New board certification method requires perpetual evaluation

What's in a name?

To hear the American Board of Surgery tell it, quite a lot.

It recently won a $174,000 judgment in federal court against something called the American Board of General Surgery.

In a lawsuit filed in 2010, the American Board of Surgery said the American Board of General Surgery wasn't a medical board at all, but a sham created by a Las Vegas man with a history of selling bogus medical certificates to physicians.

Boards award certifications to doctors for showing expertise in a particular specialty. Though it's a voluntary process, board certification is needed to practice in many hospitals and is an important mark of approval for patients and insurers.

Doctors now must do more than pass a test to be certified. They're increasingly being asked to assess the quality of care they provide.

David Nash, dean of the Jefferson School of Population Health, says, "There's been a relative explosion in the number of boards and certificates, especially in the last five years." Most, he says, "are very credible."

Nash says the big challenge boards face isn't sham certifications - it's designing better assessments of doctors' competence, and showing that the assessments improve care.

"We all sort of assume that board certification leads to better outcomes," Nash says. But "we've not done a lot of research."

"I certainly would want my primary-care doctor and my specialist to maintain their board certification. Can I give you detailed research evidence to support it? No," says Nash, who is certified by the American Board of Internal Medicine, in Philadelphia, perhaps the nation's most influential board.

For decades, doctors got certification largely by passing a multiple-choice test, and held it for life.

Nash says that model raised questions: "Does a paper-and-pencil test assure anything? How do we know that doctors are still delivering high-quality, low-error care" over time? "And the answer is, in truth, we don't."

But the boards are working to change all that.

Major medical boards in the United States have gradually abandoned the lifetime-certification model. By the 1990s, requiring board-certified doctors, or diplomates, to renew certification through periodic assessments was common.

Then there was a sea change in 2000, when 24 boards, guided by their standard-setting authority, the American Board of Medical Specialties, adopted the maintenance-of-certification program.

The boards are implementing the program in different ways, but the guiding principle is that diplomates must submit to rigorous, lifelong assessment to maintain certification.

And a big part of that work is self-assessment; diplomates must look at how they're rendering care and pinpoint ways to improve it.

At the American Board of Internal Medicine, which rolled out its new program in January, data from patient charts (minus personal identities) is submitted into Web-based auditing tools. The audits, which center on 20 or so common medical tasks, tell diplomates how they're performing on the whole, and compare their performance to peers. The diplomates then devise self-improvement plans based on the results, and are reaudited later to see whether they've improved care.

"It's a different kind of exercise than the paper-and-pencil test because it involves actually looking at your processed care and the kinds of results you're achieving," says Richard Baron, president of the American Board of Internal Medicine. "That's new for doctors."

Self-audits tell diplomates "this percent of time you're achieving blood-pressure control, and that compares to 1,500 other doctors who used this tool," he says. "You're doing better than them or worse than them on achieving cholesterol targets, in doing smoking-cessation counseling, in various aspects of care."

They needn't show that they've improved care, just that they've done the audits, created improvement plans, and been audited again to see whether the plans helped.

It's all part of the 10-year, perpetual cycle of learning and assessment that diplomates of the internal medicine board must follow. They must meet requirements in two- and five-year intervals and sit for the board's proctored exam every decade.

Not all doctors are thrilled. "This whole thing has gotten out of hand," says plastic surgeon Kenneth Christman, a past president of the Association of American Physicians and Surgeons, which vehemently opposes the maintenance-of-certification program.

"I've been board-certified for over 30 years, and I'm proud of it," he says. But achieving certification is demanding enough, he says. Now "it never ends. You're on this treadmill forever."

Like it or not, physicians looking to be called "board certified" should get with the program, because it's here to stay, Nash says. He adds that many of the requirements, including self-audits, are a good thing for patients.

"The self-evaluation tools have a lot of promise in the near future." But, he says, that hugely important question - Are physicians doing a good job? - still looms large. And the technology needed to answer it "is still relatively in its infancy."

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