Continuing board certification has been an ongoing subject of discussion for family physicians since the creation of the American Board of Family Practice (now American Board of Family Medicine), which pioneered the practice(www.ncbi.nlm.nih.gov) of issuing time-limited certificates and requiring mandatory recertification in 1969.
While the idea behind continuing certification -- ensuring that physicians possess the skills, knowledge and experience to continue to provide their patients with the best possible care -- was and remains a noble one, over the years diplomates have raised legitimate concerns about the time and cost associated with keeping their certification current.
As these concerns grew, the American Board of Medical Specialties (ABMS) realized that a complete overhaul of the process might be necessary. In the fall of 2017, it launched(www.abms.org) Continuing Board Certification: Vision for the Future, an initiative designed to look at the current certification system and consider how it could be improved.
After an initial survey and round of feedback from physicians, physician organizations and other parties -- including the AAFP, which provided both written and oral testimony -- the Vision for the Future Commission released a draft report of its findings on Dec. 11. Among other things, the report contained 15 recommendations with regard to program expectations, stakeholders, research and evaluation, and other areas related to continuing board certification.
- The AAFP submitted comments and suggestions in response to the Vision for the Future Commission's draft report on continuing board certification.
- Overall, the AAFP praised the commission for recognizing many of the shortcomings associated with the traditional certification process and supported many of its recommendations to improve the process.
- Along with additional comments, the AAFP offered edits to two American Board of Medical Specialties policy positions.
Along with the draft report, the commission invited additional comments from the public. On Jan. 14 the Academy sent the commission an 11-page letter(11 page PDF) signed by AAFP Board Chair Michael Munger, M.D., of Overland Park., Kan., that addressed not only the recommendations but also two ABMS policy positions that were referenced and included in the report.
While AAFP members are encouraged to read the letter in its entirety, the following is a synopsis of the Academy's latest comments.
AAFP Encourages Stronger Language
Overall, the AAFP praised the commission for recognizing many of the shortcomings associated with the way continuing certification traditionally has been administered, and its attempt to combine past experiences, best practices and physician feedback into its recommendations for improving the process.
But the AAFP noted that throughout the draft report, "the commission has often chosen softer language, choosing to 'encourage' the ABMS to make a change rather than using more assertive, direct language such as 'must.'" The letter stated that the recommendations should "be rephrased in a direct, assertive manner to reflect the crisis point" of the current process and "the critical need for recommended improvements."
As examples, the AAFP "fully" supported recommendation 9, which pertained to collaborating with other organizations to facilitate and encourage research, and "strongly" supported recommendation 14, which stressed the importance of consistent certification processes for ABMS member boards. In both recommendations, however, the AAFP requested that the commission replace the word "should" with "must" to emphasize their importance and send a stronger message to ABMS.
Recommendations: Expectations for Continuing Certification Programs
The AAFP fully supported recommendation 1, which stated that continuing certification should constitute an integrated program with standards for professionalism, assessment, lifelong learning and practice improvement. However, the AAFP was clear that changes are needed to make the overall process more meaningful and practical.
The AAFP encouraged the commission to use more directive language regarding portions of recommendation 2 that discussed the need for ABMS member boards to have exam alternatives. It also encouraged the commission to "specifically recommend that boards offer a variety of options for all of the elements (parts) of certification, including options that address more than one element simultaneously," which would allow physicians to demonstrate their knowledge and competence in ways that allow for variances in learning preferences and time commitment.
Finally, the AAFP requested that the commission ask the ABMS to "strongly enforce" one point of the recommendation that stated continuing certification should not depend solely on a diplomate's performance on a single, infrequently-offered assessment.
"Having a physician's entire career and livelihood hang on the single score of an exam" -- which is offered only every seven to 10 years -- "is an outdated travesty and must not be permitted moving forward," the AAFP wrote.
The AAFP supported the commission's focus on professionalism as outlined in recommendation 3. In particular, the AAFP urged the commission to be more direct regarding the need for ABMS boards to have common standards for how to address licensure actions for professionalism, and how those actions could affect continuing board certification. The AAFP also requested clarification regarding the definition of professionalism with regard to board certification purposes.
While the AAFP supported the sharing of diplomate performance data, a component of recommendation 4, it noted that "there are limitations to the utility of aggregated data," and said ABMS boards should share this data "at both the aggregated and individual level." The AAFP also told the commission that the recommendation must be updated to acknowledge the role of the AAFP and other CME accreditors in supporting family physicians and helping fulfill their certification needs.
The AAFP supported recommendation 5, which stated that ABMS boards have a responsibility and obligation to change a diplomate's certification status when certification standards aren't met -- as long as physicians have "strong supports" that allow them to identify and remedy areas of deficiency, as well as multiple options for meeting certification requirements. The AAFP also urged the commission to rethink the idea of creating other certification categories, as it could lead to further confusion about the certification process.
The AAFP was "strongly supportive" of recommendation 6, which discussed remediation pathways for physicians to regain certification. Toward this end, the AAFP encouraged the ABMS and member boards to contact the Coalition on Physician Enhancement, which has been working with licensing boards on remediation efforts.
Recommendations: Stakeholders in Continuing Certification
While the AAFP supported recommendation 7's focus on collaboration with specialty societies and sharing of data, it also pointed out the commission's own acknowledgement that physicians aren't well-equipped to identify and address their own knowledge gaps. As such, it requested that the commission direct boards and specialty societies to identify ways to share both aggregated and individual physician data. This process would allow these groups to create and direct physicians to activities that would address knowledge gaps at the individual level.
The AAFP also urged the commission to amend part of the recommendation to read: "ABMS boards must share aggregated results and trends in knowledge gaps with other specialty organizations to assist in the promulgation of medical advances to result in safe, higher-quality patient care. In addition to aggregated data, the ABMS boards must also share data at the individual diplomate level with other specialty organizations in order to assist with personalized learning plan development."
The AAFP wrote that recommendation 8, which states that the certificate has value, meaning and purpose in the health care environment, "is the commission's most important recommendation." It applauded the commission's stance on making sure the ABMS enlightens hospitals, health systems, payers and other health care organizations on the criteria used in credentialing and privileging decisions, and recommended that the commission amend part of the recommendation to read: "ABMS must inform and educate these organizations that continuing certification should not be the only criterion used in these decisions and these organizations should use a wide portfolio of criteria in these decisions."
Recommendations: Research and Evaluation of Continuing Certification
The AAFP wrote, "We fully support the focus on research and collaboration" set out in recommendation 9, but the letter said the commission should use more directive language on that point.
The AAFP also supported recommendation 10, but expressed concern that it did not address reasonableness of fees. As a result, the letter recommended that recommendation 10 be amended to read: "ABMS boards must collectively engage in a regular continuous quality improvement process and improve the effectiveness and efficiency of continuing certification programs. Boards should also assess the efficiency of internal operations as well as their financing. Fees charged to diplomates should be the minimum necessary to finance board operations and to have sufficient reserves to invest in programmatic initiatives that advance the quality and applicability of certification programs."
Recommendations: ABMS Boards' Support of Diplomates
While the AAFP agreed with recommendation 11's stance on governance of ABMS boards, the Academy thought it was lacking in the areas of board finances and diplomate fees. As a result, the AAFP requested that the commission "greatly strengthen this recommendation" regarding the finances of ABMS member boards. Specifically, the AAFP requested that the commission
- clearly state that all ABMS boards must have yearly external audits of each board and, if applicable, their foundations;
- include in its final recommendation a firm and clear statement that diplomate fees should not be used to support programs and activities unrelated to the certification program; and
- question the need for ABMS boards to have foundations if they are funded in any way by fees obtained from diplomates.
The AAFP expressed concern about a requirement in recommendation 12 that diplomates engage with their board (or boards) at least once a year. "This seems to be counterintuitive given the prevalence of burnout and concerns about administrative burden among physicians," the AAFP wrote. The letter also strongly suggested that the commission broaden recommendation 12 to prevent the certification process from becoming more burdensome.
The AAFP supported recommendation 13, but suggested that it be amended to read: "ABMS boards must actively collaborate with specialty organizations to develop the standards for the specialty. ABMS boards must regularly communicate with their diplomates about the standards for the specialty and to foster feedback about the program."
The AAFP strongly supported recommendation 14, which states that ABMS boards "should have consistent certification processes" for a number of elements, including cycle length, grace periods, remediation and re-entry pathways, definitions of certification status, and appeals processes. It also suggested that the commission use more direct language and change "should" to "must" to send a clear message.
Finally, the AAFP wrote, "We wholeheartedly support the focus on decreasing duplication and burden for physicians" outlined in recommendation 15.
Suggested Policy Position Revisions
In addition to comments and suggestions on the recommendations, the AAFP recommended the commission suggest edits to two ABMS policy positions linked to recommendation 8.
The AAFP recommended amending part of the ABMS Position Statement on the Delineation of Clinical Privileges to read: "ABMS supports consideration of a physician's education, training, practice experience, performance and other criteria, including specialty and subspecialty certification, as important and equal criteria in granting and delineating the physician's clinical privileges. ABMS also believes that neither specialty certification nor subspecialty certification should be the sole determinant in granting and delineating the scope of a physician's clinical privileges."
The AAFP also recommended amending part of the ABMS Statement on the Use of Certification to read: "ABMS and its member boards believe that physicians should be eligible for a medical license without specialty board certification or continuing certification. However, licensing boards should also be free to use specialty board certification and continuing certification as one of many indicators of current competence, including documented training, experience and demonstrated competence."
Final Comments … and Final Report
"Overall, the AAFP recognizes that a significant number of the concerns and considerations expressed through our testimony and written comments have been addressed by the commission in their draft recommendations and we appreciate this chance to offer our input for areas of opportunity for improvement," the Academy's letter concluded. "The AAFP looks forward to the commission's final recommendations and to enthusiastically working with the ABMS and the ABFM to identify ways to collaborate on implementing the recommendations and moving forward from the certification concerns of the current state."
The Vision for the Future Commission is expected to present the final report to ABMS in February.
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Continuing Board Certification: Vision for the Future(visioninitiative.org)