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Recertification: A Tale of Good Intentions but Lots of Strife

      The American Board of Internal Medicine (ABIM) is the largest of 24 certifying boards recognized by the American Board of Medical Specialties (ABMS) and currently certifies approximately 25% of all physicians in the United States.
      • Baron RJ
      • Krumholz HM
      • Jessup M
      • Brosseau JL
      Board certification in internal medicine and cardiology: Historical success and future challenges.
      The ABIM was founded in 1936, and in December of that year offered its first certifying written examination in Internal Medicine. In later years, the ABIM offered certifying examinations in various subspecialties of medicine. Since its foundation, the mission of the ABIM has been “to enhance the quality of health care by certifying internists who demonstrate the knowledge, skills and attitudes essential for excellent patient care.”
      • Baron RJ
      • Krumholz HM
      • Jessup M
      • Brosseau JL
      Board certification in internal medicine and cardiology: Historical success and future challenges.
      In particular, from its beginning, the ABIM strove to reassure the public that a board-certified internist is a well-trained and competent internist. Accordingly, more than 60 years before terms such as public reporting and public accountability entered everyday medical language, the ABIM had already embraced these concepts.
      Initially, the ABIM issued lifetime certification. However, in 1969, in an attempt to ensure that diplomates kept abreast of their field, the board adopted a resolution favoring the concept of recertification.
      • Meskauskas JA
      • Webster GD
      The American Board of Internal Medicine recertification examination: process and results.
      In parallel, the ABIM's sister board, the American Board of Family Medicine, right from its inception in 1969, offered only time-limited certification.
      • Iglehart JK
      • Baron RB
      Ensuring physicians competence–is maintenance of certification the answer?.
      To promote the idea of voluntary recertification being of value to diplomates, the ABIM, starting in October 1974 and ending in 1986, offered a series of voluntary recertification examinations (with no risk to the diplomate's lifetime certification status). However, less than 10% of those eligible elected to undertake voluntary recertification.
      • Wasserman SI
      • Kimball HR
      • Duffy FD
      Recertification in internal medicine: a program of continuous professional development. Task Force on Recertification.
      It became apparent that, although well intentioned, a voluntary approach to recertification was not going to work. Accordingly, citing the need for public accountability and the professional obligations of self-regulation, the ABIM then adopted a mandatory approach to recertification. As of 1990, all ABIM certificates were limited to 10 years. To maintain certification status, diplomates were required, among other things, to pass a secure, proctored recertifying examination within 10 years. Diplomates who obtained certification prior to 1990 (so-called grandfathers) continued to enjoy lifetime certification.
      Over the past 10 years, the value of the ABIM recertification process has been increasingly questioned by diplomates of the board. Physicians have complained that the recertification examinations are out of touch, testing on conditions and diseases they have never seen, nor ever will see, in their practice.
      • Drazen JM
      • Weinstein DF
      Considering recertification.
      They have found some maintenance of certification activities, such as patient and peer ratings, to be pointless, time-consuming exercises. Moreover, physicians have noted the paucity of high-quality data in support of ABIM's assertion that maintenance of certification improves quality of care.
      • Teirstein PS
      • Topol EJ
      The role of maintenance of certification programs in governance and professionalism.
      These concerns began to percolate at a time when physicians became increasingly frustrated by the drain on their time and energy by, among other things, ever-mounting government regulations and insurance documentation requirements, and implementation of electronic medical records. Moreover, by this stage, the number of diplomates with time-limited certification far exceeded the number of grandfathers. Among these time-limited diplomates, there was an ever-increasing sense of discontent and revolution against the ABIM.
      The revolt against the ABIM finally erupted in 2014, when the board added a number of particularly onerous requirements to the maintenance of certification process. Time-limited diplomates (now making up 80% of all diplomates) could no longer simply recertify every 10 years. Instead, they were ordered to enroll in continuous certification, pay annual dues, and complete practice improvement modules.
      Many diplomates were appalled at these additional demands and began to protest. There then emerged a somewhat unexpected champion for the battle-weary and jaded diplomates who simply had had enough of ABIM regulations. Dr. Paul Teirstein, one of the aristocrats of US cardiology, quickly created an online petition requesting a recall of the maintenance of certification process.
      • Teirstein PS
      • Topol EJ
      The role of maintenance of certification programs in governance and professionalism.
      Within a few months he had gathered more than 22,000 signatures. In subsequent debates, interviews,

      Damania Z, Teirstein P. Meet the doctor the American Board of Medical Specialties wants dead. ZDoggMD. February 5, 2018. Available at: http://zdoggmd.com/against-medical-advice-035/. Accessed July 10, 2018.

      and writings,
      • Teirstein PS
      • Topol EJ
      The role of maintenance of certification programs in governance and professionalism.
      Teirstein persuasively laid out the case for limiting certification examinations just to initial certification, and pointed out the futility of many aspects of the ABIM maintenance of certification process. Soon, this debate spilled over into the general public, with Newsweek magazine printing a somewhat provocative article about the matter, entitled “The Ugly Civil War in American Medicine.”

      Eichenwald K. The ugly civil war in American Medicine. Newsweek. March 10, 2015. Available at: www.newsweek.com/2015/03/27/ugly-civil-war-american-medicine-312662.html. Accessed July 10, 2018.

      In 2015, an alternative certification board, the National Board of Physicians and Surgeons, was formed. In a salute of recognition to the ABMS, a requirement of this new board is initial certification with an ABMS member board. However, the National Board of Physicians and Surgeons requires no recertification examinations and its continuing professional development program is considerably less demanding than that required by the ABIM.
      • Teirstein PS
      • Topol EJ
      The role of maintenance of certification programs in governance and professionalism.
      Given the ever-rising tide of opposition to the maintenance of certification process, the ABIM had no choice but to respond. Dr. Richard Baron, President and CEO of the ABIM, had, for more than 20 years prior to joining the board, been a highly respected internist practicing in the community. Moreover, he had completed the voluntary recertification process twice. Such a distinguished clinician and manifest believer in the maintenance of certification process was the perfect choice to deliver the necessary mea culpa on behalf of the ABIM. Baron conceded that ABIM had launched programs that were not ready for use and that the board had failed to deliver a maintenance of certification program that physicians found meaningful. Vowing to right these shortcomings, he immediately suspended the much-despised Practice Assessment module and froze increases in maintenance of certification enrollment fees.

      Baron RJ. ABIM announces immediate changes to MOC program. ABIM - American Board of Internal Medicine. February 3, 2015. Available at: https://www.abim.org/news/abim-announces-immediate-changes-to-moc-program.aspx. Accessed July 10, 2018.

      He also promised to make the recertification examinations more reflective of what physicians in practice are actually doing. In a nod to those physicians who elect to pursue their own path of continuing medical education rather than one laid out for them by ABIM, Baron agreed to change the phrase “not meeting maintenance of certification requirements” to the friendlier “not participating in maintenance of certification.”

      Baron RJ. ABIM announces immediate changes to MOC program. ABIM - American Board of Internal Medicine. February 3, 2015. Available at: https://www.abim.org/news/abim-announces-immediate-changes-to-moc-program.aspx. Accessed July 10, 2018.

      However, the high-stakes recertification examination (if you fail the examination, you lose your certification) remained.
      There is widespread acceptance among ABIM diplomates that the initial certification examination provides important testimony to a physician's competence as an internist or subspecialist. However, these same physicians have expressed considerable doubt about the value of regular recertification examinations throughout the rest of a diplomate's career. To make the reexamination process more palatable, this June the ABIM rolled out a new reexamination option called Knowledge Check-In.

      ABIM –American Board of Internal Medicine. MOC assessments in 2018. February 2018. Available at: www.abim.org/maintenance-of-certification/moc-faq/moc-assessments.aspx. Accessed July 10, 2018.

      Instead of having to take a day-long proctored examination every 10 years, diplomates now have the option of taking a mini (3-hour) examination every 2 years throughout the recertification cycle. Examinations may be taken at home or in the workplace, and there is immediate availability of results. A particularly important innovation (and one that simulates real-life clinical practice), is that, during the examination, candidates have access to an online evidence-based clinical decision support service called UpToDate.

      ABIM –American Board of Internal Medicine. MOC assessments in 2018. February 2018. Available at: www.abim.org/maintenance-of-certification/moc-faq/moc-assessments.aspx. Accessed July 10, 2018.

      Although these changes are laudable, they may not be enough to satisfy many diplomates.
      The ABIM currently requires that physicians be continuously tested in their acquisition and retention of medical knowledge. In turn, it is hoped and expected that the board is continuously searching for ways to make the maintenance of certification process more appealing and relevant to their diplomates.

      References

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        • Krumholz HM
        • Jessup M
        • Brosseau JL
        Board certification in internal medicine and cardiology: Historical success and future challenges.
        Trends Cardiovasc Med. 2015; 25: 305-311
        • Meskauskas JA
        • Webster GD
        The American Board of Internal Medicine recertification examination: process and results.
        Ann Intern Med. 1975; 82: 577-581
        • Iglehart JK
        • Baron RB
        Ensuring physicians competence–is maintenance of certification the answer?.
        N Engl J Med. 2012; 367: 2543-2549
        • Wasserman SI
        • Kimball HR
        • Duffy FD
        Recertification in internal medicine: a program of continuous professional development. Task Force on Recertification.
        Ann Intern Med. 2000; 133: 202-208
        • Drazen JM
        • Weinstein DF
        Considering recertification.
        N Engl J Med. 2010; 362: 946-947
        • Teirstein PS
        • Topol EJ
        The role of maintenance of certification programs in governance and professionalism.
        JAMA. 2015; 313: 1809-1810
      1. Damania Z, Teirstein P. Meet the doctor the American Board of Medical Specialties wants dead. ZDoggMD. February 5, 2018. Available at: http://zdoggmd.com/against-medical-advice-035/. Accessed July 10, 2018.

      2. Eichenwald K. The ugly civil war in American Medicine. Newsweek. March 10, 2015. Available at: www.newsweek.com/2015/03/27/ugly-civil-war-american-medicine-312662.html. Accessed July 10, 2018.

      3. Baron RJ. ABIM announces immediate changes to MOC program. ABIM - American Board of Internal Medicine. February 3, 2015. Available at: https://www.abim.org/news/abim-announces-immediate-changes-to-moc-program.aspx. Accessed July 10, 2018.

      4. ABIM –American Board of Internal Medicine. MOC assessments in 2018. February 2018. Available at: www.abim.org/maintenance-of-certification/moc-faq/moc-assessments.aspx. Accessed July 10, 2018.