Testing, testing: For doctors, it never ends

Family physician Tony Golden, MD, has been through board recertification three times. He isn't sure he can stomach a fourth one.

"I've seriously questioned doing it again," said Dr. Golden, who practices in Idaho Falls, Idaho.

Board-certified family physicians go through recertification every seven years, but Dr. Golden and other doctors are facing a new era in recertification. In 2000, medical specialty boards agreed to transition their recertification programs into maintenance-of-certification processes, which focus on continuous lifelong learning.

For most physicians, this new focus means more frequent testing of their knowledge until they are recertified. For example, family physicians must undergo six self-assessment modules to evaluate medical knowledge and judgment. The American Board of Family Practice recommends that diplomates complete one module per year rather than do them all near the end of the seven-year cycle. Internists must complete five self-evaluation modules in their 10-year recertification cycle, which would mean doing a module every two years to stay on pace, doctors said.

Some doctors are balking. They say the process is burdensome because too-frequent testing taxes their time. They also think the testing is too expensive. And they question whether the tests apply to their daily practice.

"I've never had a single patient ask me if I was board certified, and I'm not seeing a lack of trust among patients I see," said Dr. Golden, who has practiced for 25 years. "It's just one other thing to dump on the head of the practicing doctor to distract us from our job of taking care of patients."

Health leaders say maintenance of certification tests medical knowledge and skills throughout a physician's career, which ensures competence and improves quality of care.

"The world of medicine -- the knowledge, the skills and the techniques -- continues to dramatically change very, very, very rapidly. So for someone who was trained 20 years ago, the knowledge base is different," said Stephen H. Miller, MD, MPH, executive vice president of the American Board of Medical Specialties, which represents 24 medical specialty boards. "Ultimately, it's for the benefit of their patients."

Physicians used to get board certified once during their careers. But after the American Board of Family Practice was founded in 1969, it began to issue time-limited certificates and require recertification every seven years.

Other boards followed. In 1990, the American Board of Internal Medicine started issuing 10-year certificates. Physicians who received their board certificates before recertification began have been exempted from the process by some boards.

Maintenance of certification arrives

In 2000, member boards of the ABMS agreed to transition to maintenance of certification. Most boards view the program as a continuing process and encourage diplomates to spread learning throughout the years, rather than bunching up self-assessment modules at the end of the recertification cycle.

The 1999 Institute of Medicine study that reported medical errors in hospitals kill up to 98,000 Americans each year was a driving force for change, according to specialty board officials. The report's findings were disputed by some in the medical community, but patient-safety and quality-of-care concerns began to attract more attention from the public and policymakers. Meanwhile, specialty boards worked to shift recertification to maintenance of certification to continuously assess physician competence.

In maintenance of certification, physicians demonstrate competency in six areas: medical knowledge; patient care; interpersonal and communication skills; professionalism; practice-based learning and improvement; and systems-based practice.

Maintenance of certification has four basic components to measure those competencies:

• Evidence of professional standing: maintaining a full, unrestricted medical license.
• Evidence of commitment to lifelong learning and involvement in a periodic self-assessment process.
• Evidence of cognitive expertise based on performance of an exam.
• Evidence of evaluation of performance in practice.

The ABMS required member boards to submit final plans for implementing the first three maintenance components by July 1, 2003. Plans for adding the evidence of physician practice performance component are due Dec. 31.

"Maintenance of certification has some advantages. It does a better job of convincing the public that physicians are continually keeping up [with medical knowledge] all of the time, and that's a good message," said Norman Kahn, MD, vice president of science and education for the American Academy of Family Physicians.

Change has not come easy. When the American Board of Internal Medicine introduced its program, called Continuous Professional Development, some internists supported the concept.

Others voiced displeasure. They viewed the program as burdensome, costly and not relevant to the current practice environment. They said recertification should take into consideration a doctor's insight and judgment to make decisions.

The American College of Physicians took issue with its lack of input in evaluating recertification and said some of the program intruded on the ACP's continuing medical education program. The college considered the possibility of creating another path of recertifying physicians.

The American Board of Internal Medicine and the American College of Physicians decided it was best to work together. In 2002, the ACP's board of regents approved an agreement between the two groups, and a liaison committee was formed to make recommendations on recertification.

Despite cooperation, "Large numbers are saying [maintenance of certification] isn't worth it," said Jim Stackhouse, MD, who serves on the ACP's board of regents. "I hate to see it splitting the profession."

Patricia Raymond, MD, a gastroenterologist in Chesapeake, Va., is glad she didn't have to be recertified in internal medicine. She was board certified in 1989, the year before the ABIM started recertification.

But she was board certified in gastroenterology in 1991, so she didn't make the 1990 cut-off for recertification exemption. In 2001, she went through recertification for gastroenterology. She struggled with the self-evaluation modules of 60 multiple-choice questions, failing the first time she took a module while on an airplane.

She then cracked the books and got the questions she missed. But she found the process frustrating. She said the test questions "were esoteric trivia questions written in academia with little clinical utility for the practicing physician."

Dr. Raymond struggled to answer one question about a woman who gives birth then later goes into a coma. Her ob-gyn friends didn't know the answer. Finally, she found it in a book, about a month later.

"It went crazy over diseases I don't ever expect to see in my career," she said. "Is recertification supposed to be a speed bump or is it supposed to bring a gastroenterologist to another level? It didn't take me to another level."

Dr. Raymond will consider retiring before being recertified again. "I would rather be tarred and feathered than do that."

Family physicians take issue

Some family physicians also voice frustration. The American Board of Family Practice requires diplomates to complete six self-assessment modules during a seven-year cycle.

Richard Feldman, MD, an Indianapolis family physician, said the modules are time-consuming, onerous and of questionable value. The board said each module takes about 15 hours to complete, but Dr. Feldman said it takes some doctors 25 to 80 hours.

Board leaders, however, disagree that the system is burdensome to physicians.

"[The modules are] online. You can access them from your home or office. You can complete them whenever you choose and stop them when you have a patient to see or have family activities," said Joseph Tollison, MD, ABFP's deputy executive director.

The Indiana Academy of Family Physicians passed a resolution asking the AAFP to call for the family medicine board to give doctors a chance to provide new input in reshaping the program, Dr. Feldman said.

"I'm not proposing that we scrap this whole maintenance-of-certification concept. We need to revisit this whole process. It's too complicated," said Dr. Feldman, immediate past president of the Indiana academy.

Some doctors object to the cost, which is about $1,000 to $1,100. Others oppose performance measures, saying it's an intrusion on their practice. And some say test failure rates are too high. But the ABFP said the failure rate for first-time recertification takers dipped from 9% to 8% last year.

Doctors have incentive to stay board-certified. Most hospitals and health plans require board certification. Failing to get certified can mean losing managed care contracts. Some hospitals, health plans and insurers are exploring whether to require maintenance of certification of their doctors.

"The vast majority of internists are signing up for recertification. They're signing up and not complaining about it," said Christine K. Cassel, MD, president of the American Board of Internal Medicine. Dr. Cassel said 75% of internists with expired certificates had enrolled.

Recertification has support from major medical organizations.

The American Medical Association supports the concept of voluntary recertification but opposes recertification as a condition of employment.

The American Osteopathic Assn. backs recertification to assess continued competence of DOs but opposes any attempt by state or federal agencies to mandate recertification as a condition of re-licensure.

A new study in the Sept. 1 Journal of the American Medical Association said board certification is an important part of the quality movement. The study said maintenance of certification is highly valued by the public, and most patients claimed they would change doctors if their physicians failed to maintain certification.