Table Of Content(cid:2)MEDICAL EDUCATION/MEDICAL STUDENT
Maintenance of certification in
Internal Medicine: participation
rates and patient outcomes
Dolores Buscemi, MD*, Helen Wang, BS, Michael Phy, DO and
Kenneth Nugent, MD
Department ofInternalMedicine, TexasTech University HSC,Lubbock, TX,USA
The clinical practice of internal medicine continues to evolve with the addition of new information and
newtechnology.Mostinternistsinpracticewillhaveerosionoftheirknowledgeaftertheycompletetraining
unless life-long learning occurs. The American Board of Internal Medicine (ABIM) began to issue time-
limitedcertificationin1990andassertsthattheMaintenanceofCertification(MOC)programpromotesthe
professional development of internists. However, the available medical literature does not provide strong
support for the assumption that internistswith certification or recertification havebetter patient outcomes.
This relationship between recertification and patient outcomes needs more study. In addition, the
participation in the Maintenance of Certification program by internists with lifetime certifications has
beenlow,andrecertificationbyleadersininternalmedicinehasalsobeenrelativelylow.Somephysiciansin
practicehaveconcernsabouttherelevanceoftheprogramandthecost.OurreviewsuggeststhattheABIM
needs to review its currentMaintenance of Certification program and make changes to enhance its clinical
relevance and educational value. We suggest that professional development should be based on focused
reviews of the current literature, which is immediately relevant to clinical practice, and that recertification
couldbebasedon completionof modules andmorefrequent, less oneroustesting.
Keywords: certification;recertification;internalmedicine;patientoutcomes;mortality
Received:20 September 2012; Revised:21 November 2012; Accepted:5 December 2012; Published:7 January 2013
In 1990, the American Board of Internal Medicine programto determine thevalueplaced on recertification
(ABIM) began to issue time-limited certifications. by current diplomates.
This decision reflected the ABIM’s assertion that its
diplomates involved in such a program would maintain Methods
competency in clinical medicine and up-to-date medical We carried out PubMed searches using the MeSH terms
knowledge. The ABIM outlined these goals for recertifi- Internal Medicine, Patient Outcomes, Hospital Mortality,
cation in 1991 as follows: (1) Improve the quality of andCertification.Wealsousedthesetermsastextwords
patient care; (2) set standards of clinical competence for and used recertification as a text word. The search
the practice of internal medicine; and (3) foster the strategy combined Internal Medicine AND Certification
continuing scholarship required for professional excel- (or recertification) AND Hospital Mortality (or Patient
lence over a life-time of practice (1). Intuitively these Outcomes) using MeSH terms when available; these
goals seem reasonable. The question we ask is whether searches were then repeated using same strings as text
there are actual data to support this decision and its words. We reviewed the reference lists from articles that
goals.Doesthemedicalliteraturedemonstratearelation- reported information on certification (or recertification)
ship between certification status or recertification status and patient outcomes, and we used the PubMed related
and patient outcomes? (2). We also reviewed the partici- articles algorithms associated with pertinent articles. We
pation rates of internists with time-limited and lifetime also searched the bibliography of ES Holmboe who has
certificates in the Maintenance of Certification (MOC) publishedmultiplearticlesinthisareaandisanemployee
Transparency note:DB andMP have recertified once in internalmedicine, and KNhas recertified twicein critical caremedicine and once
voluntarilyinpulmonarymedicine.
JournalofCommunityHospitalInternalMedicinePerspectives2012.#2012DoloresBuscemietal.ThisisanOpenAccessarticledistributedunderthe 1
termsoftheCreativeCommonsAttribution-Noncommercial3.0UnportedLicense(http://creativecommons.org/licenses/by-nc/3.0/),permittingallnon-
commercialuse,distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited.
Citation:JournalofCommunityHospitalInternalMedicinePerspectives2012,2:19753-http://dx.doi.org/10.3402/jchimp.v2i4.19753
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DoloresBuscemietal.
of the ABIM. We verified certification of individual andcardiologistswithnon-certifiedphysiciansandfound
physicians using the ABIM website (www.abim.org). that certified physicians had better outcomes in patient
We identified editors and officers in various internal mortality.KellyandHellingerretrospectivelyreviewedthe
medicine organizations using official websites: ABIM influenceofselectedcharacteristicsonthesurvivalofin-
(www.abim.org), Annals of Internal Medicine (www. hospitalcardiacpatients(5).Thesepatientsweredivided
annals.org), American College of Physicians (www. into three categories: patients who underwent coronary
acponline.org), and ACGME-RRC Internal Medicine artery bypass graft (CABG), patients who underwent
(www.acgme.org). cardiaccatheterizationwithoutCABG,andpatientswith
diagnosis of AMI who did not have surgery. The board
Discussion certificationstatusdidnotinfluencepatientoutcomesfor
thefirsttwopatientgroupsbutdidinfluencetheoutcomes
Patientoutcomesandcertificationstatus in the third group. Board-certified internists had 3.1%
Chen et al. studied the association between the care of fewer patients with an AMI die than non-certified phy-
acutemyocardialinfarction(AMI)(aspirin,beta-blocker sicians, and board-certified family practitioners had
administration, and 30 day mortality) and the board 4.2% fewer patients with an AMI die. In 1989, Ramsey
certification status of the treating physicians (Table 1) et al. studied the predictive value of ABIM board
(3(cid:2)7). They reviewed the charts of 101,251 Medicare certification on several competencies (6). They prospec-
patients cared for by family practitioners, general inter- tively evaluated 185 certified and 74 non-certified inter-
nists, and cardiologists. Board-certified physicians were nists who had completed training within the last 5(cid:2)10
more likely to meet the quality of care indicators than years. The physicians were given a written examination
thosewhowerenotboardcertifiedbutdidnothavebetter of 119 questions developed by the ABIM. The other
mortalityratesintheirpatients.Norcinietal.alsostudied components of evaluation included a self-administered
mortality in patients with AMI (4). They compared patientquestionnaire,anevaluationbytheirprofessional
board-certified family practitioners, general internists, associationsintheformofaquestionnaire,andareview
Table1. StudieswithOutcomes/BoardCertification
Authors Datasource Specialtiesstudied Qualitymeasures Results
Chenetal.2006 DatafromCCPand Internalmedicine PatientsadmittedwithAMI: Board-certifiedinternistsand
AMAPhysician Cardiology AdmissionASA cardiologistsperformedbetter
Masterprofile Familymedicine DischargeASA thannon-boarded;nodifference
101,251Medicare AdmissionB-blocker inmortality
patients DischargeB-blocker
KellyandHellinger Nationalpatient Board-certifiedIM/FMand Mortalityassociatedwith Board-certifiedinternistshad3%
1989 abstractdatafor1977 non-board-certified acuteMI fewerdeathsinhospital
Norcinietal.2002 PatientswithAMI Board-certifiedand MortalityafteracuteMI 15%reductioninmortalitywith
40,684hospital non-board-certified boardcertified
admissions internists,family
practitioners,cardiologist
Ramseyetal. Internistswhohad 185boardcertified/74 Managementofspecific Certifiedinternistshadsignifi-
1989 completedtrainingin non-board-certified diseases cantlyhigherexamscores.
thelast5(cid:2)10years internists Preventivecounseling RatingofclinicalskillsbyProfSoc
RatingsbyProfessional weresignificantlyhigher.
Society Nodifferenceinpatient
Patientquestionnaire satisfaction
Writtenexam Nodifferenceinchronicdisease
management
Modestdifferenceinpreventive
counselingfavoringcertified
Phametal.2005 24,581Medicare 3660generalinternists Deliveryofpreventive Board-certifiedphysiciansdid
beneficiaries;claims andfamilypractitioners servicestoMedicare betterstatisticallyatordering
datafrom2001 patients]65 HgbA1C,coloncancerscreen,
mammograms
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Maintenanceofcertificationininternalmedicine
of their medical records. The board-certified physicians information in the PIM may not reflect actual clinical
hadhigherexamscoresandhigherratingsoftheirclinical practice since this information from PIM is collected
skills by professional societies. Based on the medical during ABIM recertification. This may motivate some
record review, board-certified internists did a better participants to get the right answer. Overall, this study
job with preventive counseling, but the difference was suggests that multiple factors influence patient care and
small. There was no difference in the patient survey thattestscoresdonotpredictcomplexpracticebehaviors,
questionnaires. Pham et al. studied how well primary and that it provides information on onlyone diagnosis.
care physicians delivered preventive services (7). The Insurance companies, hospitals, and governmental
board-certifiedphysiciansperformedbetterondelivering agencies also influence physician performance and pa-
theseservices(i.e.,coloncancerscreening,mammogram), tientoutcome.Chenetal.reportedthatASAuseinAMI
but these differences were small. In addition, overall on admission was approximately 50% during 1994(cid:2)1996
performancewaspoor(e.g.,approximately50%ofwomen (Table 1) (3). Williams et al. examined 18 qualityof care
had a mammogram during the year). Prystowsky has measures for AMI, heart failure, and pneumonia using
studied the effects of certification and experience in quarterly data from US hospitals for the period 2002(cid:2)
patient outcomes with colon surgery (8, 9). His studies 2004 (13). In July 2002, the Joint Commission on
demonstratethatbothcertification andexperienceaffect Accreditation of Healthcare Organizations implemented
primary outcomes, including in-patient mortality, com- standardizedperformancemeasures.Bythethirdquarter
plications, and length of stay. These studies on surgical of 2002, the performance was significantly better. For
performance have clear advantages when compared to example,patientsadmittedwithAMIwhoreceivedASA
studieswithinternistssincetheoutcomesaremoreeasily on admission went from 78% in the first quarter of the
defined and quantifiable, and they suggest that practice- study to 93% in the eighth quarter of the study. These
related experience has important effects on patient out- changes occurred in the hospitals with the lowest
comes. This experience might not be easily identified performance at the baseline survey. Therefore, hospitals
withstandardizedtests.All thesestudies inthe literature and the Joint Commission have been instrumental in
depended on retrospective chart reviews and, therefore, improving these measures. The studies on the effect of
provide information about associations. They are una- board certification on performance measures in Table 1
voidably limited by confounding factors and missing donotreportanyeffectwithamagnitudesimilartothis
information. change. Does the maintenance of certification program
We foundtwostudiesthatexaminedpatient outcomes haveanyadditionaleffectoncoremeasureperformance?
and maintenance of certification status (10(cid:2)12). In 2008, The available studies do not demonstrate that physi-
Holmboe studied physicians who had completed the cianswithboardcertificationprovidesubstantiallybetter
MOC requirement and divided them into four quartiles care. This is likely explained by the effect of external
based on their examination scores (10). They examined influencesonpatientcareandbythefactthatphysicians
standardqualityofcareindicatorsfordiabetes(HgbA1C, completing residency training may have similar overall
lipids, eye exam), mammogram rates for women aged performance regardless of any particular standardized
65(cid:2)74, and timely lipid testing in patients with known testresult.Hasrecertificationbeenasuccessfulendeavor?
coronary disease and found a correlation between Based on two studies, physicians who do better on the
MOCexaminationmeetqualityofcarestandardsbetter,
quartile and performance on these measures. Patients
but the overall effect is modest. Can we conclude that
whowerecaredforbyaphysicianinthetopquartilewere
physicians who have not participated in MOC would
17% more likely to receive all three diabetes QOC
not perform as well on these measures? There are no
measures; women were 14% more likely to be referred
published studies comparing physicians who have com-
for screening mammogram. The lipid testing did not
pleted the MOC program and those who have not.
showadifference,possiblyexplainedbyconcomitantcare
bycardiologists. However, in this study physicians in the
top quartile did not meet performance goals adequately. ParticipationintheMOCprogram
Physicians who scored over 600 on the examination met According to the ABIM’s official website, 79% of
all three of the diabetes quality measures only 40% of physicians with time-limited certificates (1990(cid:2)1997)
the time. Hess et al. studied the relationship between have participated in the MOC program. The ABIM
cognitive skills based on MOC examination scores and does not report data on physicians who have lifetime
quality of care scores in diabetes care using information certificates. We approached the question of whether or
from the ABIM Diabetes Practice Improvement Module not internistswith lifetime certificateswere participating
(PIM) (12). There was a significant association between intheMOCwithtwosamples.Wedevelopedasampleof
the MOC score and the diabetes composite score index, community physicians from Lubbock, TX, because we
but the overall model only explained 13% of the couldidentifyallgeneralinternistsinourhomecity.This
variability in the diabetes care score. In addition, city has a population of 260,000 with 55 general
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internists. Thirty-six have time-limited certificates, and typetestandthenumberofyearsoutofresidencytraining
seven have lifetime certification. None of the physicians (16). To limit this erosion in medical knowledge and to
with lifetime certificates have participated in the MOC help reassurethe publicabout the qualityof health care,
program.Wealsocalculatedtherecertificationrateofthe the ABIM began to issue time-limited certification in
internal medicine leadership in various organizations 1990.TheprogramhasevolvedintotheMOCandhasthe
using information collected from various websites in potential to help clinicians gain and retain medical
July 2009, which was approximately 20 years after the knowledge. Levinson and Holmboe recently reviewed
change in certification to a time-limited process. The the evolution and current status of the Maintenance of
initial ABIM task force on recertification has a recerti- Certification program (17). They quote the same articles
fication rate of 18% (3/17). The ABIM Board has a we reviewed in Table 1 to demonstrate the relationship
recertificationrateof20%(6/20).Theeditorialboardfor between certification status and patient outcome. They
the Annals of Internal Medicine has a recertification rate report that the ABIM Practice Improvement Modules
of 9% (2/22). The ACP Governors have a recertification are analyzed by unique statistical software. Although
rate of 4% (2/54). The ACP Board of Regents has a this approach is probably a practical necessity, it cannot
recertification rate of 8% (2/26). The ACGME-RRC provide the same analysis as an experienced expert
Internal Medicine Committee has a recertification rate clinician could and the real benefit of this activity is not
of0%(0/12).Thesearethestatisticsforinternalmedicine asclearastheyclaim.Theynotethatapproximately75%
recertification only; the rates for recertification in sub- ofdiplomatesstarttherecertificationprocessintheninth
specialty areas are slightly higher (Table 2). We repeated yearofthe10-yearcycle.Hence,MOChardlyrepresents
partofthisanalysisinJune2012.Twenty-sixmembersof continuousprofessionalimprovement.Finally,theyadmit
theABIMboardhadlifetimecertification,andsix(23%) that less than one percent of diplomates with lifetime
have voluntarily recertified. Thus, the participation by certificates participate. The ABIM had previously stated
seniorleadershipininternalmedicinehasbeenunusually that ‘it is convinced that as recertification becomes the
low;thisseemssurprisingsincemanyoftheseindividuals norm,olderinternistswillchoosetovoluntarilyrecertify’
promotedtheinitialprocess.TheNewEnglandJournalof (18). This has not happened to date and, based on the
Medicine recently completed a survey which asked read- participation rates of internal medicine leaders and the
ers to advise a physician with a lifetime certificate in sentimentsintheNEJMpoll,isnotgoingtohappen.This
internalmedicineandendocrinologyastowhetherornot lackof participation should raise fundamental questions
this individual should enroll in the ABIM Maintenance abouttheprocess.Finally,thepresidentoftheAlliancefor
of Certification Program (14, 15). A total of 2,512 votes Academic Internal Medicine has claimed that the public
were cast; 63% of the respondents did not recommend and payers do not consider the 10-year cycle to be a
enrollment in this current program. Reasons for this credible method to evaluate competency and that the
decision included cost, which appeared to outweigh the MOC must evolve into a continuous process (19). The
educational benefit, and the lackof relevance to day-to- basis for this conclusion is unclear, but it does represent
day patient care. These readers argued for refinement of additionalconcernsabouttheMOCprocess.
the MOC process to make it more topical and pertinent In summary, the relevance and importance of the
to practicing physicians. ABIM MOC program is a difficult calculation and will
likelyvaryfromindividualtoindividualandfromclinical
Conclusions practice to clinical practice. The ABIM is not the only
The field of internal medicine constantly acquires new organization with a strong interest in physician perfor-
studiesandinformation.Ramseyandco-authorsreported mance, and other organizations, such as state licensure
aninversecorrelationbetweenperformanceonanABIM boards, could develop competing programs to ‘certify’
Table2. Percentageof memberswithnon-time-limited certificateswhohaverecertified
Certifiedgeneralmedicine Recertifiedgeneralmedicine Certifiedsubspecialty Recertifiedsubspecialty
Organization N N(%) N N(%)
ABIM 30 6(20) 17 13(76)
Taskforce 17 3(18) 11 3(27)
Annalseditorial 22 2(9) 5 1(20)
ACPregents 26 2(8) 7 0(0)
ACPgovernors 54 2(4) 18 0(0)
ACGME 12 0(0) 8 0(0)
Total 161 15(9%) 66 17(25%)
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Maintenanceofcertificationininternalmedicine
current competency. Chaudhry outlined the expected could be practically difficult and costly, but the
changes in the maintenance of a licensure processwhich information obtained would be worth the invest-
will be required by the Federation of State medical ment. In addition, this information would provide
Boards (20). This process will have requirements like thebasisforeducationalprogramssponsoredbythe
theABIMrecertificationprocessbutwilllikelybeeasier. ABIM or ACP. Alternatively, the ABIM could
Also, hospitals and/or insurance companies could de- require internists to attend and pass clinical skills
velop other educational and professional development workshops for updates. The Advance Cardiac Life
activities that are more directly relevant to patient care SupportprogramsponsoredbytheAmericanHeart
andlocalservices.TheABIMshouldbeconcernedabout Association is one possible model for clinical
the possibility that diplomates with time-limited certifi- skill review. This activity updates physicians and
cateswilloptoutoftheMOCprogram,especiallyifmore improves performance; it also saves lives.
requirements are placed on physicians to practice med-
We think these changes will enhance the MOC
icine. Therefore, the ABIM should undertake additional
program by lowering costs, by encouraging practice
studies to correlate patient outcomes with MOC status.
review by individual physicians and experts, and by
These studies should compare physicians who choose to
continuously focusing on the current medical literature.
recertify with those who do not and should evaluate the
These changes will make the MOC process more mean-
effect of other professional development activities on
ingful and useful for physicians with both time-limited
patientoutcome.Thesestudiesareobviouslycomplicated
and lifetime certificates and will increase participation.
and will likely require more than small-scale academic
This approach will help maintain the wealth of existing
studies.Ataminimumtheyshouldincludeaprospective
knowledge of internists. However, demonstration of
design with prespecified outcomes and analysis. The
clinical skills remains a difficult transaction, and the
critical characteristics of certified physicianswhich drive
development of the best process to support this activity
outcomeswillbehardtodeterminebutcouldbemodeled
largelydepends on the commitment of internists to their
using propensity analysis. These studies will have diffi-
profession.
culty capturing the contributions of day-to-day clinical
experience in patient outcomes.
Conflict of interest and funding
We offer the following recommendations to promote
The authors have not received any funding or benefits
professional development:
from industryor elsewhere to conduct this study.
(1) The ABIM should develop a directed reading
program to focus on recent advances in internal
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