Internal Medicine Board Considers Revised Procedural Requirements

ABIM’s Internal Medicine Board  “defines the discipline” of internal medicine, and what skills and competencies should be required of a board certified internist. This includes determining the duration of training and procedural requirements for initial certification and its subspecialties.  ABIM’s current procedural requirements for Internal Medicine Certification have been in place since 2006, meaning no updates have been made in more than 12 years despite changes in practice.  

In 2018, the Accreditation Council on Graduate Medical Education (ACGME) published a revision of program requirements for accredited internal medicine residency programs. At the same time, the Internal Medicine Board had decided to revisit the procedural requirements for graduating residents, presenting a timely opportunity to make changes to these requirements.

For certification in internal medicine ABIM has identified a limited set of procedures for which it expects all candidates to be competent with regard to their knowledge and understanding. For a subset of procedures, ABIM requires all candidates to demonstrate competence and safe performance by means of evaluations performed during residency training. The set of procedures and associated competencies required for each include:  

The first itemized set of procedural requirements were published in 1990. And prior to 2006, ABIM revised its required procedures for certification in internal medicine in 2002, 1997, and 1991.

ABIM’s Internal Medicine Board has spent more than a year gathering input from stakeholders–specialty societies, residency and fellowship program directors and large health care system employers–asking how the procedural requirements for initial certification in internal medicine might better meet the needs of the graduating trainees and the communities they serve.

The Board also asked for input on whether competency in specific procedures should be required of all residency graduates for initial certification in internal medicine regardless of their career plans.  If so, which procedures should be included?  If not, what was their reasoning?

What we heard was as varied as the community internal medicine represents. Internal medicine societies generally supported removing procedure requirements for all graduating residents, but subspecialty societies generally support retaining it. Of the societies that support retaining the procedures requirement, there was no consensus as to which procedures should be required. Ultimately, 12 different procedures were suggested with no clear agreement. 

When it came to program directors (both internal medicine and subspecialty programs), the large majority of respondents agreed that there should be some procedural competencies that are required of every resident. Nearly all respondents supported residents having the opportunity to acquire competence in procedures of their career interest. A further analysis of qualitative comments revealed that program directors’ beliefs around procedural requirements were wide-ranging:

• Procedural training might generate more interest in primary care
• Procedural competency yields a more comprehensive internist
• Trainees’ varied career plans make it difficult to require common requirements
• Other teams are now responsible for procedures that internists previously performed
• Fellowship directors prefer to teach subspecialty-specific requirements to new trainees

One of the critical takeaways from  the feedback, both internal and external, was the importance of recognizing that the types and numbers of procedures performed by internists and subspecialists in practice will vary based on a number of factors and may even vary over the course of a single career. Requiring demonstrated competence in a procedure not relevant to an individual’s chosen career path could put patients at risk in the pursuit of “checking off the box”. How then can a procedural competency requirement optimally prepare trainees in internal medicine for this diversity of practice?