Gerald H. Jordan, MD, Thomas Granatir, and Michael L. Ritchey, MD, of the American Board of Urology provide an overview of the origins of certification and changes to the MOC exam that urologists can anticipate in 2017.
To understand certification and its origins, one must understand the evolution of medical education in the United States. In the late 1800s, U.S. medical education was uniformly deplorable. There were some university-affiliated medical colleges; however, the plethora of for-profit medical colleges produced physicians of questionable ability and ethics. Thus, medicine and surgery in the United States were dependent on Europe, England, France, and eventually Germany.
While the American Medical Association (AMA) had been founded in 1847 and the American Association of Medical Colleges (AAMC) in 1890, much of medical education was really not affected by either organization’s efforts. In 1904, the AMA Council on Medical Education was created. In one of its reports, the council adopted what it termed the ideal standards for medical schools. Eventually the AMA Council on Medical Education joined forces with the Carnegie Foundation for the Advancement of Teaching. They conducted an inspection of all medical schools in the United States, based on these AMA standards, school by school.
The report generated from this review, the Flexner Report, was published in 1910. It exposed medical schools by name and brought to the public’s attention the dismal state of much of medical education in the United States. Based on the significant reaction by the public and the government to that report, medical education was drastically reformed over the ensuing years.
The product of medical education in the United States was markedly improved by that reorganization. However, what now remained in disarray was postgraduate medical school education for those physicians who desired subsequent training in more specialized areas of medicine. One must keep in mind that most medicine practiced in the United States at that time was almost exclusively by the “general practitioner.” Soon, with the standardization of medical education, the urge by physicians to pursue more narrow medical or surgical fields became apparent.
Initially, post-graduate training was one of mentorships or apprenticeships, but a unified system of oversight of these programs was sought and achieved. Thus, those physicians who had achieved extra training and experience in designated specialty areas desired recognition for their expertise as well as recognition for being distinct from “general practice.”
By this time, numerous medical and surgical specialty societies had evolved. In 1916, the American Board for Ophthalmic Examinations was established and was renamed the American Board of Ophthalmology in 1933. That board said its chief functions were “to establish standards of fitness to practice the specialty and to arrange, control, and conduct examinations to test qualifications and then confer certificates on the qualified.” The board emphasized that it was not attempting to control practice by license or legal regulation and that the standards were to be maintained on a voluntary basis.
The American Board of Ophthalmology sought only to recognize its practitioners for their training and experience in the management of conditions of the eye. Their diploma was thus intended to indicate a reasonable, minimal standard of competence, not an advanced degree of skill. However, as it exists today, the nature of their organization meant that there would be those that chose to pursue certification and those that chose not to pursue it. Those who did not pursue certification were outside the board’s jurisdiction, and thus the Board then, nor any board now, can say categorically that those who are not certified are not safe specialists.
Based on the experience of the American Board of Ophthalmology, other specialty boards were formed to identify those that had pursued extra training and had extra experience in a given specialty area of medicine or surgery. All of those boards were formed basically by the same tenets as the Board of Ophthalmology, and to this day are limited in many ways by the same factors as originally limited the Board of Ophthalmology. Three more boards were created in the next dozen years and in 1933 they together formed what would become the American Board of Medical Specialties (ABMS), then titled the Advisory Board of Medical Specialties.
Next: American Board of Urology formed
The American Board of Urology was incorporated in 1935. Urology had developed itself as a separate specialty after World War I, rising quickly around instrumentation and developments in pharmacotherapy and endocrinology. By 1934, there were approximately 2,400 full-time or part-time urologists in the country. Urologists sought quickly to differentiate themselves from the “clap doctors from the West.” Interestingly, the American Board of Urology (ABU) established a grandfather clause to attract eminent members in the field, which was useful to that board as well as to other boards, both before and after.
As mentioned, the thought that voluntary certification is per se proof that the certified doctor is better than the non-certified doctor is very difficult to prove directly. There certainly is a fair amount of indirect evidence that looks at professional responsibility actions and complications of either treatment or surgery where tracked, etc., which supports that the certified physician, in general, serves better in their care of the public than the non-certified physician. With changes in medical technology, be they understanding of the disease processes, the application of innovative procedures or technology, or the better use of devices, the question was raised as to whether a single evaluation and statement of competence would be a statement of competence going through a practitioner’s career (Stevens R. American Medicine and the Public Interest. New Haven: Yale University Press, 1971. Updated [Berkeley: University of California Press], 1998).
Graduate medical education became regarded as an integrated and graded program of educational programs appropriate for the various years of training. Those years became designated as residency training, and it moved the thinking to regard all graduate medical education as essentially specialized. Thus in 1969 with the incorporation of the American Board of Family Medicine (ABFM), this concept was de facto ratified.
The incorporation of the ABFM, however, also ratified another concept, which was that a one-time evaluation and certification of competence was not appropriate with regard to a physician’s practicing lifetime. The ABFM was incorporated with required interval re-evaluation of its diplomates, and that was termed recertification. Research had already started to appear that suggested that knowledge and skills can decline as a physician moves farther from training, and it was already becoming evident that medical science was advancing at a fast pace, thus justifying the decision to incorporate recertification into ABFM’s certification process.
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What has since been recognized, again because of the pace of improvement in all facets of medical and surgical practice, is that an interval examination and recertification also failed in the goal to assist practicing physicians and surgeons in the ultimate goal of providing competent care to the public throughout a physician’s lifetime of medical practice. At that time, all board programs were examination and CME based, and those entities were not diverse enough to ensure that physicians and surgeons were keeping up in their specialties. Health care organizations were beginning to apply principles of industrial quality control to health care, moving away from quality assurance toward continuous quality improvement. Additionally, the movement to identify the competencies important to the practice of medicine had begun to transform medical residency training. All of these forces led to rethinking recertification to link knowledge assessment, education, and improvement in the certification process.
Next: ABMS implements MOC for all boards
Thus, the ABMS moved to implement Maintenance of Certification (MOC) for all its boards. The general concept was approved in the early 2000s, the first standards were adopted in 2009, and the standards were revised in 2015 to create more room for innovation and to free the specialties to tailor their programs to the needs of their diplomates. The concepts behind MOC processes may be easy to accept, but implementations of aspects of the process have rightfully been called into question.
Prime with regard to stimulating questions would be the efficacy of the interval exams that have been part of all boards’ recertification processes as well as all boards’ MOC processes. This new discussion can be summarized in three terms: “Summative, Formative, and High Stakes.”
To address the term “formative,” one must first define the term, and that definition for our purposes could be exposure to medical knowledge. That could be CME (by articles or courses), programs such as self-assessment study protocols, or staged learning. There is literature to support all of those as effective in exposing the physician to medical knowledge. “Summative” refers to testing. The testing must be consistently developed, consistently administered, and in the end, for the purposes of the test, a decision as to whether the results are a pass or a fail. Psychometrics are integral in this process, and provide exam committees with a “summative” pass-fail conclusion. Next, and integral to fulfilling the mission to the public and the certification brand, is the concept of “High Stakes.” High stakes means that a decision on retention of the certificate results (Brown PC, Roediger HL, McDaniel MA. Make it stick: The science of successful learning. Harvard University Press, April 2014).
The ABMS boards believe that a certificate should be current, and that it signifies that the diplomate is up to date in medical knowledge. The boards all periodically determine whether this is so. But many diplomates themselves would prefer a process that was more formative; ie, one that provides them feedback on what they do and don’t know and helps them find appropriate education to fill the gaps. Because the process of undergoing a high-stakes secure examination can be unpleasant, the boards have been thinking about ways to make the experience less burdensome and fearsome. Finally, we all know that “binge-and-purge” examinations do not support long-term retention. New research into the psychology of testing affirms that testing, which forces recall, is important to learning; but that smaller, less stressful, more frequent exams may be more conducive to long-term retention than infrequent high-stakes exams.
To this end, there are programs being piloted by various ABMS boards that are designed to solidify the correct balances of formative process with summative processes, with the ultimate charge of ensuring the reputation and mission of the boards as stated above. Many of these pilot programs require significant remodeling and changes to board exam committee procedures, and clearly the term pilot would suggest that after an interval of time there will be an assessment as to whether the pilot/pilots actually work.
The ABU also has questions concerning the interval exam and has received many constructive comments from our diplomates regarding how to address the issues unique to our exam process. Many of the comments stem from the current evolution of the specialty of urology in the form of significant, informal subspecialization. In the past, the ABU had modular exams that were believed to partially address this problem. However, at the time it was felt that these examinations lacked psychometric validity and needed to be abandoned.
Next: Changes to MOC exam in 2017
Just as education and testing techniques have evolved, so has the opinion of the psychometricians. Now a process that is consistently developed, consistently administered, consistently graded, and from which consistent high-stakes decisions are made is deemed valid. To this end, the ABU has changed the MOC exam to be administered in 2017. The board will go back to a modular exam. The ABU feels that this change respects the expressed need on the part of practicing physicians-appropriate for certification purposes-to be tested on aspects of urology that are relevant to their practices.
That process will consist of a general core urology module that all candidates will take, with modules better designed to reflect subspecialization added. Diplomates will be required to declare the module that they wish to add to the core module during the application process. We are enthusiastic that this will better address the issues of subspecialization. Those with pediatric urology subspecialty certification will take the pediatric MOC exam. However, individuals who are not pediatric urology subspecialty certified, but who practice primarily pediatric urology, will be given the option of also taking the pediatric MOC examination in lieu of the modular exam described above.
We soon will also have a female pelvic medicine and reconstructive surgery MOC examination. When we get to that point, the same MOC exam could possibly be offered to those individuals who have not elected female pelvic medicine and reconstructive surgery (FPMRS) subspecialty certification, but whose practices consist significantly of female pelvic medicine and reconstructive surgery.
The ABU has examined its recertification exam pass-fail data and has identified a high-risk group for failure leading to expiration of the certificate. That subgroup consists of diplomates who wait until the last opportunity to take the recertification or MOC examination and then fail the exam on that opportunity. To make sure that all individuals who are enrolled in MOC avail themselves of their three opportunities with the exam, all diplomates will take their examination in year 7. If they pass that examination, their cycle will not be reset, and they will be good to enter another 10-year MOC cycle as they are currently scheduled. If they pass the examination but have a marginal pass score, they will be given a conditional pass with feedback provided regarding content areas where they performed poorly. The conditional pass will be removed upon completion of CME activity in these problematic areas.
If a diplomate fails his or her first attempt of the MOC exam, they will be given feedback regarding content areas where they performed poorly. They will complete CME activity in these areas and come back the following year to retake the MOC exam. Individuals who fail the MOC exam a second time will be offered the option of an oral exam process. The latter will consist of protocols that are structured around basic clinical general urologic problems and emergency room practice of urology. These changes have been reviewed with a number of diplomates and have been enthusiastically endorsed.
The ABU, along with 20 other specialty boards, is a participant in the Multi-Specialty Portfolio Approval Program through which diplomates in hospitals and health care organizations can get their MOC practice improvement credit by participating in organizational quality improvement activities. Diplomates, where appropriate, should talk to their institutions about becoming sponsors thus allowing them to obtain their improvement credits in this way.
We were asked by Urology Times to address the issue of control that ABMS can exert over boards. All the ABMS member boards carry certificates that represent the whole community of ABMS boards, so it’s appropriate to create some consistency about what that means in practice. Through ABMS, the boards set standards for themselves-really a general framework-and then each board has the flexibility to develop programs within that framework that will work for their diplomates. This keeps the programs practice-relevant but also sends consistent signals to patients about what it means to be certified by an ABMS member board.
However, there are situations in which a member board can be out of compliance with the published standards of the ABMS. All of the ABMS member boards are part of a community. ABMS doesn’t want to exile any boards, but all the boards are affected by the decisions made by others in the community. That means that they should be working together to come into compliance with the expectations set by the community for the community of all of the member boards.
None of the ABMS member boards think it would be appropriate for certification to be a unique requirement for hospital privileges (for the good reasons introduced above-ABMS boards do not track the quality of non-certified physicians), but the boards do believe that their emphasis on training and assessment is an important indicator of physician competence and ought to be taken into account by hospitals and others. In any case, medical staffs set their own standards for privileges and should be encouraged to look closely at certification along with all other indicators of physician competence.
Certification has a long history. It has changed as the quality of training has changed, and knowledge about quality practice has changed. Certification is a voluntary process and as such must be acceptable to the physicians who participate in it. Many changes are being made to change that process in ways that preserve the core aspect of certification-it’s a statement that physicians are prepared with the knowledge, skills, and professionalism to practice in the specialty. However, a crucial tenet of MOC is to create an experience for clinicians that’s more relevant, less burdensome, and supports their professional development.
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