practice, such as permitting the test taker to select among focused subsections of a specialty or subspecialty examination. The material should reflect what physicians need to know, and the test should focus on the ability to access, interpret, and apply information — rather than just recall it. Incorporating medical simulation, as the U.S. Medical Licensing Examination has done, can help to achieve this aim.
Expanding the scope of MOC to address other dimensions of medical practice will also provide an important enhancement. We applaud the ABMS's commitment to incorporate an assessment of communication skills into the MOC process, through a survey of each physician's patients and colleagues, over the next few years. Likewise, the ABMS plan to require participation in practice-assessment and quality-improvement activities, along with completion of a patients' safety self-assessment program, should add value to the MOC process.2 We hope that assessments of technical expertise will also be considered as part of these planned additions to MOC.
Until the certification process is refined and updated to better reflect current medical practice, physicians with time-unlimited certification will need to weigh the relevance and value of MOC to their own circumstances. This is a key opportunity for the ABIM. If the MOC process can be improved so that people find it worthwhile and intellectually invigorating, then it will reach its goal of improving the quality of delivered care in a way that would make your grandmother and grandfather smile.
Disclosure forms provided by Dr. Weinstein are available with the full text of this article at NEJM.org.
Source Information
From the Office of Graduate Medical Education, Partners HealthCare System, and the Department of Medicine and Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School — all in Boston (D.W.).
- References
References
1
Levinson W ,King TE Jr ,Goldman L ,Goroll AH ,Kessler B . American Board of Internal Medicine maintenance of certification program. N Engl J Med 2010;362:948-952
Full Text | Web of Science | Medline2
Standards for ABMS MOC (parts 1-4) program. Evanston, IL: American Board of Medical Specialties, March 16, 2009. (Accessed January 21, 2010, at http://www.abms.org/News_and_Events/Media_Newsroom/pdf/Standards_for_ABMS_MOC_Approved_3_16_09.pdf.)
- Citing Articles (7)
Citing Articles
1
Stephen I. Wasserman. (2011) Maintenance of certification and maintenance of professionalism. Journal of Allergy and Clinical Immunology 128:3, 465-466
CrossRef2
Cassel, Christine K., Reuben, David B., . (2011) Specialization, Subspecialization, and Subsubspecialization in Internal Medicine. New England Journal of Medicine 364:12, 1169-1173
Full Text3
Kevin C. Chung, Philip J. Clapham, Donald H. Lalonde. (2011) Maintenance of Certification, Maintenance of Public Trust. Plastic and Reconstructive Surgery 127:2, 967-973
CrossRef4
John M. James, Mark Corbett. (2010) The American Board of Allergy and Immunology maintenance of certification program: “To do or not to do? That is the question.”. Annals of Allergy, Asthma & Immunology 105:6, 485-488
CrossRef5
R. D. Zimmerman. (2010) Maintenance of Certification: Where We Are, Why We Are Here, and Where We Need to Be. American Journal of Neuroradiology 31:8, 1373-1376
CrossRef6
Gary J. Becker, Matthew A. Mauro, Jeanne M. Laberge, Jennifer L. Bosma, David Laszakovits. (2010) Should “Dr. S” Maintain Her American Board of Radiology Subspecialty Certificate in Vascular and Interventional Radiology?. Journal of Vascular and Interventional Radiology 21:9, 1323-1329
CrossRef7
(2010) The ABIM and Recertification. New England Journal of Medicine 362:25, 2428-2430
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