Dr. Olakunle Akinboboye is board certified in Cardiovascular Disease and Sleep Medicine. He is an Associate Professor of Clinical Medicine at the Weill Medical College of Cornell University, New York. He is also the Medical Director of Queens Heart Institute/Laurelton Heart Specialist P.C. in Rosedale, Queens, New York. Dr. Akinboboye is Chair of the American Board of Internal Medicine Cardiovascular Board and a member of the ABIM Council.
Dr. James E. Tcheng, a board certified internist, cardiologist, interventional cardiologist and informatician, is a Professor of Medicine and Professor of Community and Family Medicine (Informatics) at Duke University in Durham, North Carolina. Dr. Tcheng serves as Chair of the American Board of Internal Medicine Cardiovascular Board Interventional Cardiology Exam Committee and is a member of the ABIM Cardiovascular Board.
Over the past four years, the American Board of Internal Medicine (ABIM) – with the engagement of the medical community – has undergone a transformation to rebuild the trust and respect it historically enjoyed among the profession for much of its existence. Harkening back to the origins of ABIM and its physician-led inception, these changes have been explicitly guided by partnership with clinicians. As two members of the ABIM Cardiovascular Board, we would like to update the community on our progress and invite all members to join us in our continued efforts to improve ABIM programs. To set the stage, we would like to first reflect on the history of board certification to better understand where ABIM began, and how we arrived at where we are today.
Origins of the Board Certification Movement
In a 1950 article in the New England Journal of Medicine, Reginald Fitz, one of the charter members of the 1936 ABIM Board of Directors, described the origins of the “board movement.” He tells the story of the 1865 American Medical Association (AMA) meeting at which the New York delegation complained that there were physicians in New York claiming special expertise in heart disease in “a naked attempt to grab patients”; the delegation was upset because these physicians had no such special expertise, and they asked the AMA to declare that specialization was unprofessional and should lead to expulsion from the AMA. Ultimately the AMA decided that specialization could actually be good for patients, the profession, and science in general. But not self-declared expertise: they recommended independent validation and verification of such claims.
In 1936, the AMA and American College of Physicians jointly created such an independent assessment organization: the ABIM. ABIM was established to improve the quality of patient care by publicly recognizing physicians who demonstrated special expertise within various disciplines of internal medicine.
As growth of information in medicine has accelerated, there has been increasing recognition that continuous, lifelong learning is required for clinicians to provide the best care possible to their patients. For example, not that long ago, it was considered inappropriate to administer beta-receptor blockers to patients with heart failure with a reduced ejection fraction. We now know that these drugs save lives in this group of patients. The boards have traditionally had a critical role in encouraging physicians to accrue and demonstrate command of medical knowledge. The implication was that verification of a physicians’ knowledge – as demonstrated by becoming board certified – could no longer be a once-in-a-career event.
Community Feedback on 2014 MOC Program
Responding to the need to better align with the paradigm of lifelong learning, in the 1990’s ABIM began making programmatic changes starting with discontinuation of lifelong board certification in favor of time-limited certification. In 2006, documentation of practice assessment activities (also known as Part IV) was implemented. In 2014, the Maintenance of Certification (MOC) program was implemented, specifically stipulating an increased frequency in MOC participatory activities more than once every 10 years.
As this series of changes demanded ever-increasing expenditures of time, effort, and money, a chorus of criticism arose about the relevance, complexity, burden and cost of ABIM programs, as well as redundancy with other reporting requirements such as hospital quality improvement efforts. The cardiovascular community in particular vocalized myriad concerns to ABIM about what many considered an excessive organizational overreach. Among them was the requirement for sub-specialized cardiologists, such as Interventional Cardiologists and Electrophysiologists, to maintain an underlying certification in cardiology; the added financial hardship associated with paying for MOC while in fellowship training for a sub-specialized cardiology area; and the dismay of physicians losing their certification – sometimes soon after they had earned it – because they had not paid for or enrolled in the 2014 MOC program.
Changes over the Past Five Years at ABIM
In response to the groundswell of feedback from the internal medicine community, on February 3, 2015 ABIM made a public apology to the more than 200,000 board certified internists and subspecialists and committed to a series of immediate changes to improve its programs:
- Suspension of the Practice Assessment, Patient Voice and Patient Safety requirements for at least two years (and subsequently indefinitely suspended).
- Updating of language used to publicly report a diplomate’s MOC status from “meeting MOC requirements” to the more accurate “participating in MOC”.
- Adjusting the blueprint for the fall 2015 Internal Medicine MOC exam to make it more reflective of physician practice.
- Freezing MOC enrollment fees at 2014 levels through 2017.
In 2013 – just as the 2014 MOC program was being finalized – ABIM’s governance structure was modernized to better represent the perspectives of internal medicine and its 20 subspecialty areas and to solicit insights from all members of the health care team including patients and other health care clinicians. This effort led to the creation of Specialty Boards that oversee the discipline specific programs, including the Cardiovascular Board which encompasses cardiovascular disease as well as all the cardiovascular tertiary subspecialties.
The Cardiovascular Board works with medical specialty societies such as the American College of Cardiology, Heart Rhythm Society, The Society for Cardiovascular Angiography and Intervention and others to promote representation on this governance board. Additional opportunities to shape the ABIM can be found across a wide variety of roles, such as the Board of Directors, Council, Specialty Boards, Exam Writing Committees or the Item-Writing Task Force. This is a fundamental departure from the governance in early years and how ABIM governance members were selected.
There are now more than 300 practicing physicians in a variety of disciplines and practice settings, patients, and other health care providers governing ABIM programs. The majority of physicians serving on ABIM’s Governance must have clinical practice experience, and 66% of the physician members of the Cardiovascular Board spend more than 50% of their time providing direct patient care. All physician Directors – including grandfathers – must participate in the MOC program and pass an exam in their discipline within three years of being appointed to the Board.
MOC Program Changes
In May 2015, ABIM created a dedicated team of staff focused exclusively on engagement and the building of connections with physicians and professional societies to solicit feedback on how to improve MOC, reduce its burden, and make it more relevant. In addition, a Community Insights Network – now consisting of more than 4,000 physicians – was launched to encourage this conversation.
By the middle of 2018, more than 44,000 physicians had provided direct input on improving the MOC program through surveys, focus groups and numerous visits by ABIM staff and governance to medical society meetings across the country. In response, key changes to the MOC Program include the following:
The American College of Cardiology echoed concerns about cardiologists who had sub-specialized and no longer practiced general cardiology, positing that ABIM should no longer require the cardiovascular disease certificate as a prerequisite for maintaining sub-specialization. The Cardiovascular Board agreed with this concern and dropped this requirement. This meant that maintaining a Cardiovascular Disease certificate was no longer a prerequisite to maintaining certification in Adult Congenital Heart Disease, Advanced Heart Failure & Transplant Cardiology, Clinical Cardiac Electrophysiology, or Interventional Cardiology.
Recognizing the financial realities of physicians in training, ABIM updated its policies so that those in fellowship would automatically receive a fee waiver and MOC points, thereby eliminating the financial burden of MOC while recognizing the ongoing learning typical of training programs. In a further effort to decouple payment from certification status, a policy requiring physicians to enroll in MOC and pay for the program in order to avoid losing their certification was rescinded. This meant a physician would never lose their certification due to lack of payment alone, and moving forward their certification status would be based on meeting the requirements of the MOC program.
Feedback from physicians about burdensome and redundant requirements led to a new collaboration between ABIM and ACCME to create a streamlined process for simultaneously earning MOC points and CME credit. Often referred to as CME for MOC, the process for earning points now occurs seamlessly for many activities such as reading journal articles, using point-of-care resources, attending meetings, grand rounds and internet courses. The number of activities that earn CME and MOC points has continued to rise via this arrangement, and as of January 2019, 144,251 diplomates had earned 11.3 million MOC points. Currently, there are more than 2,500 CME activities that offer MOC in cardiology and its subspecialties, along with CME credit.
Physicians told ABIM that too many exam questions concerned esoteric minutiae unrelated to what they saw in their daily practice. To respond to these concerns, a new blueprint review process was created whereby all physicians certified in each discipline – including cardiovascular disease and the cardiovascular subspecialties – were invited to rate the frequency and importance of each topic area on the exam to the physician’s practice. Thousands responded to this call to provide direct input into the exam blueprint from all disciplines, and their feedback has helped increase the relevance of the content upon which they are tested.
Validating this change in cardiology was the percentage of test-takers that negatively rated the statement “The examination was a fair assessment of clinical knowledge in this discipline” dropping from 32% for the last pre-blueprint review exam administration in fall 2015, to 28% in fall 2016 and 27% in fall 2017. The number of negative content-related comments by test-takers fell by 67% over the same time period.
Physicians articulated that they wanted more information about their exam performance to help them focus future learning efforts. The internal medicine community helped redesign the new score report via a series of meetings held to review various formats, provide opinions, and react to revised versions. Participants included a number who had failed the exam. Their feedback informed a new enhanced, user-friendly report that provides a detailed description of assessment performance and includes specific information on questions that were missed. The report follows the new format of the blueprint.
Members of the physician community had questioned how ABIM set passing standards for its exams, previously an opaque process that only included exam committee members. Operating under a new model of collaboration, practicing physicians were engaged to help modify standard setting – the process that sets the minimum passing score (i.e., determining the amount of medical knowledge a physician needs to pass) for all examinations. As one example of this increased engagement, the cardiovascular disease MOC exam standard setting meeting included 25 board certified cardiologists. Five of the physicians were selected from current and former Cardiovascular Disease Exam Committee members and 20 were selected from the ABIM cardiovascular diplomate population.
In an effort to make the MOC program more flexible, in 2016 ABIM announced that those certified in Internal Medicine and Nephrology would be able to choose an alternative to the high-stakes (pass/fail) 10-year exam beginning in 2018. The Knowledge Check-In (KCI) was designed based on physician input through surveys and focus groups, with over 30,000 physicians responding to an all-diplomate survey. The shorter KCI assessment can be taken at home or office (or in a testing center) and includes access to one external “open book” online resource (with plans for more resources to be added). Critically, a single unsuccessful KCI performance does not result in loss of certification. In other words, this is a much more formative process than the 10-year exam cycle.
Physicians taking the Internal Medicine KCI in 2018 reported that the assessment more closely aligned with their practice. Only 11% responded negatively to a post-assessment question asking if the examination was a fair assessment of clinical knowledge in the discipline, compared with 14% for the 10-year 2018 MOC exam. Of note, in 2017 23% responded negatively to that question after taking the MOC assessment, highlighting the increasing perception of relevance of the questions included on the exam.
KCI’s in all other subspecialties will be rolled out in subsequent years, with cardiovascular disease available this year.
To more closely align with how physicians look up information in their day-to-day practice, in 2018, ABIM introduced access to an online resource, UpToDate®, during the Knowledge Check-In and traditional MOC exams. This approach is novel to the testing environment and was informed by an evidence-based study in which 800 doctors participated to help ABIM determine the feasibility and impact of incorporating electronic resources into traditional MOC exams. The results indicated that access to resources reduced physicians’ anxiety about the exam and actually enhanced the exam’s capacity to differentiate between those likely to pass versus fail. Although UpToDate® is popular with general internists, ABIM continues to explore the potential for other external resources to be incorporated into MOC assessments, especially for subspecialty assessments.
ABIM has traditionally enjoyed a symbiotic relationship with medical specialty societies whereby they provide formative learning activities, and ABIM delivers a summative assessment of that knowledge. As more is understood about adult-learning theories and the collective medical community seeks reliable mechanisms to gain and assess knowledge, ABIM has devoted considerable resources to exploring new relationships and models with society partners.
ABIM has expressed an openness to working with any organization in the internal medicine community that agrees to a set of guiding principles, and in September 2017, it released a joint statement with the American College of Cardiology (ACC), American College of Physicians (ACP) and the American Society of Clinical Oncology (ASCO) formally announcing a Memorandum of Understanding with each organization to explore development of collaborative maintenance of certification pathways. In January 2019, a similar announcement was made with four societies representing gastroenterologists and hepatologists. The Cardiovascular Board is intimately involved in this effort, and along with staff, will work with cardiovascular medical societies to explore collaboration and development of maintenance pathways through which physicians could choose to maintain board certification. An update on this work is expected in March 2019.
In Closing
A verifiable mechanism to ensure physicians stay current with the advances in medicine provides value to all stakeholders across the health care ecosystem. While the MOC program may not be the perfect tool or the one all physicians agree upon, ABIM has redoubled efforts to engage the clinician community to enhance the program and augment its value. In an internet era where unverifiable expertise can easily be claimed, having a professionally created credential that speaks to special expertise–and the maintenance of that expertise over the course of a career–is even more important now than it was in 1865.
