Clinical Pediatrics

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Jan 28, 2010 - Maintenance of Certification: The Elephant in the Room. Published by: ... Academy of Pediatrics (AAP) know all too well, board recertification ...
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Maintenance of Certification: The Elephant in the Room Victor C. Strasburger and Donald E. Greydanus CLIN PEDIATR 2010 49: 307 originally published online 28 January 2010 DOI: 10.1177/0009922809352238 The online version of this article can be found at: http://cpj.sagepub.com/content/49/4/307

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Commentaries

Maintenance of Certification: The Elephant in the Room

Clinical Pediatrics 49(4) 307­–309 © The Author(s) 2010 Reprints and permission: http://www. sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922809352238 http://clp.sagepub.com

Victor C. Strasburger1 and Donald E. Greydanus2 As the more than 60  000 members of the American Academy of Pediatrics (AAP) know all too well, board recertification has become the elephant in the room that no one has the courage to discuss except for those who want to administer the tests.1-7 Although the American Board of Pediatrics (ABP) is doing yeoman’s work in trying to spare hospitals and pediatricians the time and expense of re-credentialing, spending $1300 on recertification and preparing for a new 4-part Maintenance of Certification (MOC) process is not ideal in our view. To be sure, there are extremely powerful political forces at work here. The American Board of Medical Specialties has mandated that every specialty board develop a recertification process. State legislatures, insurance companies, Medicare, hospital credentialing committees, national medical examiners, and the US Congress are all apparently trying hard to target physicians who don’t “keep up” and are threatening to increase the already loathsome credentialing paperwork burden on pediatricians. The ABP’s efforts to take control of the situation and head them off at the pass are laudable. If the ABP doesn’t act quickly and authoritatively, outside forces will begin making decisions for pediatricians that would probably be far more troublesome. We also appreciate the fact that the ABP is a certifying organization, not an educational one. But the answer may not be a cumbersome, 4-step process that will add to pediatricians’ burdens. And it raises the question, what—exactly—does Board certification mean? Interestingly, in the collective 60 years that we have practiced medicine, we have never been asked by parents or patients if we were board certified or have recertified. Has the ABP lost sight of its own primary (and worthy) goal, which is to ensure that pediatricians remain up-to-date and knowledgeable? Given the 21st-century technology that now exists, couldn’t this goal be better accomplished by creating an interactive computer module that every pediatrician would take annually? This module would test current knowledge, provide immediate feedback on correct responses, and give a detailed synopsis of the deficient or problem areas so that learning might occur. It could be part of a reformed continuing medical education (CME) initiative.8-10 Another way for the ABP to accomplish its goal would be to support physicians

taking the recertification exam in small groups—a practice that the ABP endorsed several years ago. In 2001, one of us (VCS) took the Adolescent Medicine recertification exam with other adolescent medicine colleagues in Philadelphia, and we were all surprised at how much of a positive learning experience it was. Even resurrecting oral board exams might be preferable to the newly instituted MOC 4-part process. The currently proposed MOC model seems a bit flawed for many reasons, one of them being the poor mechanism for feedback. For $1300, test takers should receive immediate feedback about their performance, an idea supported by adult learning theory. Yes, we understand that not all questions are “good” questions, and there is a need for validating questions and doing quality control. But we wonder if the ABP may be too focused on the test itself and not on whether actual learning is taking place? Why can’t a certifying agency be concerned about education as well? Don’t the two go hand-in-hand? Common sense tells us that what the public actually wants and needs most are knowledgeable, well-informed, sensitive, and competent physicians who are keeping up with current research. The biggest problem may be the ABP’s perception of the “public’s demand.” The Board bases this statement on a national Gallup Poll that was conducted 6 years ago using 1001 telephone interviews.11 Many of the survey responses support the ABP’s assertions that the public wants up-to-date, competent doctors—73% rated periodic reevaluations as very important, and slightly more than half of the respondents felt that doctors should be required to pass a written test every 3 to 5 years. We are not quibbling over a physician’s need to keep abreast of the latest developments in their area of medicine. However, the crux of this critical issue is how best this can be accomplished. Would an annual interactive exam that 1 University of New Mexico School of Medicine, Albuquerque, NM, USA 2 Kalamazoo Center for Medical Studies, Kalamazoo, MI, USA

Corresponding Author: Victor C. Strasburger, 10344 2nd St NW, Albuquerque, NM 87114, USA Email: [email protected]

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Clinical Pediatrics 49(4)

teaches physicians the latest information work better than the cumbersome, 4-step MOC process? The ABP maintains that board certification is the primary goal, not reeducation. The ABP relies on the Gallup Poll responses to the question beginning “When given the choice between a board certified physician and a physician who was not board certified but was recommended by a trusted friend or family member,” in response to which 75% opted for the board-certified physician and only 23% for the recommended physician. Furthermore, when the respondents were asked “If you knew your doctor’s board certification had expired, would you change doctors,” 54% said they were “very likely” to do so, and 27% said “somewhat likely.” However, there are 2 other, very interesting responses on the survey; fully one quarter of all respondents either did not know what board certification means or if their own doctor was board certified, and 79% of respondents had never bothered to verify their physician’s credentials. There is definitely an argument to be made for the public seeming to care about board certification but actually caring more about their doctor being “good,” up-to-date, knowledgeable, and sympathetic. This survey of 1000 adults, taken 6 years ago,11 seems to be dictating ABP policy and costing pediatricians countless hours of testing, documentation, and thousands of dollars. Perhaps this entire process deserves careful scrutiny by those outside of the ABP? What, exactly, are the costs of forcing thousands of pediatricians to go through this 4-step program, and what will be achieved? Should the organization doing the testing play such a large role in determining all the criteria for certification and recertification? Pediatricians spending $1300 for their recertification exam and countless hours preparing for and taking the exam will want “bang for their bucks.” In the future, how many hours will be required to deliver all the information necessary to achieve the 4 different parts of the MOC? Why should physicians who have safely and effectively practiced for many years (decades) and earned the trust of their colleagues as well as patients now be told that the MOC is the only way to safeguard the public? Many will avoid such exams because of lack of resources (ie, money, time, administrative support).12 How do you develop an examination that will “test” individuals who are involved in a wide variety of practices over many decades? How do you measure experience gained over many years or decades? What is the evidence that passing such an examination means that one is a “competent” physician and that failing the exam means one is not competent? What the public wants is a well-trained doctor who has experience, is professional, cares for them, and keeps up with new developments. The purpose of such “exams” should

then be to educate this experienced and “tested” clinician to “new” developments, not prove that suddenly she or he is not trustworthy to practice after successful practice over many years to decades. It is safe to assume that we all agree that the general public and even regulatory agencies desire pediatricians who are well trained, competent, and up-to-date. But we have to wonder if the 4-part MOC—a cumbersome, expensive, time-consuming process—is the best way to achieve this. With all due respect for the folks at the ABP and their efforts to keep pediatricians out of regulatory hell, the following is what we propose:

First, a more comprehensive survey needs to be performed—that is, not just a sampling of 1000 adults nationwide but a survey of insurance companies, state licensing agencies, and state legislators to determine precisely what they know about board certification or recertification. The survey needs to be designed to answer critical questions related to education, knowledge maintenance, and testing, such as “What is the best way for physicians to maintain a high level of competence and knowledge?” and “Is board recertification important to the public?” Similarly, a survey of general pediatricians and subspecialists needs to be done to determine their needs and views. Amazingly, this has never been done! Second, an immediate meeting should be convened of a planning group of AAP and ABP members, with input from the general public as well. Critics of the current MOC plan should be well represented. Third, the ABP should consider placing a moratorium on their MOC plan until the above items have been accomplished. Fourth, the AAP and ABP should seriously consider a new mechanism for recertification of pediatricians— one that would “test” physicians but, at the same time, educate and update them as well. Given the new technologies available to medical education (podcasts, Webcasts, online updates), we think that an annual or biannual “exam” could be devised so that pediatricians could take it at their convenience. It should not be designed to fail a portion of aging physicians who have been in successful careers for decades, who do not represent a threat to the public, and who were told many years ago that such exams would not be given to them. Furthermore, the test would last no more than a few hours, would give immediate feedback about errors made, would provide up-to-date information, would

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Strasburger and Greydanus cost much less than $1300, and would provide the reassurance that the public desires and deserves. We hope that the elephant has been in the room long enough for people to start commenting and questioning its presence and to respond in an appropriate fashion to honor the many years of service of thousands of pediatricians who have contributed so much for so long to the health of American children.

Declaration of Conflicting Interests The authors declared no conflicts of interest with respect to the authorship and/or publication of this article. Funding The authors received no financial support for the research and/or authorship of this article. References   1. Brown HJ, Miles PV, Perelman RH, Stockman JA III. A continuum of competency assessment: the potential for reciprocal use of the Accreditation Council for Graduate Medical Education toolbox and the components of the American Board of Pediatrics Maintenance-of-Certification Program. Pediatrics. 2009;123(suppl 1):S56-S58.   2. Miles P. Health information systems and physician quality: role of the American Board of Pediatrics Maintenance of Certification in improving children’s health care. Pediatrics. 2009;123(suppl 2):S108-S110.   3. Miles PV. Pediatric recertification and quality of care: the role of the American Board of Pediatrics in improving

children’s health care. J Pediatr. 2007;151(5 suppl): S17-S20.   4. Madewell JE. Lifelong learning and the maintenance of certification. J Am Coll Radiol. 2004;1:199-207.   5. Miller SH. American Board of Medical Specialties and repositioning for excellence in lifelong learning: maintenance of certification. J Contin Educ Health Prof. 2005;25: 151-156.   6. Batmangelich S, Adamowski S. Maintenance of certification in the United States: a progress report. J Contin Educ Health Prof. 2004;24:134-138.   7. Miller SH. ABMS’ Maintenance of Certification: the challenge of continuing competence. Clin Orthop Relat Res. 2006;449:155-158.   8. Nahrwold DL. Continuing medical education reform for competency-based education and assessment. J Contin Educ Health Prof. 2005;25:168-173.   9. Davis N, Davis D, Bloch R. Continuing medical education: AMEE Education Guide No 35. Med Teach. 2008;30: 652-666. 10. Miller SH, Thompson JN, Mazmanian PE, et al. Continuing medical education, professional development, and requirements for medical licensure: a white paper of the Conjoint Committee on Continuing Medical Education. J Contin Educ Health Prof. 2008;28:95-98. 11. Awareness of and Attitudes Toward Board-Certification of Physicians. Princeton, NJ: Gallup Organization; 2003. 12. Bower EA, Choi D, Becker TM, Girard DE. Awareness of and participation in maintenance of professional certification: a prospective study. J Contin Educ Health Prof. 2007;27:164-172.

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