Responds to public demand for professional accountability;
stimulates study which increases knowledge, skills
By Michael A. Simon, MD, and G. Paul DeRosa, MD
"The Value of Recertification to Orthopaedic Surgery and to the Public" is being reprinted with permission of The Journal of Bone and Joint Surgery. The article appeared as Commentary in the February 1999 issue of JBJS.
Rationale for recertification
There is an increasing demand for accountability in all areas of our society. State licensing boards, while thorough, are perceived as too lenient, and physicians tend to shield inept colleagues from public scrutiny. All the while, medical practice has become much more specialized and complex. For these reasons and more, the public is more concerned than ever about the continuing competence of their physicians and surgeons. Beginning efforts to establish practice guidelines now underscore the public's desire to be assured that orthopaedic surgeons are knowledgeable and competent to treat with use of the latest clinical innovations. Although the initial impetus for recertification came from the public, recertification also benefits our profession immensely. Through periodic evaluation, the recertification process demonstrates to the profession and to the public that the orthopaedic surgeon has maintained an acceptable level of continuing qualifications, knowledge, and skills in his or her area of practice.
The rapidly changing scope of medical information, the public's demand for professional accountability, and the need to recredential physicians periodically are the major reasons why the American Board of Orthopaedic Surgery decided to implement recertification. It is illogical, in fact incredible, to accept that an initial, single evaluation of a practitioner's skills is sufficient for 30 years of clinical or operative practice, or both, when one considers the changes in medical information and technology in the operating room. In fact, if one believes in the certification process, one must support the concept of recertification. If the use of objective examinations to determine which physicians are qualified as specialists is acceptable, it is difficult to understand why similar tests to measure continuing qualifications to practice are often criticized. The recertification process embodies orthopaedic surgery's commitment to professionalism and to the awareness that lifelong clinical and psychomotor skills as well as scholarship are required in order to continue the clinical practice of orthopaedic surgery while providing for the judicious care of patients. The process of recertification improves the overall quality of orthopaedic care of patients, establishes higher standards of clinical competence, and promotes continuing scholarship as the orthopaedic surgeon strives for professional excellence over the entire period of his or her clinical and operative practice.
The public is interested in continuing competence. This is made evident by the activity of nonphysicians and institutions in areas such as systematic local credentialing, utilization review, practice guidelines, establishment of the National Practitioner Data Bank and outcomes research. (The effectiveness of practice guidelines or algorithms ultimately depends on the competence of individual physicians.) Thus, consumer groups as well as those who are charged with protecting the public's welfare hold the profession accountable for continuing competence. Even third party payers are beginning to require evidence of continued competence. Recertification, although imperfect, is an attempt by our profession to respond to these external forces. Enforced standards of learning are the basis of accountability, and orthopaedic surgeons must support them. If we abdicate our responsibility to improve credible standards, then other, less knowledgeable parties will gladly perform this function. The need for accountability within the workplace is seen everywhere. It is important for orthopaedic surgeons to realize that medicine is not the only profession with recertification, reevaluation, or recredentialing. Nurses, nurse anesthetists, pilots, law-enforcement officers and many other professionals must undergo similar processes.
History of the recertification process
In 1973, the American Board of Medical Specialties adopted in principle, and urged its member boards to implement, voluntary periodic recertification and establishment of a deadline for recertification to become standard policy. This policy was adopted in 1978. In 1993, recertification was reaffirmed and all boards were required to establish a plan for recertifying diplomates. The stimulus for this requirement was a study showing an inverse relationship between scores on a multiple-choice examination and the number of years since initial certification of diplomates of the American Board of Internal Medicine1. The goal of recertification is to evaluate the continuing competence of a diplomat in the specialty in which he or she was initially certified. The American Board of Medical Specialties recognized that the methods and procedures that are appropriate for recertification may be different from those for initial certification. It also encouraged input from appropriate specialty societies including, for example, the American Academy of Orthopaedic Surgeons.
It was made the prerogative of individual boards to provide either voluntary or mandatory recertification, but a specialty board was not allowed to rescind initial certificates through the recertification process unless time-limited certificates were issued. The elements to be considered in recertification included evaluation (through peer review) of the applicant's skills and practice performance, assessment (by means of a test) of his or her cognitive ability, and continuing education.
After much discussion and many disagreements with the American Academy of Orthopaedic Surgeons, the American Board of Orthopaedic Surgery first issued time-limited certificates in 1986. These certificates were valid for 10 years. If the diplomates did not become recertified within 10 years, his or her name was removed from the directory of certified diplomates. Although there was a great amount of raucous debate within the orthopaedic community, the decision ultimately led to a broad-based method by which diplomates could be recertified. Initially, there were four different pathways: a general written examination, a practice audit, an oral examination and the Certificate of Added Qualifications in Surgery of the Hand. This was the largest number of pathways adopted by any member board of the American Board of Medical Specialties. In addition, the American Board of Orthopaedic Surgery initiated the most stringent peer review of all of the boards and also required 120 hours of category-I continuing medical education. The oral examination, which was taken by 100 candidates in 1998, continues to be the most valid method used by the American Board of Orthopaedic Surgery to recertify candidates because it evaluates the candidate's actual practice with his or her own patients. The American Board of Orthopaedic Surgery is only one of two boards that have an oral recertification examination. Recently, the American Board of Orthopaedic Surgery added a computer-administered general clinical examination and a computer-administered practice-profile examination in the subspecialties of adult reconstruction, sports medicine and spine. The practice-audit pathway has been eliminated.
Differences between certification and recertification
It is important to remember that all candidates for recertification have already passed a certifying examination and have been in the practice of orthopaedic surgery for a minimum of seven years. Also, the philosophy of the American Board of Orthopaedic Surgery's recertification process is to evaluate diplomates in the area of what they are currently doing-that is, their practice profile. Thus, one would expect the success rate for recertification to be higher than that for initial certification. This expectation is substantiated by the much higher pass rates for recertification candidates with time-limited certificates issued in 1987 and 1988. However, credentialing and peer review play a major role in the recertification process. The peer-review process of the American Board of Orthopaedic Surgery is the most intense of any of the member boards of the American Board of Medical Specialties. The American Board of Orthopaedic Surgery has, for the past four years, closely evaluated between 17 and 21 recertification candidates. Of this number, between four and 10 were deferred from taking the examination and between one and four had to have a site visit of their practice by representatives of the Board to decide if it met the qualifications expected of the practice of a diplomate of the American Board of Orthopaedic Surgery. None of these candidates who were so closely investigated had lost their licenses, were convicted felons or had displayed serious behavioral problems that would have prevented them from taking the examination, and almost all of them could have passed a knowledge-based examination. These individuals are not represented in any pass/fail percentages of the recertification examination. Thus, the credentialing and peer-review portion of the recertification process is another benefit to our profession. In fact, if the peer-review process were ideal (that is, without any behavior motivated by a fear of competition or a fear of legal action), there probably would not be a need for any recertification examination. The recertification program does not consist of an examination alone, but is a process that represents a complex, multistep effort to reassure the public and our profession that practicing orthopaedic surgeons are highly competent individuals.
The American Board of Orthopaedic Surgery and the American Board of Medical Specialties-why they exist
Professional accountability requires our profession to set and maintain credible, useful standards for both certification and recertification. Establishing and enforcing these standards is our responsibility, not that of governmental agencies, health maintenance organizations, hospitals or other groups. In addition, a medical society with a dues-paying membership may not have public credibility because the perception is that it will act in its own self-interest. For these reasons, an independent organization that has no conflict of interest and is knowledgeable in the evaluation procedures and processes is best equipped to perform this function. Ultimately, the success of certification and recertification rests with the credibility of the sponsoring organization. The American Board of Medical Specialties is the most credible certifying and recertifying organization because it has more than 50 years of medical-certification experience encompassing all medical specialties, and it has a large, extremely competent infrastructure of highly educated nonphysicians who are experts in the evaluation process. No other board that issues certificates has the experience, rigor, quality, ability or credibility of the American Board of Medical Specialties, of which the American Board of Orthopaedic Surgery is a member.
Recertification rate of the American Board of Orthopaedic Surgery
Although the recertification process is by no means ideal, the high rate of compliance by the diplomates with the initial time-limited certificates of 1986 is one measure of the success of the program. In 1986, 629 candidates were certified by the American Board of Orthopaedic Surgery for 10 years. As of the spring of 1998, six of those individuals had died, four had applications on file, and only 12 (2 percent) had not been recertified. Of those 12, two were practicing in Canada and were certified by the Royal College of Physicians and Surgeons of Canada; thus, they did not need recertification by the American Board of Orthopaedic Surgery. Three of the remaining 10 diplomates could not be found in the directories of the American Board of Medical Specialties, the American Board of Orthopaedic Surgery, or the American Academy of Orthopaedic Surgeons. This means that only seven of the 629 diplomates who were eligible for recertification were not recertified. Likewise, of the candidates for recertification who had originally been certified in 1987, only nine Americans were not recertified or in the process of taking the recertification examination. One of the nine was disabled, another had become a corporate executive, and another had applied for the 1999 examination. Thus, only six diplomates were not recertified or in the process of recertification. Compared with other member boards of the American Board of Medical Specialties, the American Board of Orthopaedic Surgery has the highest rate of compliance with the recertification process.
It is the perception of some orthopaedic surgeons that all recertification candidates pass; thus, they question the need for an examination. First, recertification candidates should have a higher pass rate than certification candidates. After all, they have already been certified; they passed an examination that approximately 13 to 16 percent of their peer group did not. (For example, 96 of 641 candidates failed the Part-I certification examination in 1986 and 73 of 449 failed it in 1987.) Therefore, in general, recertification candidates are more able than certification candidates. This concept is confirmed by the fact that in 1998 candidates for recertification scored higher than candidates for initial certification when both took the same hand examination. However, as implied by the study done by the American Board of Internal Medicine1, it is not clear that a subspecialist will perform well on an examination assessing competence in general orthopaedic surgery. Second, as previously stated, some diplomates are prevented from taking the recertification examination because they do not pass the credentialing process or peer review. Finally, in 1998, 14 (2 percent) of 578 candidates failed the recertification examination compared with 91 (14 percent) of 668 who failed the Part-I written certification examination and 64 (9 percent) of 709 who failed the Part-II oral certification examination.
It is clear that the process of recertification stimulates study, which increases knowledge and skills. Likewise, continuing medical education alone is not an adequate process for recertification. Continuing medical education is analogous to auditing a course, but not taking the examinations; it does not confirm to the American public that skills and knowledge have been obtained. Attendance at lectures and conferences does not guarantee that the diplomate is any wiser, any more than a fellow or resident is qualified to practice as a specialist without passing a certifying examination. In addition, many continuing medical education courses are sponsored by organizations with a dues-paying membership or by industry, both of which have a substantial financial interest in the number of attendees at the course.
An added benefit of recertification is that some states require it for renewal of licensure. If a candidate does not have such a certificate, then he or she must take a state-administered examination evaluating general knowledge in the whole field of medicine. If an orthopaedic surgeon has obtained recertification, he or she does not have to take such an onerous written examination.
As of this writing, all 24 member boards of the American Board of Medical Specialties are required to have a recertification process. Fourteen boards have an operational recertification program, eight boards are actively planning a recertification program, and the remaining two boards are starting their program this year. Of the eight boards in the planning stages, most expect to implement their recertification process before the year 2002.
Finally, the American Board of Orthopaedic Surgery has the most
flexible recertification program with the greatest number of examination
pathways. It also has the most stringent credentialing and peer-review
processes. The intent of the recertification process of the American
Board of Orthopaedic Surgery is to serve the best interests of
the public and the medical profession by evaluating the initial
and continuing qualifications and knowledge of orthopaedic surgeons.
Michael A. Simon, MD is past president of the
American Board of Orthopaedic Surgery; G. Paul DeRosa, MD, is
executive director of the American Board of Orthopaedic Surgery.