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Recertification: History of ABOS Efforts

DeRosa, G, Paul

Clinical Orthopaedics and Related Research: August 2006 - Volume 449 - Issue - p 149-154
doi: 10.1097/01.blo.0000224039.39098.0a
SECTION I: SYMPOSIUM I: C. T. Brighton/ABJS Workshop on Orthopaedic Education

The pathway to recertification of an orthopaedic surgeon was the most contentious issue facing orthopaedics in the 20th century. The history of this effort, conducted by the American Board of Orthopaedic Surgery (ABOS), is herein chronicled, including the false starts, the opposition by the American Academy of Orthopaedic Surgeons (AAOS) and the subsequent compromises. These combined efforts have yielded a process of which all of orthopaedics can be proud. Before the ABOS can successfully embark upon the concept of Maintenance of Certification (MOC©), however, the story of recertification must be understood.

This paper is derived directly from the recorded minutes of meetings of the American Board of Orthopaedic Surgery (ABOS). In addition, some information has been taken from minutes of the American Academy of Orthopaedic Surgeons (AAOS) and from Resolutions of the Academy.

From the American Board of Orthopaedic Surgery, Chapel Hill, NC.

The author certifies that he has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

Correspondence to: G. Paul DeRosa, MD, American Board of Orthopaedic Surgery, 400 Silver Cedar Court, Chapel Hill, NC 27514. Phone: 919-929-7103; Fax: 919-942-8988; E-mail:

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History of Recertification: The Early Years of Discussion

Recertification was first mentioned in the ABOS minutes in June 1954 in a letter written to the Board by Dr. Joseph Barr in which he requested, “… the ABOS see to it that competence is maintained through the professional life of the person certified.” However, there were no formal motions made relative to this first discussion regarding recertification.

Recertification was mentioned a second time during the Board's 1972 Interim Meeting held in San Francisco. A letter was received by the Board from the Board of Trustees of the American Medical Association (AMA) urging the ABOS to discuss and implement the concept of recertification. There was a brief discussion and the issue was subsequently tabled.

During the Board's Annual Meeting in September 1972, which was held in Chicago, Dr. Wood Lowell stated, “… the matter of recertification must be considered as it is almost sure to become a reality.” At that time, he raised a question about the methods to be used for recertification, specifically an examination versus attendance at courses or meetings (continuing medical education). He also asked how to differentiate between the terms “recertification” and “reevaluation”. Dr. Walter Hoyt believed the word “credentialing” should be used, and the Board should define the mechanism and needs, but the AAOS should implement the procedure. A motion was made to contact the Academy to develop guidelines and responsibilities concerning recertification. Dr. Michael Bonfiglio moved the Board adopt in principle the concept of recertification, “… the form and content to be determined by an ad hoc committee.” It was seconded by Dr. Frank Stelling and the motion carried.

During the February 1973 ABOS Interim Meeting in Las Vegas, Dr. Albert Ferguson reported the Academy was interested in the issue of requalifying diplomates and an atmosphere of acceptance had already been created. He further stated the Academy was working on an in-depth study of all continuing medical education and a proposal to establish a mechanism for a voluntary requalification process was to be delayed. Dr. Paul Lipscomb suggested an ad hoc committee for the reevaluation of diplomates become a standing committee to be called the committee on requalification. The motion was carried and passed.

During the next ABOS Interim Meeting in June 1973, Dr. Ferguson reported for the Committee on Requalification of Diplomates that no meeting of the committee had been held and it was believed “… it would be wise to lie low …” for a year to allow doctors to digest the material furnished to them so far. In a report of the Board's Planning and Development Committee provided by Dr. Ferguson at the January 1974 ABOS Interim Meeting, the matter of recertification was again mentioned and Dr. Ferguson noted “… so far as recertification is concerned, the fact of life is that the only one that can issue recertification is the ABOS…. The pressures that lead to the necessity for this cause are building up and the mechanism with which it is to be carried out must be made as palatable as possible.” There was another major discussion about the manner in which recertification was to be carried out. Dr. Ferguson further opined, “The exact mechanisms for points toward recertification must of necessity be the child and carry the approval of the Board, but the actual carrying out of these devices, whether they be a test built around a teaching course, may well be the province of the Academy.” He added, “We feel that continuing cross-exchange of information with the Academy is necessary.”

During the June 1974 ABOS Interim Meeting, the Committee to Develop the Modus Operandi for Demonstration of Continuing Competence reported the Academy was agreeable to a joint recertification venture and a committee was formed with an ABOS director as chair. The Board members serving were Dr. Murray (Chair) and Drs. Stelling, Ingram and Brashear. It was agreed the term “continuing competence” be used instead of “recertification”. Dr. Murray requested each member of the Board provide him with several suggestions as to how ABOS diplomates must demonstrate continuing competence. During the 1974 Annual Meeting, Dr. Murray reported for the committee that orthopaedists must be educated to accept the principle of recertification no matter what it is called. Members of the Academy who served on this committee were Drs. Hinchey, Herb Stark and Walter Hoyt, Jr. All Boards, other than neurosurgery, had taken some stand on recertification, and internal medicine gave its first re-certification exam in October 1974. It was suggested a series of articles be placed in the Academy Bulletin explaining the philosophy of recertification and the reasons why it is necessary that it be voluntary; otherwise, it was believed the government would take it out of the hands of medicine. Dr. Murray mentioned a resolution received by the Academy from a group in New York stating their opposition to any type of recertification and suggested the committee compose a counter-resolution. Dr. Ferguson stated there should be a new philosophy regarding the issuance of such an examination, and suggested it not be as difficult as the certifying examination and be related to practical medicine. Dr. Ingram suggested it would be a good idea for members of the committee to attend a meeting of the referenced committee of the AMA House of Delegates.

The joint committee of the ABOS and the AAOS continued to work on the issues of continuing competence, and a motion was carried that the committee continue its efforts developing the method to be employed, ie, (1) continuing education, (2) peer review, or (3) an examination. In 1974 the American Board of Medical Specialties (ABMS) published guidelines for recertification, including the purpose for recertification, essential goals, voluntary in nature on the part of the certified specialist, etc.

Dr. Albert Ferguson convened a special meeting of the Board in November 1975 to consider continuing competence in orthopaedic surgery. Those present included Drs. Ferguson, Banks, Larmor, Bonfiglio, Brashear, McEwan, Stelling, Samilson, Ingram, Murray and Mr. Tom O'Brien (counsel). A committee composed of Drs. Samilson, Enneking, and Harkess suggested a pilot study be developed to “… audit continuing competence in orthopaedic surgery.” It was the forerunner of the National Orthopaedic Audit and its establishment by the ABOS was the first concept of the method for recertifying practicing orthopaedic surgeons. It involved the selection of 200 hospitalized patients' charts in the clinical areas of adult orthopaedics and hand surgery. The committee charged with this assignment consisted of Drs. Samilson (Chair), Ferguson, Larmor, Banks, Harkess, Wilson, and Mankin. It was intended the collected records be audited and a criteria developed for best practice care. A pilot study was done in the Philadelphia area, in cooperation with the Philadelphia Orthopaedic Society, and in the Pittsburgh area under the direction of ABOS director, Dr. Albert Ferguson.

The effort began in January 1976 and work continued through early 1977, at which time it was abandoned, the committee citing problems with establishing criteria for hospitalized patients, lack of physician acceptance, validity of the audit for recertification, and costs. In reality, they found it difficult to establish a pass/fail assessment for an individual who was presenting cases. It became evident some other method for recertification was necessary.

The AAOS conducted a special meeting about recertification in Boca Raton, Florida in July 1977 where it was moved and seconded that the Board would develop a re-certification program. It was further moved a committee for recertification be established and members of Boards of Directors of appropriate organizations be invited to attend to discuss representation. Subsequently, several ways and means for recertification were established: (1) completion of an application and submission of a fee; (2) completion of a practice profile; (3) documentation of participation in continuing medical education activities; (4) documentation of participation in other professional activities, such as with hospitals and medical societies; (5) documentation of participation in an anonymously scored assessment examination with a passing grade forwarded to the applicant; (6) documentation of patient care with demonstration of satisfactory performance compared to peers; (7) a minimum of six years for the voluntary recertification process; and (8) no consequence for failing to demonstrate continuing competence so successive attempts could be made.

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More Than Just An Examination

It is obvious from all of the motions passed by the Board and the false starts concerning recertification the ABOS was seeking ways to make recertification a recredentialing effort rather than simply a cognitive exam. The ABOS was looking for ways, such as an audit, to evaluate a practice so competence could be determined. In addition, the Board was working on practice profiling to try to establish criteria for the individual practitioner's profile so special educational and testing materials could be specifically designed for a particular profile. Thirdly, it was obvious from the outset the ABOS wanted to share its responsibility for recertification with the AAOS. Hence, at the September 1978 Annual Meeting in Chicago, it was moved the Presidents of the ABOS, American Orthopaedic Association (AOA), AAOS, and the Chair of the Committee on Re-certification meet to determine the objectives, the timing, and the format for a general meeting on recertification involving those three organizations. The meeting was proposed for January 1979 in Boston.

In 1978 the Academy conducted a survey of its membership concerning the issue of recertification. At the time, there were 7864 active and emeritus members of the Academy, of which 3451 returned their survey questionnaires, or 44% of the membership. For those members under the age of 60, 95% agreed with the AAOS resolution stating it “… endorses in principle, demonstration of competence by its members through adequate continuing medical education and self-assessment.” For those members over the age of 60, 90% also agreed. In addition, 91% of the respondents agreed in part with the resolution which stated “… the official policy of the Academy opposes mandatory recertification by examination by the American Board of Orthopaedic Surgery, or any other examining board, be reaffirmed.” Seventy-four percent of those responding supported the concept of specialty recertification by methods other than by examination. Another 46% of the respondents indicated the required attendance at continuing medical education forums and the annual Academy meeting was the most acceptable method of evaluating competence. Five percent believed periodic reexamination was the most preferred method, whereas 60% considered it the least acceptable. At this meeting, it was agreed by the Board that the terminology should be changed from recertification to continuing competence. It was moved, seconded, and passed that the ABOS recognize its current certifying examination measures knowledge and attempts to assess ability and judgment, and that there is a correlation between knowledge and clinical competence. The committee also recognized there are other areas of clinical competence the examination does not measure.

The AOA sponsored a summit on recertification in Boston on January 6, 1979. It included members of the AAOS, the Board of Counselors, and the ABOS. At this point it became obvious things were heating up. During a conference call on May 11, 1979, Dr. Banks, President of the ABOS, stated a meeting scheduled for Saturday, May 12 had been cancelled. During the April 7 Advisory Committee for Orthopaedic Residency Education (ACORE) meeting on fellowships, Academy President Dr. John Gartland indicated to Dr. Henry Banks the Academy would be unwilling to cooperate with the ABOS regarding recertification. The AOA president, Dr. Thornton Brown, indicated the AOA would cooperate, but a formal proposal from the Board would have to be developed for presentation to the AOA in June 1979. Dr. Banks stated during the May 12 meeting the Board would address this proposal. On April 27, Dr. Banks addressed the Board of Directors of the Academy and at that time the group agreed to work with the ABOS, but stressed no Academy representatives would be appointed to serve on the Board's recertification committees. Because of this development, there was no urgent need for the Board meeting scheduled for May 12. In order to reestablish communication, the Academy requested a meeting with the entire ABOS Board of Directors at 7:00AM on Monday, June 18, 1979 in Puerto Rico during the AOA meeting. The Academy did not wish to have AOA representatives present because of the strong stand in favor of recertification taken by Dr. Thornton Brown, former president of the AOA. Therefore, the proposed meeting agenda was prepared by Drs. Banks and Gartland and would be circulated in advance of the meeting. After that meeting, Dr. Banks would have the opportunity to address the AOA Executive Committee. During the AOA meeting in Puerto Rico, a Steering Committee on Recertification was formed composed of members of the AOA, AAOS, and ABOS. This committee met in July 1979 in Chicago to discuss planning a workshop titled Maintenance of Orthopaedic Competence and Knowledge, which was to be held in December 1979.

There was a special meeting of the ABOS held in Atlanta in January 1980 concerning recertification. The purpose of the meeting was to define a plan for recertification to be submitted to the ABMS (American Board of Medical Specialties) for approval. Dr. Mankin held a general discussion about the workshop for continuing competence, and he reported that during the postmortem of the workshop on continuing competence the Steering Committee was in agreement with the summary being developed. However, Dr. Wells, of the Academy, stated he was not in favor of some of the points. Dr. Mankin also reported Dr. Gartland, who was the Academy president, impounded the documents so they could be reviewed by legal counsel because he was afraid there was the potential for future litigation regarding the workshop and summary provided by the Steering Committee. (Note that in a personal call made to Dr. Gartland regarding this information in the ABOS meeting minutes, Dr. Gartland stated he did not recall ever impounding any documents from any meeting nor did he believe he would have had the ability to do so.) At the conclusion of the special meeting in 1980, a recertification format including continuing medical education and a limited peer review, along with a secure, proctored examination was approved by the ABOS to be submitted to the ABMS for its approval. After review by the ABMS Committee on Certification and Recertification (COCERT) and the ABMS Executive Committee, the proposal was approved in the spring of 1980 and was sent to the ABMS Assembly for ratification at its September meeting.

During the ABOS Interim Meeting held in conjunction with the Academy in Atlanta in February 1980, Dr. Lovell, president of the AOA, was asked to speak about recertification. He stated after the report to the AOA by Dr. Enneking, president of the ABOS, at the January 12, 1980 meeting of the Executive Committee, the AOA tabled a motion to assist the Board with recertification until more information was obtained from the Academy. A motion was tabled as a result of a request by the president of the Academy to proceed slowly. Dr. Lovell further stressed the AOA had not changed its position to support the Board in its recertification efforts, but was simply responding to the Academy's request. Dr. Mankin reported he had spoken to Dr. Mason Hohl, then president of the Academy, concerning another meeting for the Steering Committee, but Dr. Hohl could not speak on behalf of the Academy as he was directed not to do so by the Academy's Board of Directors. In an attempt to get widespread opinion from the entire orthopaedic community, President Enneking sent the proposed recertification plan to each member of the Academy's Board of Directors, the Board of Counselors, the AOA Executive Committee, the President and Secretary of each group listed on the cover of the Journal of Bone and Joint Surgery, and to each ABOS Director. He asked for their input by June so the proposal to the ABMS could be made in a timely manner for the September 1980 meeting.

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The First Examination Efforts

While the debate among the societies was ongoing, the Board was busy constructing the first voluntary recertification examination. Dr. King Heiple proposed the original exam format of a core of 100 general orthopaedic questions and two 50-item profiled segments for a total of 200 questions. The six profiled areas proposed were hand, spine, trauma, children, adult reconstruction, and general orthopaedics.

A trial recertification examination was administered in 1981 to 259 ABOS diplomates, most of whom were oral examiners. The exam consisted of 100 core orthopaedic knowledge questions and 50 questions of several areas of specialization, which could be selected by the examinee.

This led to the first recertification examinations, which were voluntary, and were conducted on January 15, 1983 in three separate locations - Washington, DC, San Francisco, and Chicago. The requisites for taking the examination were 150 hours of continuing medical education credits. Of the 150 taking the examination, 134 passed.

During an ABOS Interim Meeting in June 1983 held in Hot Springs, Virginia, Dr. Mac Evarts suggested the Board look at alternate pathways for recertification rather than only having a cognitive exam, and should seek the support of the Academy. Also of note is Dr. Jerry Laros' recommendation the Board should consider a limited certificate in the future, which would make recertification mandatory.

During the 1983 Annual Meeting held in July in Chicago, Dr. Eugene Mindell first proposed a practice-based oral exam be used for certification and also commented it would be logical to examine recertification candidates-a very prophetic statement. Gleaned from the minutes of the ABOS Interim Meeting in February 1984, it was recorded that the recertification examination was conducted on January 14, 1984 at four sites-Atlanta, Chicago, Los Angeles, and New York-but only 58 individuals took the exam. During the meeting Dr. Laros stated, “… the concept of time-limited primary certification should be discussed.” (The ABOS newsletter, The Diplomate, was born during this meeting.)

During the ABOS Interim Meeting held at the time of the Academy meeting in January 1985 in Las Vegas, Dr. Jerry Laros suggested, “… a serious agenda item for the next meeting should be the topic of a time-limited certificate.” The Recertification Committee was renamed the Committee on Certificate Renewal. At the Annual Meeting held in Chicago in 1985, Dr. Mac Evarts, Chair of the Planning and Development Committee, recommended: (1) a moratorium on the topic of recertification, and (2) establishment of time limits for primary certificates. The ABOS moved, seconded, and passed that it adopt the principle of a time-limited certificate and that it move forward with discussions on the matter with representatives of the Academy, the AOA, and other interested parties. This action was finalized during the ABOS Interim Meeting of January 1986 held in Naples, Florida. Dr. Henry Banks presented some historical background regarding recertification and the fact the ABMS was planning a conference on the subject slated for 1987. Dr. Min-dell suggested the Board reaffirm the concept of recertification. A motion was passed that at the beginning of 1986 and in subsequent years, the ABOS would offer a certificate limited to 10 years to those who passed the certifying examination. It was further moved the ABOS maintain a recredentialing process that would include peer review, continuing medical education, and an examination administered at least every two years, or more frequently if the need should arise. The certificate awarded would have a 10 year time limit. Furthermore, another motion was made that by 1996 or sometime prior the Board implement a new recredentialing process to include peer review, continuing medical education with the use of an ABOS syllabus, and an exam given by the Board based on the content of the syllabus. Afterwards, another motion to table the previous motion was passed. This history is interesting because numerous meetings were held in 1984 and 1985 regarding a recredentialing process involving the Academy. The Academy's Board of Directors had adopted a motion approving, by joint statement of the AAOS and the ABOS, time-limited recredentialing. Dr. Evarts stated the Academy had agreed to: (1) support the concept orthopaedic surgery should make every effort to ensure maintenance of knowledge and competence; (2) support the principle the AAOS self-assessment examination and continuing medical education serve as an instrument for the evaluation process of the ABOS for the objective portion of any recredentialing process to accompany the time-limited certificate; (3) support the development of a pilot program along these lines with ABMS approval; and (4) ask the ABOS obtain input from the entire orthopaedic community in developing the process. The Board approved this statement at that meeting.

During an ABOS Interim Meeting held at the National Board of Medical Examiners (NBME) offices in September 1986, Drs. Tom Whitesides and Bob Leach argued against reopening old Academy wounds and suggested because 14,000 Board diplomates were against recertification, the ABOS should concentrate on those who will possess a time-limited certificate and not be concerned with those diplomates who had a time unlimited certificate. It is noted in 1987 there was only one voluntary candidate for recertification and there was an argument about the cut score for that individual.

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The ABOS/AAOS Task Force

Throughout the late 1970s and early 1980s many productive meetings of the ABOS/AAOS Task Force were held. The Academy's main concern was that a cognitive written examination as the only method of recertification was distasteful to the members of the Academy. Both the ABOS and the AAOS agreed that practice-based oral examinations or written exams based on a practice profile or a defined body of knowledge were acceptable methods for reevaluation. In addition, they all agreed central elements for the process of recertification would be community peer review and continuing medical education.

During the ABOS Interim Meeting held in Chicago in November 1988, a motion was passed that in 1994 the recertification examination avenues would be: (1) a general clinically-oriented written examination that is not the Part I exam; (2) a practice profile written examination; (3) a practice based oral examination; (4) an examination for the award of a certificate of added qualification with a supplemental examination based on a practice profile; and (5) other methods as they may be developed. In 1988 the Academy adopted several resolutions including: (1) opposition to the proposed ABOS recertification examinations; (2) a proposal for certificate renewal that would include a practice audit; and (3) the ABOS should reverse the policy on issuing time-limited certificates. Therefore, during the ABOS Interim Meeting in March 1989 in New Orleans, the Certificate Renewal Committee suggested the ABOS adopt the following methods for certificate renewal: (1) a computer administered examination based on the three previous Orthopaedic Knowledge Updates (OKU) (75% and “old knowledge” 25%); (2) a practice-based oral examination; (3) a practice profile computer-administered cognitive examination; and (4) a practice audit as suggested by the Academy. During the ABOS Midwinter Retreat in Barbados in February 1990 the components for recertification were actualized. This included: (1) continuing medical education, which would require 120 hours of AMA Category I credit hours during the 3 years preceding the filing of an exam application; (2) a statement on core orthopaedic knowledge to be developed by the ABOS/Academic Orthopaedic Society's Core Curriculum Committee and distributed to the Academy for use in planning continuing medical education offerings and to candidates for recertification to aid in their preparation; (3) a peer review as a component for each pathway of recertification, which would be reviewed by the Credentials Committee in cases where information is insufficient and, if necessary, further information could be requested from the Academy's Regional Admission's Committee or by a site visit; and (4) an application.

At the Annual Meeting held in Chicago in July 1990, correspondence from the Academy was presented in which they stated they were developing a fifth pathway for certificate renewal. It was agreed the ABOS should work with the Academy on the continuing medical education aspects for recertification, but the Academy should not be involved in the evaluation component of the recertification process. At the same meeting, the ABOS Long Range Planning Committee presented a study conducted by a consulting firm which included: (1) comments concerning recertification; (2) management of the ABOS; and (3) the potential move of the ABOS offices from Chicago to North Carolina. In December 1990 the ABOS/AAOS Certificate Renewal Task Force met and it was decided the Academy would develop educational materials and the Board would design the pathway and evaluation mechanism. Several recommendations were reached: (1) change the name of the pathway to the general clinical orthopaedic examination; (2) have the ABOS develop a table of contents for this examination pathway; (3) have the exam be ready for administration no later than early 1994; (4) have the AAOS develop the educational materials to support this pathway; (5) have the ABOS continue to review this pathway and the role of CME in this pathway; and (6) recognize information published about the pathway would change over time. During this meeting it was proposed that Dr. Jody Buckwalter chair the Certificate Renewal Committee.

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The Practice Audit

At the Midwinter Meeting held in Hawaii in March 1992, the concept of the practice audit conducted by two examiners appointed by the Board was ratified. Dr. Jody Buck-walter, who had served a sabbatical at the American Board of Pediatrics, proposed the pass/fail standardization for recertification. It was proposed the oral examiners, members of the AAOS and ABOS Boards of Directors, and members of the AAOS Board of Counselors be asked to participate in the July 1992 trial recertification at no cost. If they agreed to take the exam and passed it, they could be credentialed after the fact and provided a recertification certificate.

Through the years 1993 through 1998, seven individuals asked for and were granted recertification using the practice audit pathway. Because of the inability to standardize this pathway, it was discontinued in 1998. By that time, recertification efforts were becoming accepted by the orthopaedic community. This was exemplified in the article written by Drs. Michael Simon and G. Paul DeRosa for the Journal of Bone and Joint Surgery in 1999, which stated there was a 98% compliance rate with mandatory recertification which, at the time, was the highest compliance rate of any of the ABMS boards offering recertification vehicles.1

A paper and pencil written examination continued to be administered during the annual Academy meeting through 2003. It was discontinued in favor of a computer administered examination available at Prometric testing sites throughout the country. In addition to the computer administered general clinical examination, practice profile examinations, which included 80 core questions of basic orthopaedic knowledge, were given for individuals who believed their practices were profiled in spine surgery, sports medicine, or adult reconstruction. In 2004, the Certificate of Added Qualifications in Hand Surgery was expanded to include the same 80 core questions. The practice profile oral examination continues to be administered and its acceptance is gaining popularity among examinees. In the 2005, 1000 individuals applied, were credentialed, and sat for the various examinations for recertification. It is anticipated this compliance rate will continue and it is also anticipated as changes occur in the practice of orthopaedic surgery, so will the evaluating procedures change.

Clearly, the American Board of Orthopaedic Surgery has strived to live up to the purpose of its existence to serve the best interests of the public and the medical profession by establishing educational standards for orthopaedic residents and by evaluating the initial and continuing qualifications and competence of orthopaedic surgeons.

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It is obvious the pathway to recertification was a long, tedious and, at times, painful process. From the acceptance of the concept by the ABMS in 1972 until the first trials by the ABOS in 1981, there were more than 30 meetings of the ABOS during which this issue was discussed. It was another 11 years before the process was redefined and reworked so that those individuals in the class of 1986 with time-limited certificates could enter a process which has withstood the test of time. The American orthopaedic surgeon and the American public owe a debt of gratitude to the leaders of the Academy, the AOA and the ABOS who withstood the pressures, trials and hardships of developing the recertification process. It has evolved into a procedure that is palatable to the practicing orthopaedist, yet is rigorous enough to assure the American public that knowledge and competence are being maintained by our orthopaedic surgeons.

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1. Simon MA, DeRosa GP. The value of recertification to orthopaedic surgery and to the public. J Bone Joint Surg Am. 1999;81:292-294.
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