“There is nothing more difficult to plan, more doubtful of success, nor more dangerous to manage than the creation of a new order of things.”
The Prince Machiavelli
The purpose of this report is to provide the reader an historical context for the mission of the American Board of Medical Specialties (ABMS), a chronology outlining the development of the ABMS' Maintenance of Certification™ (MOC) program, and the broader social and political context and environment in which the MOC program was developed.
History of Certifying Medical Boards
Dr. Derrick T. Vail, during his 1908 presidential address to the American Academy of Ophthalmology and Otolaryngology, first proposed the concept of a certifying board whose primary purpose would be to assess the qualifications of ophthalmologic physicians in the United States. He correctly called attention to and identified the need for eye specialists to have adequate education and training in a recognized “ophthalmologic institution” before being allowed to sit before “a proper examining board.” In 1915, the American Ophthalmologic Society, the Section of Ophthalmology of the American Medical Association (AMA) and the American Academy of Ophthalmology joined forces to establish the American Board of Ophthalmologic Examinations. Its purpose was to test those individuals who wished to exclusively practice ophthalmology. The newly created Board was incorporated in 1917. In 1933, the Board changed its name to the American Board of Ophthalmology.
In 1924, a second specialty board, the American Board of Otolaryngology, was formed and incorporated. Subsequently, two other boards, the American Board of Obstetrics and Gynecology in 1930 and the American Board of Dermatology and Syphilology in 1932, were formed and incorporated. In 1933, representatives from the four specialty boards, in addition to representatives from the American Hospital Association, the Association of American Medical Colleges, the Federation of State Medical Boards, the AMA's Council on Medical Education and the National Board of Medical Examiners created the Advisory Board for Medical Specialties.1
“The purpose of the Advisory Board was to: (1) furnish an opportunity for the discussion of problems common to the various specialty examining boards in medicine and surgery; (2) act in an advisory capacity to the boards; (3) coordinate their work as far as possible; (4) assume jurisdiction over those policies and problems common to all of the Boards that are expressly delegated to it by the component boards; (5) not interfere with the autonomy at any examining board having representation herein; and (6) stimulate improvement in postgraduate medical education.” The purposes and goals remain similar today, although they have been substantially broadened and expanded as the organization has grown and matured.2
The organization underwent several reorganizations over the course of the ensuing 35 years. In 1970, the Advisory Board once again reorganized itself and was renamed the American Board of Medical Specialties (ABMS), and a full time Executive Director was hired. Since then, the ABMS has become the umbrella organization, consisting of 24 Member Boards and nine Associate Members. Collectively, these 24 Member Boards issue initial certificates in 37 primary general specialties and 94 subspecialties.
All Member Boards have developed rigorous criteria for entry to their certification programs. These standards, overseen by the ABMS, are important for and integral to the board certification process. The standards establish, at a minimum, that a candidate has fulfilled the education, training, and licensure standards and the ethical and professionalism requirements deemed necessary by the specialty board from which the candidate is seeking certification. The initial certifying examination(s), given by the boards, are carefully, objectively, and fairly constructed. The examinations are subject to ongoing intense psycho-metric statistical analysis and study to document their continuing reliability and validity. They are specialty specific and are used to assess the knowledge and, when possible, the relevant clinical skills of the examinees. In spite of the added time and effort required of candidates to fulfill the rigorous prerequisites for certification by an ABMS Member Board, the numbers of physicians who voluntarily choose to undergo specialty and fellowship training and become certified has been steadily increasing. In 2005, ABMS Member Boards had certified approximately 89% of all licensed US physicians.3
Although not perfect, the initial certification process is very good and does accomplish its intended purpose. However, initial certification is based on a one time, snapshot assessment rather than a continuing evaluation, which comprises an assessment and a process to inform and encourage quality improvement. Additionally, there is a need for certification to be expanded beyond an evaluation of knowledge alone to encompass competencies the profession agrees are the hallmarks of competent clinical practice. Initially, to address the perceived deficiencies in the processes of certification, the Member Boards and the ABMS developed the concept of recertification in the hope that requiring diplomates to recertify by examination would provide the necessary impetus for specialists to remain current and practice state-of-the-art medicine. In addition, time-limited certificates were introduced to ensure diplomates acquired new knowledge and skills through a variety of continuing medical education activities. It is now believed, however, although recertification by examination is necessary, it is insufficient to document a physician has maintained the competencies deemed important to provide quality medical care in a specialty. To accomplish this goal requires a broader and more comprehensive evaluation of the physician and his or her practice.
ABMS Task Force on Competence
In March 1998, the ABMS established the Task Force on Competence because of a perceived need to satisfy the public, payers, other healthcare organizations and entities, governmental agencies, and members of the profession itself that specialist physicians are competent and maintain their competency throughout the span of their professional careers.
The Task Force's charge was: (1) to develop and recommend a mission statement to include specific purposes and responsibilities that affirm, to the public and other stakeholders, the commitment of the ABMS and its Member Boards to certify and to recertify their diplomates are competent to practice their specialties; (2) to develop and recommend a definition of competence and the qualities necessary for competence in the chosen area of specialty practice useful to all Member Boards; (3) to recommend and stimulate collaborative proactive research on assessment methods for certification and recertification and the validation of those methods by Member Boards; (4) to develop and recommend a template for the design of specialty specific techniques useful to each of the Member Boards in assessing competence; (5) to develop and recommend mechanisms by which the requirements, processes, standards, and outcomes of certification of each Member Board may receive the benefits of regular peer review for the purposes of quality improvement; and (6) to develop and recommend collaborative methods to assess clinical knowledge and performance, which are common to all Member Boards.
The ABMS and its Member Boards are active stake-holders in graduate medical education and believe medical education should be a continuum rather than an isolated learning event. As a result of its involvement as a stake-holder in graduate medical education, the ABMS, in concert with the Accreditation Council for Graduate Medical Education (ACGME), developed a common set of six general competencies believed to be important for all specialists to possess and maintain throughout their professional careers. These competencies were to be developed and/or refined during residency training, evaluated during initial certification, and subsequently further refined, updated, and reassessed as they participated in programs of maintenance of certification. The six general competencies are: medical knowledge, patient care, interpersonal and communicative skills, professionalism, practice-based learning and improvement, and systems-based practice.2 Currently, the ABMS and the ACGME are encouraging the development of tools and standards by which to measure each of the six competencies. Before the ABMS and the ACGME uses them, the tools recommended must be demonstrated to be reliable, valid, and economically feasible in the context in which they will be used.
The ABMS Task Force on Competence concentrated its efforts on developing standards and methods to evaluate physician specialists after their initial certification. As a result of these efforts, a program entitled Maintenance of Certification™ (MOC) was proposed and adopted by the ABMS and the Member Boards.1 The program consists of four essential elements or components that are embedded within the six general competencies. To maintain certification, a diplomate must provide: (1) evidence of professional standing; (2) evidence of commitment to lifelong learning and involvement in a periodic self-assessment process; (3) evidence of cognitive expertise; and (4) evidence of evaluation of performance in practice.
To meet the first requirement, a diplomate must hold an unrestricted license to practice medicine in at least one jurisdiction in the United States, its territories, or Canada, and if licenses are held in more than one jurisdiction, all licenses held by the physician should meet this requirement.
For the second requirement, a diplomate must engage, at a minimum, in the lifelong learning and self-assessment processes required by his or her board. The content of lifelong learning and self-assessment should be specialty specific. The boards will set the standards for evidence of lifelong learning and the performance of diplomates evaluated according to the standards established.
Third, the diplomate must pass an examination of his or her cognitive knowledge. The boards must ensure the testing process is secure, psychometrically reliable, and clinically valid. It should evaluate necessary and clinically relevant core and current knowledge, including issues related to practice environment. Aggregate results of the examination should be available to the public. The examination should occur, and be required as a minimum, at least every 10 years.
Finally, to date, specific measures, standards, and processes to meet the fourth requirement have not been completely defined by either the ABMS or the Member Boards. However, guidelines have been promulgated by the ABMS to aid each of the boards in developing specialty specific and, as appropriate, common processes for all boards to assess the practice performance of their diplomates. The guidelines call for the development of processes to assess patient care using the most current data available. Scientifically valid and reliable data collection and methods of analysis will be used. The process will focus on improving the quality of patient care and emphasize continuous improvement of practice performance. There will be no grading per se and no high stakes decision for or against maintaining diplomate certification status, other than whether they have engaged in the processes of MOC as defined by their certifying board. The evaluation will address individual practice factors, patient and environmental, that influence performance. It will use a balanced set of measures and include assessment of clinical structure, process, outcomes, and patient satisfaction and the efficient and appropriate use of resources. Current examples of processes developed by individual boards or the ABMS and the boards in collaboration with other organizations include: the ABMS Patient Safety Module, Web-based Improvement Modules used by the disciplines of Family Medicine, Internal Medicine, and Pediatrics and the Tracking Operations and Outcomes for Plastic Surgeons (TOPS) program from the discipline of Plastic Surgery.
One of the primary responsibilities of the ABMS is to aid the Member Boards in their quasi-regulatory function: certifying physician specialists. Thus, the mission of the ABMS is to: (1) “maintain and improve the quality of medical care by assisting the Member Boards in their efforts to develop and utilize professional and educational standards for the certification of physician specialists;” and, (2) “provide assurance to the public that a physician specialist certified by a Member Board of the ABMS has successfully completed an approved educational program and evaluation process, which includes components designed to assess the medical knowledge, judgment, professionalism and clinical and communication skills required to provide quality patient care in that specialty.”4
There is little question there is an increasingly strident and urgent call for the timely institution of measures of performance and physician accountability as these factors relate to the processes and outcomes of medical care in the United States. The ABMS and the Member Boards believe now is the time for measured, thoughtful, proactive professional involvement in setting quality standards for medical practice. Principles such as those contained in the maintenance of certification programs of the ABMS and its Member Boards can be at the forefront of the quality medical care movement in the United States.
The success of MOC is also dependent on its providing value to and for participating physicians. To this end, participation and fulfillment of the requirements for MOC should be embedded within clinical practice, not as added burdens for the physician or the individual's staff. As an example, what if during the course of routine clinical practice, a problem in patient care, be it process or outcome, arises and is identified as such by the clinician? Once identified, the physician can access in real time the literature that may be available and have this search tracked for learning credits. What if the program accessed by the physician is interactive and directs the physician to begin to collect his or her own data and provides benchmarks for the physician to use to compare his or her method of handling the problem with selected peer groups? What if a program is available, online or through a mentoring process using specialty societies or academic health centers, to enable the physician to develop a quality improvement program, to actually track improvement over the course of time, and to do all this in lieu of passive CME, at the same time fulfilling the requirements for MOC? Finally, and most intriguing, is what if these processes were organized in such a way the principles of MOC were so well accepted MOC could be accepted as a proxy for continuing competency accepted by state medical licensing boards for re-licensure, by hospitals and health care organizations in their credentialing and privileging processes, and by health plans when constructing their health care panels?
One of the ways for this to become a reality is for the profession to collaborate in doing the right thing. Many of the major organizations have already begun to do so in an attempt to coordinate their efforts to avoid duplication and address the needs and expectations of their constituents. For example, the ABMS/ACGME collaboration has resulted in the development of the six general competencies and regular conferences to exchange ideas on the development of tools, measures, and standards by which to learn and assess those competencies, initially and during the course of one's entire professional career. Another example is the Joint Planning Committee of the ABMS and Council on Medical Specialty Societies (CMSS), which is working on encouraging the development of specialty specific relationships between boards and specialty societies for the express purpose of coordinating efforts towards life-long learning and self-assessment and practice performance assessment. Another collaborative effort that should prove helpful to practicing physicians is the development of an ABMS/Consumer Assessment of Health Plan Survey (CAHPS) survey instrument regarding patient care experiences. The CAHPS instruments are currently in use by healthcare plans to evaluate the experiences of patients in hospital and ambulatory settings. However, the ABMS and Member Boards had been developing their own surveys to measure the same thing. Now the two groups are collaborating so a single instrument will serve two purposes. Collaborative efforts are underway with the Accreditation Council for Continuing Medical Education, Federation of State Medical Boards of the United States, National Board of Medical Examiners, Joint Commission on Accreditation of Healthcare Organizations, and several other organizations.
While all of these efforts are laudable, the ABMS still firmly believes for the MOC processes to be accountable to and credible for the public, they should be subject to timely oversight and monitoring by a committee of knowledgeable individuals from within the ABMS, other related medical organizations, and members of the public. To accomplish this, the Committee on Oversight and Monitoring of Maintenance of Certification has been formed and charged with: (1) according to a schedule to be developed, regularly receiving and reviewing reports from individual Member Boards with respect to the progress in development and implementation of their individual MOC programs; (2) verifying and documenting compliance by individual Member Boards that have appropriately developed and implemented MOC programs; (3) providing recommendations and guidance to Member Boards with respect to segments of their MOC programs which are not adequately developed or being implemented; and (4) after appropriate discussions with Member Boards not in compliance with general ABMS MOC guidelines, reporting such noncompliance to the executive committee for appropriate review and action.
One of the major barriers to measuring and improving the quality of medical care in the United States is cultural rather than technical. Collectively, the medical profession in the United States has failed to develop a rational system necessary and sufficient to promote the continuing education and evaluation of practicing physicians. Over the next several years, the ABMS and its Foundation will foster the development of tools to evaluate other core competencies that cross specialties (eg, professionalism, patient safety, systems-based practice) for use by boards in their MOC programs.
Participation in MOC will involve most US physicians and will include assessment of physician practice performance through quality improvement initiatives. We believe the MOC programs of the ABMS Member Boards can be a major impetus to begin promoting a system that could prove helpful in advancing the public and professional movement for quality medical care to produce better patient health outcomes.