Certification by the American Board of Pathology (ABPath) is a valued credential that serves patients, families, and the public and improves patient care. The ABPath establishes professional and educational standards and assesses the knowledge of candidates for initial certification in pathology. Diplomates certified in 2006 and thereafter are required to participate in Continuing Certification (CC; formerly Maintenance of Certification) in order to maintain certification.
To inform and update the pathology community on the history of board certification, the requirements for CC, ABPath CertLink, changes to the CC program, and ABPath compliance with recommendations from the American Board of Medical Specialties Vision Commission; and to demonstrate the value of CC participation for diplomates with non–time-limited certification.
This review uses ABPath archived minutes of the CC Committee and the Board of Trustees, the ABPath CC Booklet of Information, the collective knowledge of the ABPath staff and trustees, and the American Board of Medical Specialties 2018–2019 Board Certification Report.
The ABPath continues to update the CC program to make it more relevant and meaningful and less burdensome for diplomates. Adding ABPath CertLink to the program has been a significant enhancement for the assessment of medical knowledge and has been well received by diplomates.
Medical training at the turn of the 20th century often consisted of an apprenticeship offered by for-profit proprietary schools that had minimal admission standards and inadequate training facilities and clinical material, resulting in an oversupply of poorly trained physicians. The Flexner Report1 of 1910 exposed the poor quality of medical education in America, spurred the elimination of proprietary schools, and resulted in the enactment of state medical licensing laws. The report's recommendations resulted in science-based medical education and training and the growth of specialty-specific medical knowledge.
Before the development of board certification in the 1900s, physicians could self-declare their specialty and proclaim their competence. There was little protection of the public from quacks, hucksters, and charlatans. Specialty boards were created out of concern about the quality of patient care. Boards were created by peer specialists to set standards for excellence in education and evaluation that would assure the public of a physician's competence in a specialty area. Board certification was and still is considered a mark of excellence and professional achievement.
The first board, founded in 1917, was the American Board of Ophthalmology. In 1933, the Liaison Committee for Specialty Boards, the forerunner of today's American Board of Medical Specialties (ABMS), was incorporated. The American Board of Pathology (ABPath) was incorporated in 1936, the same year as the American Board of Internal Medicine and a year before the American Board of Surgery, and was the 10th of the current 24 ABMS member boards (Table 1). Today there are more than 900 000 ABMS board–certified physicians in the United States; approximately 85% of practicing physicians are ABMS board certified.2 From 2009 to 2018 there were 6474 physicians with primary certification in pathology.2
DEVELOPMENT OF MAINTENANCE OF CERTIFICATION/CONTINUING CERTIFICATION
As consumer activism grew in the 1960s, the public began demanding assurance of the continuing competence of physicians.3 State medical boards began requiring continuing education as a condition of licensure. In 1969, the American Board of Family Medicine was founded, and in 1976, the American Board of Emergency Medicine was founded. These 2 boards were the first to issue only time-limited certificates and to require periodic assessment of their diplomates' medical knowledge with a secure examination.
In the 1970s, the ABMS urged member boards to offer voluntary recertification, and in 1993, the ABMS and its member boards adopted a policy requiring all boards to establish a program for recertification of diplomates. Reports from the Institute of Medicine4,5 that challenged the quality of care and patient safety provided motivation to develop recertification programs to demonstrate to the public that physician specialists remain skilled and knowledgeable. Passing an examination at the end of training cannot guarantee that a physician will remain competent through his or her career, and there is good evidence that a physician's knowledge and skills deteriorate over time.6 Beginning in 1996 and continuing until 2014, the ABPath offered voluntary recertification, which included requirements for continuing medical education (CME), assessment of practice performance, and a cognitive examination.
In 2000, the ABMS and the Accreditation Council for Graduate Medical Education adopted 6 core competencies for physicians (Table 2). That same year, the ABMS developed guidelines and methods to evaluate specialists that became the basis of Maintenance of Certification (MOC). The 4 components were (1) professional standing, (2) lifelong learning and self-assessment, (3) cognitive expertise, and (4) performance in practice. In 2004, ABMS member boards were required to submit an application outlining their MOC programs. In 2005, the ABPath was one of only 5 boards to receive ABMS approval of its MOC program without modifications.7
American Board of Medical Specialties/Accreditation Council for Graduate Medical Education Core Competencies
Beginning in 2006 and thereafter, all certificates issued by the ABPath are time limited and require participation in MOC, now called Continuing Certification (CC). Certificates issued in 2006 through 2014 had a 10-year expiration date, but were valid only so long as a diplomate was meeting MOC requirements. Certificates issued in 2015 and thereafter have no expiration date and state, “Participation in the Continuing Certification Program is required to maintain certification.” This change better reflects that certification is an ongoing process and not a 10-year certification. By participating in CC, physicians have a valuable credential that indicates to the public and to the profession that they are staying up to date in their medical knowledge, participating in ongoing professional development, improving the care they provide, and consistently meeting standards of professionalism.
ABPATH CC PROGRAM
The ABPath CC program was designed to incorporate professional activities that diplomates were in most cases already doing or required to do for Clinical Laboratory Improvement Amendments certification. More details of the CC/MOC Program can be found in the CC Booklet of Information on the ABPath Web site, www.abpath.org (accessed October 1, 2020). The ABMS is in the process of revising the standards for CC, which are expected to be adopted in 2021. The current components of the CC program8 are:
Professionalism and Professional Standing
Diplomates must maintain a full and unrestricted license to practice medicine in all the jurisdictions in which they practice and abide by the American Medical Association's and American Osteopathic Association's Codes of Ethics.
Lifelong Learning and Self-Assessment
Diplomates must obtain a minimum of 70 American Medical Association Physician's Recognition Award category 1 CME credits for each 2-year reporting period. At least 20 of the 70 CME credits must be self-assessment module (SAM) credits.
Improvement in Medical Practice
Diplomates must engage in at least one specialty-relevant performance-in-practice assessment and improvement activity each year. Diplomates report laboratory accreditation status and participation in interlaboratory comparison programs/proficiency testing.
Assessment of Knowledge, Judgment, and Skills
Diplomates must assess their pathology-specific knowledge, judgment, and skills by passing a secure examination at least once every 10 years. This is an open-book examination and is administered remotely and securely.
ABPath-Approved Patient Safety Course
Diplomates must complete an ABPath-approved patient safety course once every 10 years. Beginning in 2021 a patient safety course will no longer be required; however, participation in patient safety CME will be encouraged.
To maintain certification, diplomates must report their CC activities to the ABPath every 2 years in its portal called PATHway (https://www.abpath.org/index.php; accessed October 1, 2020). Assessments of the ABMS competencies are also made by peer evaluations that must be submitted every 4 years.
Trustees of the ABPath must participate in CC. The ABPath grants reciprocity and credit for MOC activities with the Royal College of Physicians and Surgeons of Canada and with other ABMS boards. There is a 1-year grace period after missing a 2-year reporting deadline, allowing diplomates to make up their CC requirements before lapse of certification. If at the end of 10 years from the year of initial certification the diplomate has not taken or passed the CC examination, the diplomate's certification lapses, but there is a 1-year grace period during which the diplomate can take and pass the examination and regain certification. After that, the diplomate must take the initial certification examination to regain certification.
ABPATH CERTLINK
The ABPath CertLink (ABPCL), developed in partnership with the ABMS, is an online longitudinal assessment program designed to support continuous learning and professional development in pathology. The ABPCL will complete its pilot phase in 2020. The ABPCL was approved by the ABMS CC Committee to become a permanent component of the CC program beginning in January 2021. In 2021, the ABPCL will replace the once-every-10 years high-stakes examination that diplomates were required to take to fulfill their CC part III Assessment of Knowledge, Judgment, and Skills requirement.
The ABPCL pilot program was successfully launched in 2018 and as of January 2020 has more than 9450 participants. The program is designed to do more frequent assessments of knowledge and provide feedback to reinforce learning and retention. Surveys of participants have shown a high degree of satisfaction and that ABPCL better meets the needs of pathologists and enhances the CC assessment experience (Figure).
Diplomate feedback. Survey results from pilot participants showing a high degree of satisfaction with ABPath CertLink. There were 5043 total participants with a 54% survey response rate (n = 2723).
Diplomate feedback. Survey results from pilot participants showing a high degree of satisfaction with ABPath CertLink. There were 5043 total participants with a 54% survey response rate (n = 2723).
The ABPCL program is designed to have participants answer 15 new multiple-choice, single-best-answer questions each quarter (every 3 months) at their convenience. The ABPCL can be accessed using any modern Web browser. There are also CertLink apps available for tablets (https://apps.apple.com/us/app/certlink/id1172843542; https://appagg.com/android/medical/certlink-31649588.html?hl=en; both accessed October 1, 2020). All questions do not have to be completed at the same time. Participants have 5 minutes for each question and can use any resource to answer a question except another person. They receive immediate feedback including a short narrative (critique) that explains why the correct answer is correct and why the other choices are wrong and references. They can provide feedback on each individual item. A second attempt is offered after the participant answers a question incorrectly and reads the critique in order to reinforce learning and retention. This second attempt is for educational purposes and does not change the original answer. During a later quarter, participants can receive up to 10 additional questions that are clones of questions that they previously answered incorrectly. This also reinforces learning and measures retention. Diplomates have a personal dashboard showing their ongoing performance, comparison with their peers, and knowledge gaps. They have a question history that shows the key point of questions they have answered, whether those questions were answered correctly or incorrectly, and the critiques and references for those questions.
Diplomates are required to receive 20% of questions in their area of primary certification (ie, anatomic pathology and/or clinical pathology). If they have one subspecialty certificate, they receive 20% of questions in that subspecialty. If they have more than one subspecialty, they receive 10% of questions in each subspecialty area. The remainder of the questions can be selected from more than 30 elective practice areas (Table 3) in increments of 10%. This allows the assessment to be customized and relevant to their practice.
Diplomates meeting the ABPCL participation standard and the performance standard set by the ABPath will fulfill the assessment requirement of the CC program. All diplomates certified after 2006 are registered for the ABPCL, and the transition to the permanent program in 2021 will be seamless. All newly board-certified pathologists are automatically registered. The ABPath encourages diplomates who hold lifetime certifications to participate in the ABPCL, currently at no cost and always with no jeopardy to their lifetime certificates.
Diplomates can claim up to 5 SAM-eligible CME credits for participation. Credits are claimed through the American Society for Clinical Pathology in collaboration with the ABPath. Lifetime diplomates are also able to claim CME credit for their participation.
EVOLUTION OF CC
Since inception, the CC program has made a number of changes and improvements to make the program more relevant and less burdensome for diplomates. In 2015, the ABPath began offering the CC examination remotely, so diplomates no longer had the expense and time away from practice and family in order to come to the Tampa examination center. In 2016, new examination special-emphasis modules were created to make the primary examination more relevant to subspecialists. More than 90 modules are available for diplomates to design a relevant CC assessment, and there are comprehensive study guides to aid diplomates preparing for the examination. In 2016, a CC Advisory Committee was formed to provide feedback and suggestions to the ABPath about the CC program. The committee has 12 members, all participating in CC, from a variety of practice settings and subspecialties. In 2016, the ABPath was selected to participate in the ABMS longitudinal assessment pilot, which is now known as the ABPCL. In 2018, the examination became open book. In 2018, the ABPath partnered with the Accreditation Council for Continuing Medical Education to develop automated reporting to the ABPath of diplomates' CME, SAM, and Improvement in Medical Practice activities through the Program and Activity Reporting System to reduce the burden of manual data entry. Diplomates were given access to the Accreditation Council for Continuing Medical Education CME Finder for search and selection of relevant CME. This investment in the Program and Activity Reporting System lessened the burden of CC reporting. In 2018, the ABPath recognized new types of assessments that would qualify CME activities as SAMs. All of these improvements were made at no additional cost to diplomates.
There are important upcoming changes to the CC program. In 2021, there will no longer be a SAM requirement, because the ABPCL is a self-assessment and because accredited CME must include an assessment of participants. Diplomates will still have the 70 category 1 CME credits requirement for every 2-year reporting period. Diplomates who have not met SAM requirements in 2020 will be able to use CME to make up credits. In 2021, there will no longer be a requirement for a patient safety course. In 2021, diplomates with 2021 certificate expiration dates will retain certification if they meet the ABPCL participation requirement or pass the CC examination. Sabbaticals taken because of COVID-19 will not adversely impact their ABPCL participation requirement.
Beginning in 2022, all diplomates with time-limited certification will be required to participate in ABPCL. The current CC examination will no longer be available. There will be an examination developed for diplomates who require a secure examination for obtaining a medical license. A remediation pathway will be established for diplomates who let their certification lapse. Beginning in 2022, the ABPath will begin to measure ABPCL participant performance. Diplomates will be given annual feedback that they are or are not meeting the longitudinal assessment program's performance standard. After 4 years (in 2025) the ABPath will make a summative decision about each diplomate meeting the CC medical knowledge requirement. If a diplomate is not meeting the performance standard, the diplomate will be given a 2-year grace period to improve performance before loss of certification.
Beginning in 2026, diplomates will have a 4-year rolling average of ABPCL performance with annual assessment and reporting of a diplomate meeting or not meeting the performance standard. Diplomates will continue to have their current 2-year CC reporting requirements for professionalism, lifelong learning and self-assessment, and improvement in practice.
Currently the fee for CC is $100 every 2 years due when finalizing the CC reporting form and $700 for the remote, secure CC examination, for a total of $1200 during the current 10-year cycle. Beginning in 2021, there will be an annual CC fee of $150, which includes participation in ABPCL. The ABPath has the lowest fees of any of the 24 ABMS member boards.9
VISION COMMISSION RECOMMENDATIONS: THE RESPONSE
In 2017, the ABMS and its 24 member boards launched a major initiative, “Continuing Board Certification: Vision for the Future.” The American Board of Medical Specialties Vision Commission brought together multiple stakeholders to vision a system of continuing board certification that would be meaningful, relevant, and of value, while remaining responsive to the patients, hospitals, and others who expect that physician specialists are maintaining their knowledge and skills to provide quality specialty care.
The following are some of the recommendation from the commission's report10 released in 2019 and the ABPath's response to those recommendations.
CC Must Integrate Professionalism, Assessment, Lifelong Learning, and Advancing Practice to Determine the CC Status of a Diplomate
The ABPath considers all components of the CC program when making a summative decision about the certification status of a diplomate. The ABPath CC program incorporates assessment of the ABMS/Accreditation Council for Graduate Medical Education 6 competencies. The American Board of Medical Specialties Vision Commission recommended eliminating the name MOC because it has become a damaged brand. The ABPath preemptively adopted CC in 2019 to better reflect the intent of the program.
CC Must Change to Incorporate Longitudinal and Other Innovative Formative Assessment Strategies That Support Learning, Identify Knowledge and Skills Gaps, and Help Diplomates Stay Current. The ABMS Boards Must Offer an Alternative to Burdensome Highly Secure, Point-in-Time Examinations of Knowledge
The ABPath launched the ABPCL pilot in July of 2018, in partnership with the ABMS, as an eventual alternative to the high-stakes, once-every-10-years CC Part III examination. This new assessment pilot has practice relevance (31 practice areas), flexibility, and convenient delivery.
The ABPCL and the Accreditation Council for Continuing Medical Education CME Finder provide diplomates with effective tools for identifying their knowledge gaps and enhancing their knowledge, judgment, and skills.
The ABMS Boards Must Regularly Communicate With Their Diplomates About the Standards for the Specialty and Encourage Feedback About the Program
The ABPath CC Booklet of Information (available on our Web site at www.abpath.org; accessed August 24, 2020) provides a comprehensive description of the CC program and requirements.
The ABPath has hired a director of communications to enhance our communications with stakeholders. The director regularly updates our Web site with messages and announcements and has created a social media presence for us to better engage with diplomates (Facebook @theabpath; Twitter @theabpath; Instagram @theabpath; LinkedIn @abpath).
The ABPath encourages and provides open, bidirectional communications and is always available for questions and concerns via various channels (phone, email, Web site). The ABPath actively engages with and surveys our diplomates. We have a CC advisory committee that meets monthly by teleconference. It is composed of diplomates from diverse practice settings who are participating in CC. The ABPath has a booth at annual meetings of some of the cooperating societies.
The ABMS Boards Must Enable Multispecialty and Subspecialty Diplomates to Remain Certified Across Multiple ABMS Boards Without Duplication of Effort
The ABPath has a reciprocity policy for diplomates maintaining their primary certification with another ABMS member board's CC/MOC program.
The ABMS and the ABMS Boards Must Facilitate and Encourage Independent Research to Build on the Existing Evidence Base About the Value of CC
The ABPath is a member of the ABMS Assessment and Research & Evaluation Collaborative and is participating in their research efforts on the value of longitudinal assessment.
The ABPath encourages and would support research that assesses the value of CC.
The ABMS Boards Must Change a Diplomate's Certification Status When CC Standards Are Not Met
Diplomates' certification is lapsed if they do not meet CC requirements.
The ABMS Boards Must Have Clearly Defined Remediation Pathways to Enable Diplomates to Meet CC Standards in Advance of and Following any Loss of Certification
The ABPath CC Booklet of Information describes the appeals process, pathways for reinstatement of certification, and the remediation process and timeline. The ABPath is proactive in communicating reminders of CC requirements and deadlines to diplomates. The ABMS has a task force to recommend a consistent process of remediation. The ABPath will consider new recommendations or processes as they are developed for the ABMS member boards.
The ABMS and the ABMS Boards Must Make Publicly Available the Certification History of All Diplomates, Including Their Participation in the CC Process. The ABMS Boards Must Facilitate Voluntary Reengagement Into the CC Process for Lifetime Certificate Holders and Others Not Currently Participating in the CC Process
The ABPath routinely reports diplomate CC status to ABMS for its publicly available Certification Matters Web site and its annually published directory that is routinely used by credentialers. The new ABPath Web site will provide public access to this information beginning in 2022. The ABPath provides certification information to its cooperating societies and on request to recognized pathology societies. The ABPath actively encourages non–time-limited diplomates to participate in the CC program and the ABPCL pilot program with no risk of losing their certifications.
The ABMS Boards Must Comply With All ABMS Certification and Organizational Standards, Including Financial Stewardship and Ensuring That Diverse Groups of Practicing Physicians and the Public Voice Are Represented
The ABPath complies with all ABMS certification and organizational standards. The ABPath is governed by a volunteer board of trustees who establish the strategic directions for the organization. They are clinically active as per the Vision recommendations. The board of trustees consists of 13 trustees, including one public member to represent and recognize the public as a stakeholder. The members represent multiple pathology subspecialties, practice settings, and years in practice. The ABPath has CC and resident and fellow advisory committees that meet monthly. The ABPath has published a financial statement in its newsletter and in the 2019 annual report.
The ABMS Must Demonstrate and Communicate That CC Has Value, Meaning, and Purpose in the Health Care Environment
Hospitals, health systems, payers, and other health care organizations should independently decide what factors are used in credentialing and privileging decisions. The ABMS informs these organizations that CC should not be the only criterion used in these decisions. Organizations should use a wide portfolio of criteria.
The ABMS has encouraged hospitals, health systems, payers, and other health care organizations to not deny credentialing or privileging to a physician solely based on certification status.
The ABMS and the ABMS Boards Should Collaborate With Specialty Societies, the CME/Continuous Professional Development Community, and Other Expert Stakeholders to Develop the Infrastructure to Support Learning Activities That Produce Data-Driven Advances in Clinical Practice
The ABMS boards must ensure that their CC programs recognize and document participation in a wide range of quality assessment activities in which diplomates already engage.
The ABMS Boards Must Collaborate With Professional and/or CME/Continuous Professional Development Organizations to Share Data and Information to Guide and Support Diplomate Engagement in CC
The ABPath has always collaborated with specialty societies, the CME provider community, and other stakeholders to meet these objectives. The ABPath does not produce any products or activities for CC, except for the examination. We rely on our specialty societies to create learning and quality improvement/quality assurance activities for CC. The ABPath plans to share knowledge gap data obtained from ABPCL with CME providers. The ABPath hosts annual meetings with our cooperating societies to identify and address issues of importance to our profession. The ABPath has a wide door for accepting improvement in practice activities that our diplomates engage in. We also allow diplomates to design their own quality assurance/quality improvement. The ABPath has a CC advisory committee composed of diplomates/stakeholders from a variety of subspecialties and practice settings that meets monthly. The ABPath trustees and chief executive officer are members of or participate in other pathology and medical societies/organizations' boards and committees.
CONCLUSIONS
The ABPath continues to update and improve the CC program to make it more relevant and meaningful and less burdensome for diplomates. Adding ABPCL to the program has been a significant enhancement for the assessment of medical knowledge and has been well received by diplomates.
MISSION, VISION, AND VALUES
The mission of the ABPath, a member of the ABMS, is to serve the public and advance the profession of pathology by setting certification standards and promoting lifelong competency of pathologists.
Vision Statement
The ABPath improves the health of the public by promoting excellence in the practice of pathology.
Our Core Values
See Table 4.
