Primary care recertification eased after physician complaints

Primary care physicians spoke up, and the certifying boards listened.

Some family physicians and internists made it clear that they weren't happy with the rollout of maintenance-of-certification programs intended to ensure professional competence.

While most agreed with the concept of doctors keeping up to date with medicine, they complained that the process was unwieldy, time-consuming and sometimes impractical.

After they expressed concerns to medical specialty groups, those groups got together with certifying boards. Now physicians and board leaders say the feedback and give-and-take discussions with medical associations and diplomates have led to changes that are making the maintenance-of-certification process more user-friendly to internists and family physicians.

"Diplomates see this as much improved," said Richard Feldman, MD, an Indianapolis family physician and a past president of the Indiana Academy of Family Physicians. He has been an outspoken critic of the new process. "People are getting through it much more easily now."

James Puffer, MD, president and CEO of the American Board of Family Medicine, said that, based on physician feedback, the board had made more than 25 major changes to the self-assessment module. "It's made a dramatic difference," he said.

The American Board of Internal Medicine has used input from internists to help refine its process, too.

"We have had a commitment to make this process meaningful and doable," said ABIM President Christine K. Cassel, MD.

Officials from both boards say the changes are improving the systems they originally put in place.

Included in the ABFM's roughly two dozen adjustments to its maintenance-of-certification program are allowing physicians to download and print questions for work off the computer; providing critiques for all knowledge assessment items; and enabling doctors to preview a number of items before committing to a particular self-assessment module.

The ABIM said it was enhancing its maintenance-of-certification program to be responsive to internists' needs. In 2006, the board will streamline requirements for self-evaluation and make it easier to renew more than one certificate.

"It's a really good example of the various elements of a profession working together to come up with a coherent, seamless process for the members of the profession," said F. Daniel Duffy, MD, the ABIM's executive vice president.

New era of recertification

Years ago, physicians were board-certified once during their careers. But after the American Board of Family Practice (now the ABFM) was founded in 1969, it began issuing time-limited certificates and requiring recertification every seven years. Other boards followed, and then in 1990, the ABIM started issuing 10-year certificates.

In 2000, medical specialty boards agreed to transition their recertification programs into maintenance-of-certification programs, which focus on lifelong learning. Most boards view MOC as a continuous process and encourage diplomates to spread learning throughout the years instead of bunching up self-assessment modules at the end of the recertification cycle.

Some doctors grumbled that the new process meant more frequent testing, took too much time and was not always relevant to their practices.

Physicians were particularly vocal on this issue because they have incentive to stay board-certified. Most hospitals and health plans require it, and failing to get certified can mean losing managed care contracts.

The American College of Physicians was concerned with its lack of input in evaluating maintenance of certification and said some parts of the ABIM's program intruded on its continuing medical education program. Both sides agreed to work together and formed a liaison committee to make recommendations. The committee started meeting in 2003 and now meets twice a year.

"Now the college and the board are working very closely together," said Troyen A. Brennan, MD, MPH, a professor of medicine at Brigham and Women's Hospital and Harvard Medical School, Boston. He is past chair of the ABIM board.

In January 2006, the ABIM will enhance its program by streamlining requirements, providing flexibility to diplomates and reducing redundancy with other programs.

Currently, diplomates must complete five self-evaluation modules to renew one certificate and extra modules for others. Module counts will end and be replaced by a point system that creates a flexible self-evaluation process and grants credit for self-assessment tools that other groups, such as the ACP, develop.

Instead of completing modules for additional certificates, diplomates will need to pass a secure exam in their subspecialty. A self-evaluation module for practice performance also will be required beginning in 2006.

Dr. Duffy said most of the changes were the result of feedback from the ACP and diplomates.

Family physicians have their say

Family physicians expressed frustrations in 2004 during the meeting of the American Academy of Family Physicians. Delegates passed a resolution calling for educating family physicians about maintenance of certification. They also wanted the required self-assessment modules suspended until technical and content problems were resolved. The ABFM extended the self-assessment module deadline 3½ months until mid-April 2005.

"They have been listening and taking input from diplomates and from the AAFP. They're making it easier to complete the modules," said AAFP President Larry Fields, MD, of Ashland, Ky.

While certifying boards say they respond to feedback from diplomates and medical societies, they also make changes after doing self-evaluations. As part of its review, the ABFM's board of directors in October voted on improvements, including extending recertification from seven to 10 years. Starting in January 2007, family physicians will have the option of extending their seven-year certificate by three years. The board will announce other changes in January 2006.

Primary care physicians said they are glad the boards have listened to their concerns, and they say changes have made maintenance-of-certification easier to handle. But Dr. Feldman said he still questions how meaningful the process is. He wonders if MOC reflects how good a doctor is and plans to watch how the process develops.

"They have improved the entire process because of the intense pressure that was brought on them," he said.