It wasn’t long ago that a neurosurgeon could display his or her certificate from the American Board of Neurological Surgery (ABNS) and know the validation of competency was good for a lifetime. That changed for younger neurosurgeons in 1999 when the ABNS endorsed recertification and began issuing 10-year time-limited certificates. Now the concept of recertification is likely to give way to an entirely new process.
Neurosurgery and other medical specialties are considering adopting maintenance of certification. Instead of testing a physician every seven to 10 years, as the specialty Boards do now, physicians without lifetime certificates would have to demonstrate competence on an ongoing basis. A physician would not only take a test but also undertake periodic self-assessment and have his or her practice performance evaluated.
The American Board of Medical Specialties (ABMS) is the driving force behind maintenance of certification. It launched a study of physician competence three years ago in order to meet the demands of the public and legislators.
Maintenance of certification would significantly change how the ABNS and the 23 other specialty Boards, which constitute the ABMS, monitor the professionalism of specialists. For neurosurgeons and other specialties, maintenance of certification would significantly influence CME, annual meetings, journals, and other professional activities. CME, for example, may have to be reconfigured and tailor-made to ensure a neurosurgeon is meeting the requirements of maintenance of certification.
Maintenance of certification also would change the way a neurosurgeon approaches his or her career. For most specialties, recertification is centered on a test. Pass the test, hang the recertification certificate on the wall, and return your focus to your practice. Maintenance of certification brings a new dimension of continual attention to keeping skill sets and knowledge current. It means paying frequent and more focused attention to requirements for maintaining one’s good standing within the profession.
Many of the details of how maintenance of certification will work remain completely open. Like other specialties, the ABNS is free to turn away from the broad recommendations of the ABMS (though that is unlikely). The ABNS is also free to implement the principles of maintenance of certification in a manner that works for neurosurgeons. That is what the ABNS is working on now. The recertification process approved by ABNS in 1998, not scheduled to be implemented until 2006, is being reassessed in light of the principles of maintenance of certification.
“Maintenance of certification is here to stay,” said Volker K.H. Sonntag, MD, Chair of the ABNS Committee on Maintenance of Certification. “The train has come in, and we’ve jumped aboard. But we need to get organized neurosurgery and practicing neurosurgeons to work together on this. We’re not about to shove this down anyone’s throat. We’ll present this to neurosurgeons as we go along. We want input.”
Task Force Formed
The roots of maintenance of certification go back to the decision by the American Board of Family Practice in 1969 to limit the validity of its certificates to seven years. The ABMS took notice and urged other member Boards in 1973 to implement voluntary, periodic recertification. In 1993 the ABMS reaffirmed recertification and required all its Boards to establish plans for recertifying diplomates.
All 24 specialty Boards now limit (or plan to limit) the duration of the validity of their certificates. Some began recertification early on. Thoracic surgeons began receiving time-limited certificates in 1976, and urologists in 1985. Like neurosurgeons, other specialists took awhile to implement recertification. Anesthesiologists began receiving time-limited certificates in 2000. Otolaryngolists will not begin receiving time-limited certificates until 2002.
The traditional goals for recertification have been to improve the care of patients, to set standards for the practice of medicine, to encourage continued learning, and to reassure patients and the public that doctors remain competent throughout their careers. The public’s concern about competency has escalated in recent years, especially after the Institute of Medicine released a report in 1999 that revealed that as many as 98,000 people die annually as a result of medical errors.
Recognizing the growing public demand for physician competency, the ABMS created a Task Force on Competence in 1998. David Nahrwold, MD, who heads the Task Force, said, “None of us tolerate incompetence in anything anymore, whether it’s having your automobile repaired or any service you receive. We expect that, when we pay the bill, the job has been completely done. Needless to say, the medical profession is not immune to this.”
Competency Defined
The Task Force has delineated six general areas of competency: medical knowledge, patient care, interpersonal and communication skills, professionalism, practice-based learning and improvement, and systems-based practice. The Task Force has also developed examples of the six areas. According to Ralph G. Dacey Jr., MD, ABNS Secretary, most of the examples can be applied fairly easily to all specialties, but the examples in the areas of professionalism and practice-based learning are problematic for neurosurgeons. In a March 2001 report from the ABNS to the AANS, he wrote, “It will be the responsibility of the neurosurgical specialty societies and the ABNS to define exactly what is competence for a neurosurgeon in these six areas. If our specialty does not do this, it is likely that a generic definition of physician competence will be applied to us.”
The ABMS focus on physician competency has been mirrored and in some instances done in collaboration with similar efforts by other medical associations. Both the Accreditation Council for Graduate Medical Education and the Association of American Medical Colleges have committed to the six areas of core competencies, assuring that the same principles of competency are nurtured at all levels of medical education and thereafter. Moreover, the ABMS is partnering with the Council of Medical Specialty Societies (CMSS) on competency issues. The ABMS/CMSS Joint Planning Committee is a distinct entity complementary to the Task Force on Competence.
The number of prominent medical groups exploring competency demonstrates the strength of the commitment of organized medicine to the issue. Assuring competency is a movement with powerful momentum.
Maintenance of Certification
Besides defining physician competency, the Task Force on Competence supported and outlined maintenance of certification. A report from the Task Force stated, “It is now recognized that recertification is necessary but not sufficient to document that a physician is competent to practice a specialty.” The Task Force recommends that to maintain certification a specialist provide:
- Evidence of professional standing
- Evidence of commitment to lifelong learning and involvement in a periodic self-assessment process
- Evidence of cognitive expertise
- Evidence of evaluation of performance in practice
Exactly how these requirements are fulfilled needs to be further developed by the ABMS and ultimately interpreted and implemented by the ABNS. Some preliminary details, which may or may not hold up, have emerged. Evidence of professional standing will mean maintaining a valid, unrestricted license, but it also may involve consideration of malpractice claims, peer review, and patient review such as patient satisfaction surveys.
Lifelong learning and self-assessment involve CME and self-assessment tools. “CME will have to support and be part of any program for maintenance of certification. You can’t have maintenance of certification without CME,” said Dr. Dacey. “CME will be done at a higher standard, in a more professional way.”
Some specialties that began recertification years ago already are using self-assessment tools. The American Board of Internal Medicine is developing one of the most sophisticated self-assessment procedures. Diplomates complete self-evaluation modules in clinical and communication skills, practice performance, medical knowledge, and patient/peer feedback. The modules can be completed in any sequence at one- to two-year intervals over the 10-year certification span of the ABIM. The modules generally have a pass-fail standard, may be repeated as often as needed, and can be done alone or in groups at home or in the office. The clinical and communications module, for example, consists of multimedia questions about standard physical examinations and communications techniques. Video clips and still images display physical findings, and they test skills such as visual inspection, auscultation, and percussion ability.
Cognitive expertise will be measured by a written examination, most likely proctored. The ABNS Recertification Committee already has been working on a cognitive exam. The Board expects to offer the test in 2006. It probably will consist of 250 general questions and possibly 200 questions related to a neurosurgeon’s subspecialty. It may be taken as many times as needed to pass. Some neurosurgeons will fail at least on their first attempt. “The public won’t accept it if everyone passes. That won’t pass the muster,” said Steven L. Giannotta, MD, Chairman of the ABNS.
Practice performance expertise may be measured by taking key cases covering the scope and range of a specialty, and identifying and assessing critical events in those cases. The American Board of Family Practice (ABFP) is one of the specialties that currently require demonstration of practice performance to earn recertification. The ABFP Office Records Review assesses how well a family physician does in caring for patients with hypertension, coronary artery disease, urinary tract infection, and other stipulated conditions. The physicians fill out data collection forms based on his or her review of patient charts, and the ABFP analyzes the physician’s competence in treating illness.
Concerns Raised
Establishing a maintenance of certification program raises issues of oversight, cost, fairness, and legalities. The ABNS will have to resolve these issues while framing its own maintenance of certification program.
Some specialty Boards are concerned that maintenance of certification alone is not sufficient to assure the public that physicians are competent. They question whether the public would allow a specialty to monitor itself. It has been suggested that an independent oversight body may be needed. Pediatricians and internists have established the National Physician Quality Council. The council, consisting of physicians and non-physicians, would oversee the practice performance component of maintenance of certification. If the council comes to fruition, they may invite other Boards to participate. The ABNS is not interested in an oversight council and wants to oversee its own maintenance of certification.
“What internal medicine and pediatricians want sounds reasonable, but it’s not for us,” said Dr. Sonntag. “Who better to judge neurosurgeons than neurosurgeons? What could be more credible with the public than to ask patients how we’re doing, to administer peer review, and to pass an exam?”
Cost is another factor in making maintenance of certification difficult for neurosurgeons. The ABNS may have to invest in additional staff and technology to administer the program. Dr. Sonntag, for one, holds that costs would be reasonable after the initial outlay to set up a program. “Once the process is established, it’s more of a clerical matter than anything else,” he said. “It might be more work for the ABNS office, but it’s doable.”
A thornier issue is imposing a set of requirements on younger diplomates, while neurosurgeons with lifetime certificates are exempt. (See Personal Perspective.) Unhappy younger neurosurgeons may argue that older neurosurgeons are the ones who have a greater need to renew their knowledge base. “I am concerned about the idea of taking a written exam on potentially irrelevant material,” said John S. Yu, MD, of Los Angeles. “I am also concerned that the exam is limited to more recent graduates. That does not seem fair to me. Review of cases and peer comment seem more relevant.”
Hugh Garton, MD, of Ann Arbor, Mich., another younger neurosurgeon, said, “Recertification should just document a process that should be going on anyway. As a subspecialist, my only concern is that the process take into account the specific practice patterns of the candidate.”
Having only newly certified specialists subject to maintenance of certification also may cause a public relations problem. The public may not trust a system in which only some physicians among a specialty are rigorously monitored. It may, in fact, turn away from older specialists who are not subjected to the same requirements as younger ones.
However, the lifetime certificates are just that-lifetime. Altering that would be unfair and probably nearly impossible to uphold in court. Over the long haul the problem will disappear on its own. In the meantime, neurosurgeons with lifetime certificates may choose to undergo maintenance of certification voluntarily to prove their worth and marketability. Others may find they need to take part in maintenance of certification if they wish to get a license in another state. Some specialists who have crossed state lines have been denied a license because they had not been recertified.
Cost, fairness, and administrative concerns also were challenges when the specialty Boards established recertification. The Boards that began recertification years ago handled these issues and moved ahead. A challenge they are still grappling with in varying degrees is the harm that may come to specialists who fail to recertify. Physicians without certification are in danger of losing managed care contracts, as well as the prestige associated with higher professional standing.
The failure rate for recertification for general internists usually hovers around 10 percent. The failure rate for family practice physicians was 8 percent in 1999. Other specialties have fared better. The failure rate for obstetricians-gynecologists is 4 percent, and the rate for orthopedic surgeons is minuscule.
ABNS leaders offer assurances that the exam for neurosurgeons will be fair and that neurosurgeons will have ample opportunity to meet all recertification requirements. “They will be given every chance in the world,” said Mary Louise Sanderson, ABNS Administrator. Yet, she cautioned, “Every exam has to have a failing point; otherwise, it doesn’t accomplish anything.”
Maintenance of certification isn’t a matter of “either you’re in or you’re out,” said Dr. Giannotta. “We’ll partner with the educational societies like the AANS to put on remedial sessions to get doctors up to speed.”
A final concern is a legal one. The ABMS wants to reassure the public that physicians are competent, but it needs to avoid appointing itself as the final arbiter of who is qualified to practice and who is not. “There are restraint of trade laws that must be observed,” said Dr. Giannotta. “We want to avoid a class action lawsuit. If recertification is linked directly to competence, the whole process could end up getting overturned in the courts.”
Organized neurosurgery is taking steps to address these various concerns. The Council of State Neurosurgical Societies decided at its semiannual assembly in April in Toronto to ask the AANS Board of Directors and CNS Executive Committee to petition the ABNS to consider naming a liaison to the ABNS who received board certification after May 1999.
Conclusion
The Directors of the ABNS held a retreat in February to discuss maintenance of certification. Experts from the military, aviation, and other medical specialties described their extensive mechanisms to ensure competence. The Directors emerged from the retreat with the realization that neurosurgery lags far behind these fields in monitoring competence, and they resolved to move ahead with maintenance of certification.
The journey will be long, collaborative, and worthwhile. “This is an opportunity to make a common sense and effective process that works for neurosurgeons and satisfies the demands of the public and various regulatory bodies,” said Dr. Dacey. “The tendency might be to think that this is another burdensome set of requirements, but we have to respond to it. It won’t go away.”