Certification has long been accepted as a process to ensure a specified level of qualifications of practitioners of a given medical specialty. This process is conducted by the member boards of the American Board of Medical Specialties (ABMS). Although certification was traditionally completed at the end of training and was granted lifelong, in the 1980s this began to change. Concern that practitioners remain current and up-to-date in their practice skills led to a movement to time limit certification and require periodic recertification. This process has been well established and accepted over the past two decades. However, recent changes in definitions of physician competencies and recognition of weaknesses in the current recertification process have led to the development of a more continuous concept for recertification, or Maintenance of Certification, among the member boards of the ABMS.
The American Board of Orthopaedic Surgery has embraced these concepts in an effort to improve the process, and is currently phasing in a Maintenance of Certification process that will incorporate several new measures, including more frequent learning and self-assessment requirements, case list evaluations, and patient satisfaction and communication surveys in an effort to provide feedback to physicians to improve their practices.
I will review the evolving certification and recertification processes and describe planned modifications.
Certification and Recertification
The certification process grants recognition to an individual who has met specific predetermined qualifications. The current configuration of board certification in orthopaedic surgery includes the Part I written and Part II practice-based oral examinations after completion of accredited residency education. Part I tests cognitive knowledge, while Part II is intended to test the application of knowledge in an appropriate and safe manner. An individual's performance on the written examination does not predict performance on the oral examination, given these differences. Since 1986, certification has become time-limited, requiring recertification at 10 year intervals. Diplomates obtain 10 year, renewable certificates. Application can be made for recertification during the 7th year of the certification period, allowing three attempts to recertify without lapse of certification. The American Board of Orthopaedic Surgery (ABOS), the body responsible for the certification and recertification processes, has developed multiple pathways for the recertification examination process.
Board certification and recertification help to evaluate continuing physician competence in a medical specialty. Increased concerns about physician competence by the public have arisen as a result of patient safety concerns highlighted by the Institute of Medicine report of 2000,2 the difficult and worsening malpractice climate, and the perception by the public medicine has taken a minimalist approach to quality control.5,7 This is in contrast to well known examples in other industries, such as the airline industry, which have far more stringent and frequent evaluations of competency. Additional focus on the erosion of medical professionalism has also contributed to the maintenance of competence movement.3,4,6,8 Recertification is undergoing an evolution to a more continuous process with emphasis on quality improvement and lifelong learning, which is now termed Maintenance of Certification (MOC). Currently the recertification requirements include: (1) successful completion of the initial certification process; (2) current medical licensure; (3) a credentialing process including peer review; (4) 120 hours of continuing medical education (CME) Category I credit during the 3 years prior to the recertification examination; and (5) passing an examination by one of several available pathways.
All of the 24 member boards of the ABMS have adopted recertification processes, including secure, proctored examinations. The only nonsecure examination procedure was implemented by the American Board of Pediatrics, but recently was abandoned in favor of a secure examination. The examination venues of the ABOS include practice-based oral examinations and computerized examinations as options. The general examination, which is not subspecialty focused, was originally a written examination, but is now administered as a computerized examination at Prometrics testing centers, which are widely distributed nationally, minimizing inconvenience, travel time, and time away from practice for candidates. Computerized subspecialty examinations are also offered in spine surgery, adult reconstructive surgery, sports medicine, and hand surgery. All computerized examinations are offered at Prometrics centers in March and April, except for the hand surgery computerized examination, which is offered in August and September. Because all of these pathways are for recertification in orthopaedic surgery and not solely a subspecialty, the examinations all contain general orthopaedic knowledge questions in addition to questions in the particular subspecialty, the general content comprising approximately 40% of the examination questions. A practice-based oral examination similar to the Part II certification examination is also an optional pathway offered in Chicago in July in conjunction with the Part II exams. Of the various examinations, by far the most popular is the general computerized examination, with relatively small numbers of candidates electing the other pathways.9 The overall passing rate for all the orthopaedic recertification examinations has been approximately 98%, although the practice-based oral examination has a passing rate of only 85% to 90%, making it the more difficult pathway for recertification. The compliance rate of recertification has been 98% of all diplomates with time-limited certificates issued since 1986. In addition, 12% to 15% of nonlimited certificate holders have voluntarily recertified.
An extensive process for generating examination questions and statistical evaluation of question validity has been developed by the ABOS, in conjunction with the National Board of Medical Examiners (NBME). The questions are written by a task force of volunteers from private practice and academic environments. There are multiple reviews of the questions by the written examination committee of the ABOS, and a Field Test Task Force of practitioners who take the examination before finalizing the examination in a given year. Extensive psychometric analysis of each question is carried out by the NBME, enabling elimination of poorly performing questions (those that fail to statistically discriminate between the most able and least able test takers, or questions that are ambiguous or too difficult). Given the relative homogeneity of orthopaedic surgeons as a test group, and the number of candidates taking the examinations in a given year, approximately 200 questions per examination are required for statistical validity. The oral examinations are also analyzed for statistical validity by a psychometric testing organization. The statistical validation of the examinations enables passing standards to be set that are psychometrically and, therefore, legally defensible. This ensures fairness of the testing methodology, and these concepts have been adopted by all the ABMS specialty member boards.
Evolution of Maintenance of Certification
The next step in the evolution of recertification is MOC, as mentioned above. The ABMS and the Accreditation Council for Graduate Medical Education (ACGME) developed the definition of the competent physician in 1999, and adopted the six general competencies.1,8,10 The six general competencies are: (1) patient care, (2) medical knowledge, (3) practice-based learning and improvement, (4) interpersonal and communication skills, (5) professionalism, and (6) systems-based practice. These competencies have been incorporated, through the ACGME, into the evaluation procedures for residency programs. Maintenance of competency, and therefore of certification, requires evaluation of four specific elements.8 These include: (1) professional standing, (2) commitment to lifelong learning and involvement in periodic self-assessment processes, (3) cognitive expertise, and (4) performance in practice. The MOC concept is continuous performance and practice improvement, rather than episodic evaluation alone at long intervals. Processes have been developed by the ABMS member boards to evaluate the four elements of MOC, with the idea different elements could be evaluated at different times, allowing a more continuous process. Several examples illustrate the methods by which MOC elements are currently evaluated. The computerized examinations evaluate cognitive expertise and lifelong learning, while the oral recertification examination evaluates practice performance. Credentials review, peer review, and licensure evaluate professional standing and practice performance. Continuing medical education credits evaluate lifelong learning.
The ABOS and American Association of Orthopaedic Surgeons (AAOS) formed a task force on recertification in May 2001, consisting of five members from each organization. They conducted a review of current procedures, alternative pathways, and a number of concerns of the AAOS and the Board of Councilors. The goal was to evolve toward the MOC program, while minimizing onerousness and cost for candidates, and engage the AAOS in enhancing continuing medical education (CME), lifelong learning, and self-assessment processes. The task force examined psychometric evaluations of CME-linked approaches to testing, and developed a survey of the AAOS fellowship regarding attitudes and opinions about MOC. In addition, an AAOS Bulletin article was published by the task force to appraise the membership of these activities. In 2004, the task force became a standing joint committee between the ABOS and AAOS to continue the work on evolving from recertification to the MOC program. It is anticipated the AAOS will play a major role in the CME offerings and self-assessment programs that will be a part of MOC.
The current change to MOC will officially begin with candidates recertifying in 2007 and beyond. Professional standing will be evaluated by requirement of valid medical licensure, a credentialing process including peer review as is currently in place for Part II, and documentation of admitting privileges to practice orthopaedic surgery. Self-assessment and lifelong learning will require 120 Category I CME credits over 3 years for two cycles during the 10-year MOC interval. A self-assessment examination will also be required for each 3 year CME cycle. It is expected diplomates will develop a course of self-study based on the self-assessments and their individual practice profile. The CME curriculum is to include approved CME in communication, patient safety, and professionalism. Cognitive expertise will be evaluated by a secure examination in every 10-year cycle, as is currently the case for recertification. After the sixth year in the cycle, and completion of the second self assessment examination, diplomates can apply for the examination pathway of their choice, which includes all the current recertification examination type offerings. Credentialing will be carried out, as it is currently for recertification, for the candidate to be able to sit for the examination. Performance in practice will be evaluated by several methods, all aimed at facilitating practice improvement. A 3-month case list will be required, similar to the 6-month computerized case lists used for the Part II and oral recertification examinations. For high surgical volume practices, 75 consecutive cases in lieu of a full 3-month case list would be accepted. It is anticipated quality and safety indicators, such as deep venous thrombosis prophylaxis, antibiotic prophylaxis, and signing of the operative site would be evaluated. Patient satisfaction and communication surveys will also be required. Two instruments, one from the AAOS and one from the ABMS, are currently being evaluated by the ABOS for use in the MOC program. The patient surveys will be for feedback to the practitioner for quality improvement and will not be evaluated specifically by the ABOS, which will require documentation of survey completion. The surveys will be done during the first half of the 10-year MOC cycle. Candidates who fail to carry out the case lists and/or patient surveys will be required to take the oral practice-based recertification examination rather than other examination pathways.
An additional issue that has been discussed is a mandatory oral examination, which many past and present ABOS directors and diplomates of the ABOS feel is the best method to evaluate practice performance. However, there are important logistical issues with this approach and a potential level of onerousness for the candidates that might be undesirable. Given the obvious value of practice-based oral examinations to evaluate practice performance, this issue will undoubtedly continue to be studied, and conceivably future technological developments may diminish the logistical difficulty of this approach.
Currently, the plan for nonoperating orthopaedic surgeons will require patient surveys and a case list of 30 new consecutive patients. For orthopaedic surgeons not involved in any clinical care, there will not be requirements for surveys or case lists, but cognitive examination and peer review will still be required for MOC. Any orthopaedic surgeon who recertifies as a nonoperating physician or a physician without any patient contact will be required to notify the ABOS if they resume patient contact or surgery. Some additional issues include development of a curriculum in conjunction with the AAOS, finalizing the type of patient satisfaction and communication surveys, and exploring patient outcomes evaluation methodologies in the future. The use of web-based assessment tools, tracking mechanisms for keeping candidates apprised of their status and timeline of their MOC requirements, optimization of the methods of practice performance assessment, and minimizing the cost and inconvenience of the MOC program are also all still under study.
The ABOS is committed to MOC to improve safety of patients, stimulate practice improvement and lifelong learning, and enhance physician interpersonal communication and professionalism. Certification, recertification, and MOC have been components of an evolution toward ensuring physicians maintain and improve practice skills and care of their patients. The new components being phased into the MOC program by the ABOS, including more frequent learning and self-assessment requirements, patient satisfaction and communication surveys for physician practice feedback, and case list reviews focused on issues such as patient safety measures to encourage adoption of best practices are intended to improve patient care while minimizing the intrusiveness and onerousness of the MOC process. Undoubtedly, new ideas will develop over time and further change and improvement to the MOC process will occur. Long term goals of evaluating and improving patient outcomes have been articulated, but at present the tools available do not enable a realistic approach to outcomes assessment. As a profession, we must maintain professional credibility with the public, while fostering the best possible patient care, practice improvement, and professional development of our diplomates.