February 5, 2024
Maintenance of Certification—The Value to Patients and Physicians
Robert O. Roswell, MD1; Erica N. Johnson, MD2; Rajeev Jain, MD3
JAMA. 2024;331(9):727-728. doi:10.1001/jama.2024.0374
In 1936, the American Medical Association and the American College of Physicians jointly formed the American Board of Internal Medicine (ABIM) as an independent assessment organization to distinguish internists who met peer-reviewed established standards. The mission of the 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.1 For more than half a century, the process of board certification ended at the beginning of a physician’s career with initial certification. In 1990, with the goal to assure the public that certified physicians are maintaining their knowledge and skills, ABIM began requiring periodic reassessment of medical knowledge to maintain certification in all disciplines. Medicine is evolving at a rapid pace, and by participating in maintenance of certification (MOC), physicians can reassure patients, colleagues, and themselves that they are doing what they need to do to stay current in medical knowledge and practice.
At a time when physicians are overwhelmed by bureaucratic requirements of prior authorization, required institutional trainings in everything from workplace safety to billing and coding, and collectively recovering from the massive and ongoing trauma that is COVID-19, some physicians have begun to question the benefits of certification.
ABIM acknowledges the challenges and demands facing today’s practicing physicians and uses diplomate feedback to improve its programs and processes. Based on feedback from the diplomate community, ABIM has launched the Longitudinal Knowledge Assessment (LKA). The LKA was designed to better accommodate physicians’ schedules and desires for flexibility. Approximately 80% of ABIM-certified physicians across all disciplines are choosing the LKA over the traditional long-form MOC examination. The LKA does not require preparation, takes 4 hours per year on average, and, after questions are answered, provides the diplomate with immediate feedback, rationales, and references while offering the opportunity to provide critiques of the item to ABIM. Across all disciplines, 70% of diplomates agree, 16% are neutral, and 14% disagree with the statement that “the LKA is a fair assessment of clinical knowledge in this discipline.”
Importantly, all of these innovations occur with the oversight of a diverse governance structure that includes physicians from a vast array of practice types, and also nonphysician public members. Early in its history—dating back to 1936—ABIM governance was largely drawn from the ranks of the academy and specialty societies. But in 2014, ABIM substantially modified its governance to oversee policy in each of its disciplines and complement the work of committees creating examination content; newly appointed governance members were selected to represent the range of practice types and physician experience within each discipline, along with both patient and nonphysician clinical team members. With the launch of the LKA in 2022, content generation was expanded to more than 1000 volunteers. This expansion intentionally included a majority of practicing physicians from the community who work in a broad range of settings. ABIM aims to be a vehicle through which the profession of internal medicine sets standards for itself.
All physicians engaged in patient care bear the heavy burden of all the cost and work it takes to stay current in the field to provide state-of-the-art evidence-based care to their patients. To help with these challenges, in launching the LKA, ABIM lowered the 10-year cost of the continuing certification program for all physicians—regardless of how many certificates they hold—if they participate in the LKA to maintain them. It now costs $220 per year to maintain 1 certificate and $120 for each additional certificate.2 To ensure financial transparency, audited financial statements including Internal Revenue Service Form 990 are made public by ABIM as soon as they are available, an action that not all nonprofits follow.2 The organization has earned a Platinum Seal of Transparency from Candid for its financial transparency, which includes publicly posting financial statements and a guide on how to read the organization’s posted financial documents.2,3
A large and growing body of evidence from published, peer-reviewed, cohort studies with adjusted statistical analyses has shown that patients who are cared for by physicians who demonstrate more medical knowledge through certification and MOC have a better prognosis for a host of important outcomes including lower mortality from cardiovascular disease, fewer emergency department visits, fewer unplanned hospitalizations, better adherence to medical guidelines, improved results on myriad process-of-care measures such as opioid prescribing and diabetes care, and fewer state medical board disciplinary actions.4
Physicians who were required to complete MOC to stay certified provided 2.5% lower total cost of care to Medicare beneficiaries without any decline in measured quality. This translates into approximately $5 billion per year in health care savings when extrapolated to the entire Medicare population.5 The totality of evidence around certification and MOC now includes studies collectively involving tens of thousands of physicians and hundreds of thousands of patients. Despite limitations in these studies, there are important positive associations on patient outcomes.
Some physicians wonder if self-assessment alone could ensure better outcomes and more efficient care. The president and chief executive officer of the Accreditation Council for Continuing Medical Education recently argued that for CME to be effective in closing identified knowledge gaps, it was necessary to have a continuing certification program using objective assessments of medical knowledge.6
ABIM continually seeks to improve its certification procedures. To ensure fairness and recognition of the structural forces that may bias assessments such as certification questions, ABIM has invested in fairness reviews of questions on several examinations to identify and remove bias if it is found. Health equity was recently approved as a new content area on ABIM assessments. There is ongoing work to enhance the knowledge of extant health disparities on examinations, including best practices in advancing health equity. ABIM meets regularly with specialty society leadership. A future assessment innovation requested by some medical societies will include the introduction of practice profiles in some disciplines where practice data demonstrate concentrations of practice within the discipline; these concentrations will facilitate the design of more tailored assessments that will enhance relevance.
Emerging technologies, like artificial intelligence and large language models, will create innovative assessment approaches, and ABIM has committed to explore them, even as we ensure that demonstration of individual physician knowledge remains the foundation of certification, a process that explicitly and publicly recognizes the skills and expertise of an individual physician.
Prior conversations with physicians have led to significant changes in MOC. With physicians’ input and keeping patients at the forefront, ABIM’s programs will continue to evolve. Physicians earning and maintaining certification should be recognized for their accomplishments in obtaining and keeping their medical knowledge current throughout their careers. We look forward to continuing to engage the community of internists and subspecialists as we also continue to provide a way to recognize the value of the hard-earned expertise board-certified physicians offer to their patients, colleagues, and the medical community.
Article Information
Corresponding Author: Robert O. Roswell, MD, Associate Dean for Diversity, Equity, and Inclusion, Departments of Cardiology and Science Education, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 2000 Marcus Ave, Ste 300, New Hyde Park, NY 11042-1069 (rroswell@northwell.edu).
Published Online: February 5, 2024. doi:10.1001/jama.2024.0374
Conflict of Interest Disclosures: Drs Roswell, Johnson, and Jain report that they are officers of the ABIM Board of Directors and receive an honorarium for their service.
Additional Contributions: We acknowledge Seth Landefeld, MD, officer, ABIM Board of Directors, for his contributions to this work. No compensation was received.
References
American Board of Internal Medicine. About ABIM. Accessed November 17, 2023. https://www.abim.org/about/mission/
American Board of Internal Medicine. ABIM fees. Accessed November 17, 2023. https://www.abim.org/maintenance-of-certification/policies-fees/
American Board of Internal Medicine. ABIM candid profile. Accessed December 20, 2023. https://www.guidestar.org/profile/39-0866228
American Board of Internal Medicine. Evidence supporting certification and MOC. Accessed November 17, 2023. https://www.abim.org/evidence
Gray BM, Vandergrift JL, Johnston MM, et al. Association between imposition of a maintenance of certification requirement and ambulatory care–sensitive hospitalizations and health care costs. JAMA. 2014;312(22):2348-2357. doi:10.1001/jama.2014.12716
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