Dr Baron is Director, American Board of Internal Medicine, and President, Greenhouse Internists, Philadelphia, Pa.
It is not an easy time for physicians at any stage of our careers. Beset by increased demands, lower reimbursements, and intrusive oversight by insurance companies, many of us are unhappy and frustrated. So why did the American Board of Internal Medicine (ABIM) add to the collective misery by moving to time-limited certification and adding a requirement for Maintenance of Certification to the already full plate of practicing doctors? This is a question I am often asked. But I do not look at it that way. I believe the Maintenance of Certification process adds value for me personally and for our profession as a whole, and I think it is important for us to embrace it.
First, the personal value. The process includes 3 major components: self-study (a variant of continuing medical education); a secure exam (like we all took to become internists, only now it's done on a computer at a testing center); and a self-audit designed to measure and improve performance in practice. It is fair to say that I was more focused and more serious in my self-study knowing that I was going to have to take an exam at the end. I did that part using the ABIM's Self-Evaluation Process modules, which presented some very challenging questions (no answers or educational text provided), for which I had to do research and talk to colleagues to get an answer. Another option (not available when I renewed my lifetime certificate in 1998) is to use the Medical Knowl?edge Self-Assessment Pro?gram materials prepared by the American College of Physicians. These represent a com?prehensive review of internal medicine, and those of us, like I, who have practiced outside an academic health center for more than 15 years can truly benefit from the full update.
Then there is the secure exam. Even after a comprehensive review, it was humbling to see how difficult it was. But like 97% of my colleagues, I passed, and like 89% of them, I did so on the first try. And that was very satisfying?to know that a "jury of my peers" felt that I had the knowledge and ?judgment required to provide high-quality care to my patients, even 20 years after my training.
But my favorite part was the Diabetes Practice Improve?ment Module, which gave me the opportunity to survey my patients about their experience in our practice (using a structured survey, with patients calling an ABIM automatic response system) and to audit 20 of my charts against standards of care which I believe in (such as achieving a low-density lipo?protein level below 100 mg/dL in patients with diabetes or screening for microalbuminuria). The results were reassuring?and disturbing. Although we were doing a good job on most screening measures, and patients were not having trouble getting appointments or prescription refills, my patients did not feel that I communicated much understanding of what it was like to live with diabetes. You can't improve what you don't measure?and measuring patient satisfaction has changed the way I interact with my diabetic patients.
But how about the value to the profession? It is difficult to defend lifetime ?certification for doctors. Other professionals, from pilots to teachers to electricians, are asked to demonstrate that they remain competent to do what they were trained to do years ago. Our patients should expect no less from us. But there is another reality: there are a lot of people who want to measure what we do. If we do not get involved as a profession, it will be done to us, not with us or by us?and almost certainly will not be done as well.
As professionals we have the ?knowledge to figure out what matters, what makes a difference in patient outcomes. ?Measuring ourselves against standards we create and believe in makes the measurement process meaningful and credible for us, while it assures the public that we are paying attention to quality. It also leads to better care for our patients, which is why most of us go to work.
Patients, purchasers, and health plans are demanding that physicians document and improve quality of care. We can demonstrate our commitment and achievement through Board certification and ongoing Maintenance of Certification. imwr
Why Internists Do?and Do Not?Maintain Their Certification
By Laura Brasseur
Almost 9 of 10 internists maintain their certification in internal medicine (IM), but usually for reasons other than that they are required to do so. Results of a survey study published in the Annals of Internal Medicine (2006;144:29-36) also reveal that many internists switch from IM to another medical field.
In the past, the voluntary recertification program offered by the American Board of Internal Medicine (ABIM) attracted few participants. As a result, in 1990 the ABIM started issuing time-?limited, 10-year certificates, which required participation in a Maintenance of Certification (MOC) program for renewal.
Until now, little was known about the 23% of general internists and the 40% of subspecialists who were not renewing their IM certificates or the 14% of ?subspecialists who were not renewing their subspecialty or added qualifications certificates.
Surveys sent to a nationally representative sample of 3500 certified internists in the United States garnered 1799 responses. Of these, 1607 responses were deemed usable for the purpose of the study. All had participated in the first wave of required certification in the early 1990s in either IM, an IM subspecialty, or an area of added qualifications.
The reasons cited for both participating and not participating in MOC varied widely. The final sample used for these results included 305 general internists, 663 subspecialists who were eligible to renew their IM certificate, and 639 subspecialists eligible to renew their subspecialty or additional qualification certificate.
Responders provided more than 1 reason for participating or not participating in the certification process. The main reasons for participation were: maintain professional image, update knowledge, improve patient care or personal inter?-est; employment requirement; improve patient care.
The main reasons for not participating included too much time; too expensive; not required for employment; requirements unreasonable; no monetary benefit; not relevant to current practice; and unclear requirements (see Chart, page 1).
"The most surprising finding is the relatively large proportion of general internists (21%) compared with the small proportion of subspecialists (5%) who claim to be working in a medical field other than internal medicine," write Rebecca S. Lipner, PhD, of the ABIM, and colleagues.
More than two thirds (78%) of the general internists who were no longer working in IM were currently working in another medical field, and 17% said they may return to IM. Only 3% were no longer working in medicine, and 2% had retired.
After adjusting for attrition (by assuming that the 52% of general internists who left IM and did not enroll in MOC probably never would enroll), investigators determined that about 86.5% of general internists and subspecialists participated in MOC. Three fourths of the survey respondents believed that in?ternists who are involved with direct patient care should be certified. However, only 44% believed that MOC was necessary for keeping up to date, and only 38% felt that program requirements were appropriate.