“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 concept of a board to evaluate the qualifications of specialist physicians in the United States was initially proposed by Dr. Derrick T. Vail in 1908 during his presidential address to the American Academy of Ophthalmology and Otolaryngology. He called and identified the need for “oculists” to have adequate education and training in a recognized “ophthalmologic institution” prior to being allowed to sit before “a proper examining board.” In 1915, the American Ophthalmologic Society, the Section of Ophthalmology of the AMA, and the American Academy of Ophthalmology joined together to establish a board to test those individuals who wished to exclusively practice ophthalmology. The newly created American Board of Ophthalmologic Examinations 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. Two other boards were formed not long after: the American Board of Obstetrics and Gynecology (founded in 1930) and the American Board of Dermatology and Syphilology (founded in 1932). In 1933 representatives from the four specialty boards — together with the Association of American Medical Colleges, the Federation of State Medical Boards, the American Medical Association’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 which are expressly delegated to it by the component boards; (5) not interfere with the autonomy at any examining board having representation herein; (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.1
During the course of the ensuing 35 years, the organization underwent several reorganizations. In 1970 the Advisory Board of Medical Specialties reorganized itself once again, changed its name to the American Board of Medical Specialties (ABMS), and hired a full-time executive director. Since then the ABMS has become an organization of 24 member boards and 8 associate members. Collectively, these 24 member boards issue initial certificates in 36 primary general specialties and 88 subspecialties.
Each member board has developed rigorous criteria for entry into its certification programs. These standards are integral to the board certification process and are overseen by the ABMS in its capacity as the umbrella organization. The criteria establish, as a minimum, that a candidate for certification has fulfilled the education, training, and licensure standards of each board, as well as the ethical and professionalism requirements deemed necessary for board certification. The initial certifying examination(s) given by the boards are carefully and objectively constructed, and subject to ongoing intense study and statistical analysis to document their reliability and validity. The examinations 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 1999, ABMS member boards certified approximately 89% of all licensed US physicians.2
The initial certification process, while not perfect, is quite good and accomplishes its intended purpose. The obvious deficiency in the current board certification system is a process to evaluate diplomates in a reliable, clinically valid, and economically feasible manner following their initial certification. To address this deficiency, 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 that diplomates acquired new knowledge and skills through a variety of continuing medical education activities. However, it is now believed that although recertification by examination is necessary, it is insufficient to document that 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 physicians and their practices.
In March 1998, the ABMS created the Task Force on Competence. It was formed because of a perceived need to satisfy the public, payers, other health care organizations and entities, governmental agencies, and members of the medical profession that specialist physicians are competent and maintain their competency throughout the span of their professional careers.
The task force’s charge was:
To develop and recommend a mission statement to include specific purposes and responsibilities which affirm, to the public and to other stakeholders, the commitment of the ABMS and its member boards to certify and to recertify that their diplomates are competent to practice their specialties.
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.
To recommend and stimulate collaborative, proactive research on assessment methods for certification and recertification and the validation of those methods by member boards.
To develop and recommend a template for the design of specialty-specific techniques useful to each of the member boards when assessing competence.
To develop and recommend mechanisms by which the requirements, processes, standards, and outcomes of certification by each member board may receive the benefits of regular review for the purposes of quality improvement.
Develop and recommend collaborative methods to assess clinical knowledge and performance that are common to all member boards.
Cognizant of its role as a stakeholder in graduate medical education, and that medical education was, or should, be viewed as a continual rather than an isolated learning opportunity, the ABMS Task Force on Competence,” 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 to 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 re-assessed as physicians 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. Currently both the ABMS and the ACGME are developing and evaluating tools to measure each of the six competencies. Prior to their utilization by the ABMS and the ACGME, the tools selected must be demonstrated to be reliable, valid, and economically feasible.
The ABMS Task Force on Competence has concentrated its efforts on developing standards and methods to evaluate physician specialists following their initial certification. As a result of these efforts, a program for the Maintenance of Certification” (MOC) was proposed and will gradually be improved as methods of assessment become available. It consists of four essential components. To maintain certification a diplomate must provide:
Evidence of professional standing
To meet this 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.
Evidence of commitment to lifelong learning and involvement in periodic self-assessment processes
To meet this requirement, a diplomate must engage, at minimum, in the lifelong learning and self-assessment processes required by his board. The content of lifelong learning and self-assessment should be specialty specific. Boards will set the standards for evidence of lifelong learning and the performance of diplomates should be evaluated according to established standards.
Evidence of cognitive expertise
To meet this requirement, the diplomate must pass an examination of their cognitive knowledge. The boards must ensure that 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 be required, at minimum, every 10 years.
Evidence of evaluation of performance in practice
To date, specific measures, standards and processes to meet this requirement have not been completely defined by either the ABMS or the member boards. However, guidelines to aid each of the boards in developing specialty specific, appropriate, common processes for all boards to use when assessing the practice performance of their diplomates have been promulgated by the ABMS. 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. Assessment will focus on improving the quality of patient care and emphasize continuous improvement of practice performance. It will begin during residency and continue throughout the career of each diplomate. The evaluation will address individual practice factors, both 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, as well as the efficient and appropriate use of resources.
In the past, one of the primary responsibilities of the ABMS was to aid the member boards in their quasi-regulatory function, certifying physician specialists. Thus, the mission of the ABMS was 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 evaluation and certification of physician specialists”; and, (2) “provide assurance to the public that a physician specialist certified by a member board of ABMS had successfully completed an approved educational program and an evaluation process, which includes an examination designed to assess the knowledge, skills, and experience required to provide quality patient care in that specialty.”
The ABMS and the member boards now believe that if certification of physician specialists is to remain credible as a credential signifying quality medical care, the organizations involved must be accountable to a variety of interested stakeholders. That accountability must be not only for initial certification, but for an ongoing and continuing affirmation that certified specialists are maintaining the necessary capability to provide patients with quality medical care based on the most up-to-date scientific evidence. Moreover, the ABMS firmly believes that for the MOC processes of each member board to be both accountable to and credible for the public, these processes should be subject to timely oversight and monitoring by a committee of knowledgeable individuals both from within the ABMS, other related medical organizations, and members of the public. This committee, COMMOC, has been charged with:
Receiving and reviewing regular reports, according to a schedule to be developed, from individual member boards with respect to the progress in development and implementation of their individual MOC programs.
Verifying and documenting compliance by individual member boards that have appropriately developed and implemented MOC programs.
Providing recommendations and guidance to member boards with respect to segments of their MOC programs which are not adequately developed or being implemented.
Reporting member boards that are not in compliance with general ABMS MOC guidelines (after appropriate discussions) to the executive committee for appropriate review and action.
Public accountability is an important prerequisite when a profession is granted the moral authority and responsibility to oversee its education, evaluation and the scope of its practice, as well as that of its practitioners. However, the vision for the ABMS MOC program envisions an added role: that of being a stakeholder and an integral player in developing processes to promote quality improvement in practice and in practitioners. While not directly nor historically a board responsibility, this vision will necessitate that boards and specialty societies coordinate their respective and distinct roles as evaluators and educators. The goals of these joint efforts are to develop programs that promote and encourage learning and assessment by the diplomate and the diplomate’s board that are clinically relevant, professionally rewarding, and ultimately provides value for the public and the profession.
One of the primary 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. We believe that the MOC programs of the ABMS can be the impetus to begin to promote such a system. Such a system could prove helpful to licensing jurisdictions as they fulfill their missions to document the competence of their medical licensees, to hospital and health care organizations as they credential their staffs and grant clinical bodies privileges, and to insurance companies as they underwrite liability insurance for malpractice.