Time-limited certification and recertification: the program of the American Board of Internal Medicine. The Task Force on Recertification

Definitions of Physician Certification Used in the North American Literature: A Scoping Review

INTRODUCTION

The authors sought to identify how physician specialty certification is defined in the North American literature.

METHODS

A rigorous, established six-stage scoping review framework was used to identify the North American certification literature published between January 2006 and May 2016 relating to physician specialty certification. Data were abstracted using a charting form developed by the study team. Quantitative summary data and qualitative thematic analysis of the purpose of certification were derived from the extracted data.

RESULTS

A two stage screening process identified 88 articles that met predefined criteria. Only 14 of the 88 articles (16%) contained a referenced purpose of certification. Eighteen definitions were identified from these articles. Definitional concepts included lifelong learning and continuous professional development, assessment of competence and performance, performance improvement, public accountability, and professional standing.

DISCUSSION

Most articles identified in this scoping review did not define certification or describe its purpose or intent. Future studies should provide a definition of certification to further scholarly examination of its intent and effects and inform its further evolution.

Medical specialty certification in the United States-a false idol?

PURPOSE

Recent changes to medical specialty certification in the USA have prompted the process to come under intense scrutiny.

METHODS

We review the history of board certification and the changes made to the process. As part of this review, we examine both literature and public record to examine the motives behind the changes made. We then review the legal challenges and changes under way to modify the current ABMS board re-certification process.

RESULTS

In 1917, the first board certification was a lifetime designation, voluntary, and managed by unpaid board members with a focus to enhance quality for patients. Corresponding to the implementation of time-limited certification, $55 million of physician testing fees were transferred from the American Board of Internal Medicine to its Foundation between 1989 and 1999. From 2000 through 2007, and additional $20.66 million were transferred from the ABIM to its Foundation culminating in the purchase of a $2.3 million luxury condominium in December 2007.

CONCLUSIONS

Significant financial conflicts of interest for the implementation of time-limited specialty certification exited and continue to plague the medical profession. The specialty boards and the organizations that created them should remove all requirements for time-limited board certification and resort to conventional self-selected ACGME-approved CME programs for ongoing education.

Association of Physician Certification in Interventional Cardiology With In-Hospital Outcomes of Percutaneous Coronary Intervention

BACKGROUND

The value of American Board of Internal Medicine certification has been questioned. We evaluated the Association of Interventional Cardiology certification with in-hospital outcomes of patients undergoing percutaneous coronary intervention (PCI) in 2010.

METHODS AND RESULTS

We identified physicians who performed ≥10 PCIs in 2010 in the CathPCI Registry and determined interventional cardiology (ICARD) certification status using American Board of Internal Medicine data. We compared in-hospital outcomes of patients treated by certified and noncertified physicians using hierarchical multivariable models adjusted for differences in patient characteristics and PCI volume. Primary end points were all-cause in-hospital mortality and bleeding complications. Secondary end points included emergency coronary artery bypass grafting, vascular complications, and a composite of any adverse outcome. With 510,708 PCI procedures performed by 5175 physicians, case mix and unadjusted outcomes were similar among certified and noncertified physicians. The adjusted risks of in-hospital mortality (odds ratio, 1.10; 95% confidence interval, 1.02-1.19) and emergency coronary artery bypass grafting (odds ratio, 1.32; 95% confidence interval, 1.12-1.56) were higher in the non-ICARD-certified group, but the risks of bleeding and vascular complications and the composite end point were not statistically significantly different between groups.

CONCLUSIONS

We did not observe a consistent association between ICARD certification and the outcomes of PCI procedures. Although there was a significantly higher risk of mortality and emergency coronary artery bypass grafting in patients treated by non-ICARD-certified physicians, the risks of vascular complications and bleeding were similar. Our findings suggest that ICARD certification status alone is not a strong predictor of patient outcomes and indicate a need to enhance the value of subspecialty certification.

Maintenance of certification in Internal Medicine: participation rates and patient outcomes

The clinical practice of internal medicine continues to evolve with the addition of new information and new technology. Most internists in practice will have erosion of their knowledge after they complete training unless life-long learning occurs. The American Board of Internal Medicine (ABIM) began to issue time-limited certification in 1990 and asserts that the Maintenance of Certification (MOC) program promotes the professional development of internists. However, the available medical literature does not provide strong support for the assumption that internists with certification or recertification have better patient outcomes. This relationship between recertification and patient outcomes needs more study. In addition, the participation in the Maintenance of Certification program by internists with lifetime certifications has been low, and recertification by leaders in internal medicine has also been relatively low. Some physicians in practice have concerns about the relevance of the program and the cost. Our review suggests that the ABIM needs to review its current Maintenance of Certification program and make changes to enhance its clinical relevance and educational value. We suggest that professional development should be based on focused reviews of the current literature, which is immediately relevant to clinical practice, and that recertification could be based on completion of modules and more frequent, less onerous testing.

A critical analysis of mini peer assessment tool (mini-PAT)

The structured evaluation of doctors' performance through peer review is a relatively new phenomenon brought about by public demand for accountability to patients. Medical knowledge (as assessed by examination score) is no longer a good predictor of individual performance, humanistic qualities and communication skills. The process of peer review (or multi-source assessment) was developed over the last two decades in the USA and has started to pick up momentum in the UK through the introduction of Modernizing Medical Careers. However the concept is not new. Driven by market forces, it was initially developed by industrial organizations to improve leadership qualities with a view to increasing productivity through positive behaviour change and self-awareness. Multi-source feedback is not without its problems and may not always produce its desired outcomes. In this article we review the evidence for peer review and critically discuss the current process of mini peer assessment tool (mini-PAT) as the assessment tool for peer review employed in UK.

Accuracy of medical staff assessment of trainees' operative performance

The aim of this study was to determine the accuracy of medical staff assessment of trainees' operative competence. Over 18 months all 36 basic surgical trainees in SE Scotland were evaluated at the end of each attachment by consultants and registrars on their ability to perform key operative procedures using a previously validated assessment form. Frequency of assessment was compared with: (1) trainee's recording of whether the specific assessor had actually directly supervised them performing the procedure and (2) number of supervised procedures performed by trainees as determined by logbook data. A high percentage of both assessor groups provided assessment of procedures which they had not observed. Only 19/102 consultants and 20/95 registrars assessed only those procedures directly observed. A median of 9% (range 0-54%) of staff provided assessment for procedures that trainees had never even performed during that attachment. Such discrepancy needs to be addressed if accurate assessment of competence is to be achieved by trainers.

31. Assessment of clinical competence of the allergist/immunologist

The assessment of physician performance is increasingly central to the practice of medicine. Participation in such assessment is a manifestation of adherence by the physician to the highest standards of professionalism. The goal of physician assessment is to assure patients and their families, the public, fellow physicians, and ourselves that we are continuing to perform at the highest levels possible. Traditionally, trainees have been assessed by their program directors, and the methods for such assessment are in place and have, in some cases, been validated against outcomes. Assessment of practicing physicians is a newer concept and arose as a response to the needs of physicians to demonstrate accountability and the demands of the public and regulatory bodies. The leadership of the medical profession and the certifying boards are committed to effective and appropriate assessment and are in the process of implementing physician assessments. To do so, multiple innovative and exciting new evaluative tools are under development. This review discusses the history, background, and current state of the art in this arena.

Evaluation of an audience response system for the continuing education of health professionals

INTRODUCTION

Continuing medical education (CME) for physicians and other health personnel is becoming increasingly important in light of recertification requirements. Interactive learning is more effective and may be useful in a continuing education setting. This study examines the use of an audience response system (ARS) as an interactive learning tool for health care providers.

METHOD

We conducted a national randomized controlled trial to evaluate the utility of an ARS to enhance attention and learning. Speakers at 42 clinical round table (CRT) programs in five regions across the United States were randomized to "use" or "no use" of an ARS during their lectures. We surveyed participants to collect data regarding presentation and speaker quality, impressions of the ARS, and knowledge of the material presented. We collected information from speakers regarding ease of use and overall opinions of the ARS.

RESULTS

A total of 283 surveys were completed (164 from participants using the ARS and 119 from participants not using the ARS). ARS participants rated the quality of the presentation, the quality of the speaker, and their level of attention more highly than non-ARS participants (p < .05). Knowledge scores (of material presented) were not significantly different between the two groups. Both participants and speakers felt that the ARS was easy to use and preferred to use the system in future CRTs.

DISCUSSION

Participants in CRTs with the ARS rated presentation and speaker quality more favorably than those participants in CRTs without the tool. Participant knowledge scores, however, were not significantly different. ARSs may provide easy-to-use tools to enhance attention and enthusiasm in CME learners.

Continuing education for cytotechnologists: the Australian experience

The development of a continuing education scheme for cytotechonologists in Australia is described. The process involved the establishment of a working party with Terms of Reference to review current practice in Australia and existing schemes in other parts of the world. The scheme developed takes the form of a continuing education diary that provides guidelines on the various forms of continuing education activity and corresponding credit points. The diary also provides for a record of activity to be kept. The scheme requires bi-annual submission of personal activity which is logged into a national database. A peer profile is provided and successful achievement is marked by the issue of a certificate of participation. The programme has achieved a 57% compliance in its first year of operation.

The relevance to clinical practice of the certifying examination in internal medicine

OBJECTIVE

To determine the relevance of the initial certifying examination to the practice of internal medicine and the suitability of items used in initial certification for recertification.

DESIGN

Using a matrix-sampling approach, items from the 1991 Certifying Examination were assigned to two sets of judges: directors of the American Board of Internal Medicine (ABIM) and practicing general internists. Each judge rated the relevance of items on a five-point scale.

PARTICIPANTS

54 current or former directors of the ABIM and 72 practicing general internists; practitioners were nominated by directors and their ratings were included if they spent > 80% of their time in direct patient care.

RESULTS

The directors' mean rating of all 576 items was 3.98 (SD = 0.62); the practitioners' mean rating was 4.11 (SD = 0.82). The directors assigned to 27 items ratings of less than 3 and the practitioners assigned to 42 items ratings of less than 3; seven of these items received low ratings from both groups. There were differences in the two groups' ratings of the relevance of various medical content categories, but the mean rating of core items was higher than that of noncore items and the mean rating of items testing clinical judgment was higher than that of items testing knowledge or synthesis.

CONCLUSIONS

These findings suggest that the initial certifying examination is relevant to clinical practice and that many of the examination items are suitable for use in recertification. Differences in perception appear to exist between practitioners and directors, and the use of practitioner ratings is likely to be a routine part of judging the suitability of items for Board examinations in the future.