April 2003 Bulletin

Maintenance of Certification: A progress report

By James V. Luck, Jr., MD, and Roby C. Thompson, MD

For the past 20 years, the American Board of Medical Specialties* (ABMS) has charged its member boards with the implementation of a credible process to assure the American public of the continued competence of their diplomates. Currently, the American Board of Orthopaedic Surgery (ABOS) evaluation includes CME credits, evaluation of practice performance and one of a variety of secure examinations including:

In response to ongoing concerns from multiple constituents, the ABMS created a task force on physician competence in 1998. This task force focused on methods to evaluate specialists after completion of initial certification. Their report was adopted by the ABMS as a program for maintenance of certification (MOC). In the report, the ABMS task force identified four essential elements for maintenance of certification:

The ABMS requested that individual specialty boards submit plans for implementation of the first three MOC components by February 2003.

The ABMS and the Council of Medical Specialties Societies ** (CMSS) established a joint planning committee on Physician Competence and Policy Development. Those discussions focused on how best to demonstrate cognitive expertise and the frequency of evaluation. Most boards currently utilize a six-to-10-year cycle for reevaluation.

The significant elements of an examination to test cognitive expertise have been defined by the ABMS Task Force and include the following:

The fourth element for assessing maintenance of certification includes a program for evaluation of practice performance that must be developed over the next year and presented to ABMS by the member boards in 2004. The purpose of this component is to demonstrate to patients, the public and the profession that physicians provide safe, effective, patient-centered, timely, efficient and equitable health care. The ABMS Subcommittee on Practice Performance is developing a framework to assist member boards. Discussions to date indicate the process will emphasize continuous improvement and will address individual physician performance, patient factors and practice site factors that influence performance. Assessment will include clinical processes and outcomes, patient satisfaction and the efficient and appropriate use of resources.

Orthopaedic surgery’s response to Maintenance of Certification

In 2000, the ABOS and the AAOS established a task force with six members from each organization to address how orthopaedic surgery could best respond to the maintenance of certification requirements defined initially by the ABMS and to address concerns and issues raised by the AAOS membership. The first meeting of this joint task force resulted in a plan for a membership survey of the AAOS and an independent opinion on the validity of using testing following continuing medical education courses as a mechanism for the assessment of cognitive expertise. Those tasks have been completed.

The three psychometric consultant opinions obtained on post-CME testing have concurred that validity testing is extremely difficult principally because of the inadequate number of participants and questions to set reliable psychometric standards, the variability of examinations from one course to another and the difficulty in developing appropriate questions.

The Academy’s membership survey was developed after two telephone conference calls with members of the Board of Councilors and focus group discussions in cooperation with the ABOS. The survey went to 1,300 members certified before 1992, 750 members certified between 1993 and 1995 and 950 members who were exempt from recertification. Nine hundred seventy-three (32 percent) responded. Among the highlights of that survey, 76 percent of the respondents agreed it was necessary to have a system that ensures competence. Seventy percent of the respondents agreed it should be a documented system, but there was no clear position on the question, "is the current system effective and fair?"

Several specialty societies and their corresponding boards have already developed dyads consisting of representatives from the specialty societies and their corresponding certifying boards to work on the first three components of the maintenance of certification. The joint task force appointed by the ABOS and the AAOS is working on a process to fulfill the first three components of the maintenance of certification.

The ABOS has a well-defined process for the ongoing evidence of professional standing, which includes extensive credentialing and peer review. It also requires 120 CME credits within three years prior to application for recertification. The ABOS plans to work with the Academy to establish acceptable mechanisms for demonstrating lifelong learning and self-assessment. This will include elements such as the Orthopaedic Self-Assessment Exam with additional modules that include patient safety, ethics and professionalism as well as general and special interest exams such as those currently offered by the AAOS. This anticipates that the ABOS will have a variety of mechanisms for self-assessment, which would include home-based exams as well as other mechanisms.

The joint task force of the AAOS and the ABOS will meet again this spring and it is anticipated that a recommendation will go to the respective boards of each organization to create a permanent joint task force that would define the curriculum for orthopaedics in a core knowledge base, a general knowledge base and a practice emphasis knowledge base for cognitive testing examination. It is anticipated that the AAOS will develop modules for each of these that would fulfill the lifelong learning and self-assessment for the Board exams.

The overwhelming interest on the part of the public and government agencies will demand such a program. Members from the federation of state medical boards announced that plans are being considered for 10-year limited licensure in many states. Recently the Texas State Board of Medical Examiners announced it would ask the state legislature to allow it to require proficiency of competency testing of physicians every 10 years.

*The ABMS represents 24 specialty boards.

**The CMSS represents 20 medical specialty societies.

James V. Luck, Jr., MD, is chair of the AAOS/ABOS Combined Task Force on Maintenance of Certification, and Roby C. Thompson, MD, is a past president of the AAOS and primary AAOS representative to the task force.

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