Ideas and Opinions
Annals of Internal Medicine
The American Board of Internal Medicine: Evolving Professional Self-regulation Richard J. Baron, MD, and David Johnson, MD
T
he mission of the American Board of Internal Medicine (ABIM) is “To enhance the quality of health care by certifying internists and subspecialists who demonstrate the knowledge, skills, and attitudes essential for excellent patient care.” As the largest of the American Board of Medical Specialties’ 24 certifying boards, the ABIM certifies approximately 1 of every 4 physicians in the United States (1). The board was created in 1936 by a joint action of the American College of Physicians and the American Medical Association; their goal was to distinguish internists who met peer-established standards from those who could not or chose not to do so. Although the ABIM’s roots lie in these membership organizations, it is insulated from the pressure of dues-paying members by being an independent organization with a self-perpetuating governance that relies on experts to set standards. The ABIM has 2 core functions: defining disciplines and setting standards. Defining a discipline is not an abstract exercise, and creating standards that need to be met defines what physicians must know to achieve board certification in their discipline. The assessment instruments, however imperfect, are anchored in a conversation among experts who ask the question, “What should persons who call themselves internists know and be able to do?” The ABIM’s credential derives its value from the experience that diplomates have obtaining and maintaining it (training, professional self-development, and lifelong learning) and the way that others choose to use it. For example, we are licensed “physicians and surgeons.” Our licenses authorize us to remove brain tumors and replace heart valves. What keeps us from doing those things? In addition to our own judgment, a “subregulatory” medical ecosystem of credentialing and privileging prevents us and other internists from practicing beyond our training. This ecosystem relies on recognition by credible, independent third parties, such as the ABIM. Standards that define what it means to be an internist must evolve as medicine does. Most internists practicing today would be unfamiliar with and perhaps unable to pass the first ABIM examination, a written essay test with 8 questions (Figure). As what we need to know and do as certified internists (or subspecialists) has changed, so have the requirements for obtaining the ABIM credential. The Table shows some of the most consequential changes in the ABIM’s process and expectations. The most recent change— one that has provoked considerable protest—is the decision to make the credential more continuous by requiring evidence of ongoing engagement in learning and
practice improvement. The ABIM made this change because a 10-year maintenance-of-certification (MOC) cycle simply is not credible today. As of 1 January 2014, the ABIM has instituted requirements for more frequent participation in activities to assess medical knowledge and practice. At the same time, it recognizes many pathways to meet those requirements that are not created by the ABIM, including programs from medical societies (such as the American College of Physicians) or health systems (such as the Mayo Clinic). The ABIM will begin to publicly report the status “meeting MOC requirements” (or, alternatively, “not meeting MOC requirements”) on the basis of successful completion of these activities at specified intervals (see www.moc2014 .abim.org for more information). The goal remains to create a professionally recognized framework for distinguishing those who meet a peer standard from those who do not or choose not to do so. Who is setting the standards matters for credibility and rigor. The 1936 documents establishing the ABIM required 5 members from the American College of Physicians and 4 from the American Medical Association; more than half of them had to be “at the rank of full professor in a U.S. medical school.” But what it means to be a “good doctor” is no longer the exclusive purview of medical school professors. Taking a dramatic action under its new governance structure, the ABIM will now require all of its boards—the entities that define the standards in internal medicine and all of its subspecialties—to have at least 2 noninternist public members, one a member of the interprofessional health care team and one with “patient/caregiver perspective.” The ABIM also codified what had been an informal practice by requiring “a minimum of one practitioner whose primary practice is in a non-university, community setting” on each board. These newly constituted boards will oversee all aspects of the MOC process, including selfevaluation of medical knowledge and of practice assessment, within their respective disciplines. To fill these critically important positions, the ABIM reached out to professional societies, health systems, and patient groups to help identify distinguished internists with records of achievement in diverse health care settings. We believe that
See also: Editorial comment. . . . . . . . . . . . . . . . . . . . . . . . . . 226
This article was published online first at www.annals.org on 13 May 2014. © 2014 American College of Physicians 221
Ideas and Opinions
The American Board of Internal Medicine
Figure. First American Board of Internal Medicine examination.
usually not reliable judges of their own knowledge gaps. It also discusses several observational studies that correlate examination performance and various clinical outcome measures, including those used by Medicare and some standard clinical measures for diabetes and hypertension, and describes several studies that show that MOC tools help physicians change their practice. As ABIM programs become more continuous and, we believe, more relevant to practice, program evaluation and ongoing surveys of diplomates will continue to be an essential element in monitoring both the relationship of MOC to the quality of care that physicians deliver and physician accountability to the public. The ABIM is a tangible example of professional selfregulation, something in which all internists can take pride. Internists set the standards, which are better informed than those set by governments, payers, businesses, or others who have an increasing interest in the quality of their physicians. The ABIM will continue to work to ensure that internists who meet its standards get “credit” for as many quality incentive programs as possible, including those used by Medicare and other payers. We are proud to Table. Key Milestones in the Evolution of ABIM Standards and Certifications Year
Milestone
1936 1941
First ABIM examination administered First ABIM subspecialties introduced in cardiology, gastroenterology, and pulmonary disease Essay questions discontinued and replaced by multiple-choice questions ABIM Board of Directors decides to discontinue “lifetime” certification but ultimately concludes that ABIM does not yet have the capacity to develop a comprehensive recertification program New ABIM subspecialties approved in endocrinology, hematology, infectious disease, nephrology, and rheumatology Oral examinations discontinued New ABIM subspecialty approved in medical oncology ABIM Board of Directors votes to discontinue “lifetime” certification, becoming the 18th ABMS board to make this decision All new ABIM certificates are limited to 10 y Self-evaluation of practice assessment becomes a requirement for MOC, with several ABIM PIMs introduced MOC credit offered for approved society-developed medical knowledge modules All examinations converted from pencil and paper to computer-based MOC credit offered for approved external quality improvement activities ABIM works with 9 other ABMS boards to develop a subspecialty in hospice and palliative care medicine ABIM introduces its first medical simulation module for MOC credit ABIM launches redesigned Self-Directed PIM and Completed Project PIM to give MOC credit for quality improvement activities in which physicians are already engaged ABIM introduces a more continuous MOC program
1946 1968
1971
1972 1986
these changes in board composition will improve the certification and MOC programs through broader engagement of the internal medicine community and the public whom the ABIM serves. The board-certification enterprise is at a critical juncture. There is skepticism about the value added and the evidence that the process makes a difference (2–5), suspicion about motives (6), and a broad frustration among practicing physicians who perceive that autonomy and respect for their skills have eroded (7–9). Some of physicians’ skepticism of MOC has arisen from concerns about the quality of the evidence showing that it “makes a difference” in improving patient care outcomes. A recent review summarizing this evidence (10) shows that knowledge decays over time and that physicians and persons in general are 222 5 August 2014 Annals of Internal Medicine Volume 161 • Number 3
1990 2005
2006
2008 2010
2014
ABIM ⫽ American Board of Internal Medicine; ABMS ⫽ American Board of Medical Specialties; MOC ⫽ maintenance of certification; PIM ⫽ practice improvement module. www.annals.org
The American Board of Internal Medicine
have recertified and to count as colleagues around the country so many who have continued to work hard to meet standards set by their peers. In a rapidly evolving world with many new expectations for internists, the ABIM will use its governance structure and evolving program requirements to continue to offer a professionally generated definition of “the good doctor” and proudly recognize those who meet its standards. From the American Board of Internal Medicine, Philadelphia, Pennsylvania, and University of Texas Southwestern Medical Center, Dallas, Texas. Disclosures: Disclosures can be viewed at www.acponline.org/authors /icmje/ConflictOfInterestForms.do?msNum⫽M13-2478. Requests for Single Reprints: Richard J. Baron, MD, American Board
of Internal Medicine, 510 Walnut Street, Philadelphia, PA 19106; e-mail, [email protected]. Current author addresses and author contributions are available at www.annals.org. Ann Intern Med. 2014;161:221-223. doi:10.7326/M13-2478
Ideas and Opinions
References 1. Table 3B: ABMS member boards general certificates issued 2002-2011. In: 2012 ABMS Certificate Statistics. Chicago: American Board Med Specialties; 2012:22. Accessed at www.abms.org/News_and_Events/Media_Newsroom/pdf /ABMS%202012_CertStats_Table3B.pdf on 3 October 2013. 2. Iglehart JK, Baron RB. Ensuring physicians’ competence—is maintenance of certification the answer? N Engl J Med. 2012;367:2543-9. [PMID: 23268670] 3. Levinson W, King TE Jr, Goldman L, Goroll AH, Kessler B. Clinical decisions. American Board of Internal Medicine maintenance of certification program. N Engl J Med. 2010;362:948-52. [PMID: 20220192] 4. Drazen JM, Weinstein DF. Considering recertification [Editorial]. N Engl J Med. 2010;362:946-7. [PMID: 20220191] 5. Frager MS. Debating maintenance of certification [Letter]. ACP Internist. 2013;(Sep). Accessed at www.acpinternist.org/archives/2013/09/letters.htm on 3 October 2013. 6. Kempen PM. Maintenance of Certification—important and to whom? J Community Hosp Intern Med Perspect. 2013;3. [PMID: 23882395] 7. Emanuel EJ, Pearson SD. Physician autonomy and health care reform. JAMA. 2012;307:367-8. [PMID: 22274681] 8. Mechanic D. Physician discontent: challenges and opportunities. JAMA. 2003;290:941-6. [PMID: 12928472] 9. Reinertsen JL. Zen and the art of physician autonomy maintenance. Ann Intern Med. 2003;138:992-5. [PMID: 12809456] 10. Lipner RS, Hess BJ, Phillips RL Jr. Specialty board certification in the United States: issues and evidence. J Contin Educ Health Prof. 2013;33 Suppl 1:S20-35. [PMID: 24347150]
CME CREDIT Readers can get CME credit for the following: 1) questions from the ACP’s Medical Knowledge Self-Assessment Program (MKSAP) related to In the Clinic articles that are published in the first issue of every month, and 2) designated articles in each issue. To access CME questions, click on the CME option under an article’s title on the table of contents at www.annals.org. Subscribers may take the tests free of charge. For a nominal fee, nonsubscribers can purchase tokens electronically that enable them to take the CME quizzes. Reviewers who provide timely, high-quality reviews also may get CME credit.
www.annals.org
5 August 2014 Annals of Internal Medicine Volume 161 • Number 3 223
Annals of Internal Medicine Current Author Addresses: Dr. Baron: American Board of Internal
Medicine, 510 Walnut Street, Philadelphia, PA 19106. Dr. Johnson: Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, G5.206, Dallas, TX 75390-9030.
www.annals.org
Author Contributions: Conception and design: R.J. Baron, D. Johnson. Analysis and interpretation of the data: R.J. Baron. Drafting of the article: R.J. Baron, D. Johnson. Critical revision of the article for important intellectual content: R.J. Baron, D. Johnson. Final approval of the article: R.J. Baron, D. Johnson. Administrative, technical, or logistic support: R.J. Baron, D. Johnson.
5 August 2014 Annals of Internal Medicine Volume 161 • Number 3
Copyright © American College of Physicians 2014.
Annals of Internal Medicine
The American Board of Internal Medicine: Evolving Professional Self-regulation Richard J. Baron, MD, and David Johnson, MD
T
he mission of the American Board of Internal Medicine (ABIM) is “To enhance the quality of health care by certifying internists and subspecialists who demonstrate the knowledge, skills, and attitudes essential for excellent patient care.” As the largest of the American Board of Medical Specialties’ 24 certifying boards, the ABIM certifies approximately 1 of every 4 physicians in the United States (1). The board was created in 1936 by a joint action of the American College of Physicians and the American Medical Association; their goal was to distinguish internists who met peer-established standards from those who could not or chose not to do so. Although the ABIM’s roots lie in these membership organizations, it is insulated from the pressure of dues-paying members by being an independent organization with a self-perpetuating governance that relies on experts to set standards. The ABIM has 2 core functions: defining disciplines and setting standards. Defining a discipline is not an abstract exercise, and creating standards that need to be met defines what physicians must know to achieve board certification in their discipline. The assessment instruments, however imperfect, are anchored in a conversation among experts who ask the question, “What should persons who call themselves internists know and be able to do?” The ABIM’s credential derives its value from the experience that diplomates have obtaining and maintaining it (training, professional self-development, and lifelong learning) and the way that others choose to use it. For example, we are licensed “physicians and surgeons.” Our licenses authorize us to remove brain tumors and replace heart valves. What keeps us from doing those things? In addition to our own judgment, a “subregulatory” medical ecosystem of credentialing and privileging prevents us and other internists from practicing beyond our training. This ecosystem relies on recognition by credible, independent third parties, such as the ABIM. Standards that define what it means to be an internist must evolve as medicine does. Most internists practicing today would be unfamiliar with and perhaps unable to pass the first ABIM examination, a written essay test with 8 questions (Figure). As what we need to know and do as certified internists (or subspecialists) has changed, so have the requirements for obtaining the ABIM credential. The Table shows some of the most consequential changes in the ABIM’s process and expectations. The most recent change— one that has provoked considerable protest—is the decision to make the credential more continuous by requiring evidence of ongoing engagement in learning and
practice improvement. The ABIM made this change because a 10-year maintenance-of-certification (MOC) cycle simply is not credible today. As of 1 January 2014, the ABIM has instituted requirements for more frequent participation in activities to assess medical knowledge and practice. At the same time, it recognizes many pathways to meet those requirements that are not created by the ABIM, including programs from medical societies (such as the American College of Physicians) or health systems (such as the Mayo Clinic). The ABIM will begin to publicly report the status “meeting MOC requirements” (or, alternatively, “not meeting MOC requirements”) on the basis of successful completion of these activities at specified intervals (see www.moc2014 .abim.org for more information). The goal remains to create a professionally recognized framework for distinguishing those who meet a peer standard from those who do not or choose not to do so. Who is setting the standards matters for credibility and rigor. The 1936 documents establishing the ABIM required 5 members from the American College of Physicians and 4 from the American Medical Association; more than half of them had to be “at the rank of full professor in a U.S. medical school.” But what it means to be a “good doctor” is no longer the exclusive purview of medical school professors. Taking a dramatic action under its new governance structure, the ABIM will now require all of its boards—the entities that define the standards in internal medicine and all of its subspecialties—to have at least 2 noninternist public members, one a member of the interprofessional health care team and one with “patient/caregiver perspective.” The ABIM also codified what had been an informal practice by requiring “a minimum of one practitioner whose primary practice is in a non-university, community setting” on each board. These newly constituted boards will oversee all aspects of the MOC process, including selfevaluation of medical knowledge and of practice assessment, within their respective disciplines. To fill these critically important positions, the ABIM reached out to professional societies, health systems, and patient groups to help identify distinguished internists with records of achievement in diverse health care settings. We believe that
See also: Editorial comment. . . . . . . . . . . . . . . . . . . . . . . . . . 226
This article was published online first at www.annals.org on 13 May 2014. © 2014 American College of Physicians 221
Ideas and Opinions
The American Board of Internal Medicine
Figure. First American Board of Internal Medicine examination.
usually not reliable judges of their own knowledge gaps. It also discusses several observational studies that correlate examination performance and various clinical outcome measures, including those used by Medicare and some standard clinical measures for diabetes and hypertension, and describes several studies that show that MOC tools help physicians change their practice. As ABIM programs become more continuous and, we believe, more relevant to practice, program evaluation and ongoing surveys of diplomates will continue to be an essential element in monitoring both the relationship of MOC to the quality of care that physicians deliver and physician accountability to the public. The ABIM is a tangible example of professional selfregulation, something in which all internists can take pride. Internists set the standards, which are better informed than those set by governments, payers, businesses, or others who have an increasing interest in the quality of their physicians. The ABIM will continue to work to ensure that internists who meet its standards get “credit” for as many quality incentive programs as possible, including those used by Medicare and other payers. We are proud to Table. Key Milestones in the Evolution of ABIM Standards and Certifications Year
Milestone
1936 1941
First ABIM examination administered First ABIM subspecialties introduced in cardiology, gastroenterology, and pulmonary disease Essay questions discontinued and replaced by multiple-choice questions ABIM Board of Directors decides to discontinue “lifetime” certification but ultimately concludes that ABIM does not yet have the capacity to develop a comprehensive recertification program New ABIM subspecialties approved in endocrinology, hematology, infectious disease, nephrology, and rheumatology Oral examinations discontinued New ABIM subspecialty approved in medical oncology ABIM Board of Directors votes to discontinue “lifetime” certification, becoming the 18th ABMS board to make this decision All new ABIM certificates are limited to 10 y Self-evaluation of practice assessment becomes a requirement for MOC, with several ABIM PIMs introduced MOC credit offered for approved society-developed medical knowledge modules All examinations converted from pencil and paper to computer-based MOC credit offered for approved external quality improvement activities ABIM works with 9 other ABMS boards to develop a subspecialty in hospice and palliative care medicine ABIM introduces its first medical simulation module for MOC credit ABIM launches redesigned Self-Directed PIM and Completed Project PIM to give MOC credit for quality improvement activities in which physicians are already engaged ABIM introduces a more continuous MOC program
1946 1968
1971
1972 1986
these changes in board composition will improve the certification and MOC programs through broader engagement of the internal medicine community and the public whom the ABIM serves. The board-certification enterprise is at a critical juncture. There is skepticism about the value added and the evidence that the process makes a difference (2–5), suspicion about motives (6), and a broad frustration among practicing physicians who perceive that autonomy and respect for their skills have eroded (7–9). Some of physicians’ skepticism of MOC has arisen from concerns about the quality of the evidence showing that it “makes a difference” in improving patient care outcomes. A recent review summarizing this evidence (10) shows that knowledge decays over time and that physicians and persons in general are 222 5 August 2014 Annals of Internal Medicine Volume 161 • Number 3
1990 2005
2006
2008 2010
2014
ABIM ⫽ American Board of Internal Medicine; ABMS ⫽ American Board of Medical Specialties; MOC ⫽ maintenance of certification; PIM ⫽ practice improvement module. www.annals.org
The American Board of Internal Medicine
have recertified and to count as colleagues around the country so many who have continued to work hard to meet standards set by their peers. In a rapidly evolving world with many new expectations for internists, the ABIM will use its governance structure and evolving program requirements to continue to offer a professionally generated definition of “the good doctor” and proudly recognize those who meet its standards. From the American Board of Internal Medicine, Philadelphia, Pennsylvania, and University of Texas Southwestern Medical Center, Dallas, Texas. Disclosures: Disclosures can be viewed at www.acponline.org/authors /icmje/ConflictOfInterestForms.do?msNum⫽M13-2478. Requests for Single Reprints: Richard J. Baron, MD, American Board
of Internal Medicine, 510 Walnut Street, Philadelphia, PA 19106; e-mail, [email protected]. Current author addresses and author contributions are available at www.annals.org. Ann Intern Med. 2014;161:221-223. doi:10.7326/M13-2478
Ideas and Opinions
References 1. Table 3B: ABMS member boards general certificates issued 2002-2011. In: 2012 ABMS Certificate Statistics. Chicago: American Board Med Specialties; 2012:22. Accessed at www.abms.org/News_and_Events/Media_Newsroom/pdf /ABMS%202012_CertStats_Table3B.pdf on 3 October 2013. 2. Iglehart JK, Baron RB. Ensuring physicians’ competence—is maintenance of certification the answer? N Engl J Med. 2012;367:2543-9. [PMID: 23268670] 3. Levinson W, King TE Jr, Goldman L, Goroll AH, Kessler B. Clinical decisions. American Board of Internal Medicine maintenance of certification program. N Engl J Med. 2010;362:948-52. [PMID: 20220192] 4. Drazen JM, Weinstein DF. Considering recertification [Editorial]. N Engl J Med. 2010;362:946-7. [PMID: 20220191] 5. Frager MS. Debating maintenance of certification [Letter]. ACP Internist. 2013;(Sep). Accessed at www.acpinternist.org/archives/2013/09/letters.htm on 3 October 2013. 6. Kempen PM. Maintenance of Certification—important and to whom? J Community Hosp Intern Med Perspect. 2013;3. [PMID: 23882395] 7. Emanuel EJ, Pearson SD. Physician autonomy and health care reform. JAMA. 2012;307:367-8. [PMID: 22274681] 8. Mechanic D. Physician discontent: challenges and opportunities. JAMA. 2003;290:941-6. [PMID: 12928472] 9. Reinertsen JL. Zen and the art of physician autonomy maintenance. Ann Intern Med. 2003;138:992-5. [PMID: 12809456] 10. Lipner RS, Hess BJ, Phillips RL Jr. Specialty board certification in the United States: issues and evidence. J Contin Educ Health Prof. 2013;33 Suppl 1:S20-35. [PMID: 24347150]
CME CREDIT Readers can get CME credit for the following: 1) questions from the ACP’s Medical Knowledge Self-Assessment Program (MKSAP) related to In the Clinic articles that are published in the first issue of every month, and 2) designated articles in each issue. To access CME questions, click on the CME option under an article’s title on the table of contents at www.annals.org. Subscribers may take the tests free of charge. For a nominal fee, nonsubscribers can purchase tokens electronically that enable them to take the CME quizzes. Reviewers who provide timely, high-quality reviews also may get CME credit.
www.annals.org
5 August 2014 Annals of Internal Medicine Volume 161 • Number 3 223
Annals of Internal Medicine Current Author Addresses: Dr. Baron: American Board of Internal
Medicine, 510 Walnut Street, Philadelphia, PA 19106. Dr. Johnson: Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, G5.206, Dallas, TX 75390-9030.
www.annals.org
Author Contributions: Conception and design: R.J. Baron, D. Johnson. Analysis and interpretation of the data: R.J. Baron. Drafting of the article: R.J. Baron, D. Johnson. Critical revision of the article for important intellectual content: R.J. Baron, D. Johnson. Final approval of the article: R.J. Baron, D. Johnson. Administrative, technical, or logistic support: R.J. Baron, D. Johnson.
5 August 2014 Annals of Internal Medicine Volume 161 • Number 3
Copyright © American College of Physicians 2014.
