Since its inception in 1934, the American Board of Psychiatry and Neurology (ABPN) has worked to design processes for the credentialing and evaluation of psychiatrists in a manner to assure the public that its diplomates are competent to practice their specialties (
1,
2). While these ABPN processes originally dealt only with initial certification, increasing public and political concerns about medical errors, patient safety, and quality of care (
3,
4,
5) have shifted the focus of attention of the ABPN and other member boards of the American Board of Medical Specialties to recertification and, more recently, to the identification and evaluation of specific psychiatry competencies and to maintenance of certification (
6,
7).
There is also evidence in the literature that supports the movement toward maintenance of certification as a program of lifelong medical learning. In their review of studies correlating measures of medical knowledge and health care quality to years in practice and physician age, Choudhry et al. (
8) found that 73% (45/62) of the studies reported decreasing physician performance with increasing years in practice for at least some outcomes; 100% (12/12) reported a negative association between physician knowledge and experience; 63% (15/24) reported a negative association between years in practice and adherence to standards of practice; 74% (14/19) reported at least a partially negative association between physician age and adherence to standards of appropriate therapy; and 57% (4/7) reported at least a partially negative association between number of years in practice and actual health outcomes. Davis et al. (
9) also cast doubt on the ability of physicians to evaluate their own performances. Of the comparisons they reviewed, 65% (13/20) found little, no, or a negative correlation between physicians’ self-assessments and observed measures of their competence. The worst accuracy in self-assessment was frequently seen among the least skilled physicians or most confident physicians.
The public also seems to support maintenance of certification. In a 2003 Gallup Poll commissioned by the American Board of Internal Medicine, 54% of respondents said they would "very likely" change physicians if they knew that their current physician’s board certification had expired; 75% would opt for a board-certified physician over a non-board-certified physician recommended by a trusted friend or family member; 73% considered it "very important" for physicians to be reevaluated on their qualifications every few years; and 68% considered it "very important" for physicians to periodically pass a written test of medical knowledge (
10).
Through its Maintenance of Certification Program, the ABPN recognizes the need to help ensure that its diplomates continually adhere to the highest quality standards in medicine, demonstrate their competence to practice their specialties, and pursue excellence in all areas of their professional endeavors (
6). The ABPN realizes that many of its already overworked diplomates are concerned about the extra burden and cost of the Maintenance of Certification Program. The conundrum for the ABPN, however, is to strike a balance in its program between the sometimes conflicting factors of quality and credibility, convenience and cost, and diplomate satisfaction and participation. The ultimate ABPN objective is to develop a program that is of high quality and credibility, relatively convenient and affordable, and sufficiently acceptable that diplomates will participate in it.
The ABPN is also aware that the Maintenance of Certification Program may be perceived as complex, represents a new way of conceptualizing board certification, and may be confusing to some of its diplomates. Some of this complexity is the result of the need to design the program to include the specific elements required by the American Board of Medical Specialties of all of its member boards. The goal of this article is to describe the ABPN Maintenance of Certification Program in a manner that will allow for diplomates to appreciate some of the underlying rationale, how it will be implemented now, and what it might look like in the future. We begin by describing the philosophical foundation behind the program. We then present its four specific components, review progress made thus far in the preparation of specific products for diplomates to use to meet its requirements, and conclude with a discussion of several unanswered questions about its current status and future development.
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Philosophical Foundation of the ABPN Maintenance of Certification Program
There are several interconnected philosophical tenets that form the rationale for the existence and current structure of the Maintenance of Certification Program. Attention to most of these issues has actually been a focus of the ABPN since its inception (
1,
2), and they are now reinforced in the program. We will only cover these complex issues briefly, as each of them could well be the subject of a lengthy discussion in its own right.
A major goal of the ABPN has always been to reassure the public about the qualifications of its diplomates (
1). This has now been extended through the Maintenance of Certification Program to cover diplomates over their entire professional careers.
Another theme from the beginning of the ABPN has been the perceived pressure to act before some government entity steps in to take control (
11). Increasing public and political concerns about patient safety and the quality of medical care have been significant stimuli for the expeditious development of the program.
Attention to diplomate competence has always been a central component of ABPN evaluation processes (
1). The recent focus on core competencies throughout medical education, however, and the identification of specific core competencies for psychiatrists, have modified the ABPN initial certification processes and also guided the design of all components of the Maintenance of Certification Program (
6).
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Continuous Quality Improvement
Increasing awareness of the importance of continuous quality improvement in the business and professional sectors was one of the major factors that called into question the adequacy of the more limited and intermittent approach of the original ABPN Recertification Program (
12,
13). It has also influenced the development of the Self-Assessment and Performance in Practice components of the program.
ABPN diplomates have always been required to possess an unrestricted medical license as one means of demonstrating acceptable professionalism (
1). The Professional Standing component of the Maintenance of Certification Program will continue this emphasis, and professionalism will be addressed in the Performance in Practice component as well.
ABPN certification has frequently been cited as one measure of diplomate qualification for academic and other purposes (
2). A major goal of the program is for it to be designed in a manner that will be acceptable to public and private organizations concerned with licensure, credentialing, privileging, accreditation, and physician reimbursement (
14).
The ABPN has always attempted to develop and implement its certification and recertification examinations in a manner consistent with state-of-the-art psychometric processes (
1,
2). The ABPN Maintenance of Certification Program has also been designed with that goal in mind, and it may well be modified in the future as data become available on the reliability and validity of its specific components.
While the ABPN has always been an independent organization (
1), it is also one of 24 member boards of the American Board of Medical Specialties which has established required guidelines for its member board certification and maintenance of certification initiatives (
15). The ABPN Maintenance of Certification Program must be developed and implemented in a manner that is consistent with those guidelines and also as responsive as possible to constructive feedback from diplomates and other professional organizations.
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Components of the ABPN Maintenance of Certification Program
Cognizant of the need to reassure the public about the competence of specialist physicians, in the late 1980s the American Board of Medical Specialties joined with the Accreditation Council for Graduate Medical Education (ACGME) to formulate the six areas of competency that physicians should develop and maintain throughout their professional careers: medical knowledge, patient care, interpersonal and communication skills, practice-based learning and improvement, professionalism, and systems-based practice (
16). The ABPN responded to the American Board of Medical Specialties mandates and established a 10-year maintenance of certification cycle, developed its own specific requirements for each of the four components of its Maintenance of Certification Program, ensured that its program addressed all six core competencies (Table 1
), and adopted a specific timetable for the phase-in of each maintenance of certification component (Table 2
).
1. Professional Standing. Lacking the resources and the mandate to implement its own independent process to thoroughly evaluate physician ethics and professionalism, the ABPN has always relied on the requirement that its candidates and diplomates must possess a license to practice medicine in at least one state, commonwealth, territory, or possession of the United States or province of Canada, and all licenses must be unrestricted. This requirement continues in the ABPN Maintenance of Certification Program and went into effect at its inception in 2007 (Table 2
).
If it is determined that ABPN diplomates have significant restrictions placed upon their licenses, their ABPN certificates are automatically invalidated. In general, restrictions due to the voluntary participation in an impaired physicians’ program, geographic limitations, or certain minor administrative difficulties do not result in ABPN certificate invalidation. Once the restrictions have been removed from their licenses, individuals must reapply to the ABPN to have their certificates reissued. Even if diplomates had lifetime certificates prior to their licensure restrictions, all reissued certificates are now time-limited and those diplomates are subsequently required to participate in the entire ABPN Maintenance of Certification Program.
Many state medical boards now mandate that physicians complete a certain number of hours of continuing medical education (CME) to maintain licensure and also require new licensure applicants to have completed some type of cognitive examination within a specified time period. The Federation of State Medical Boards and some individual state medical boards are currently considering whether or not to require physicians to participate in a Maintenance of Licensure Program that is akin to the American Board of Medical Specialties Maintenance of Certification Program (
17).
2. Self-Assessment and Lifelong Learning. This component of the ABPN Maintenance of Certification Program actually consists of two parts: self-assessment and CME. Over the 10-year maintenance of certification cycle, diplomates will be required to show evidence of participation in at least two self-assessment activities. This requirement will be phased in beginning in 2010 (Table 2
). To be accepted by the ABPN, self-assessment activities (e.g., examinations) must total at least 100 questions, cover new knowledge and/or current best practices, and provide feedback to diplomates that can be used to guide subsequent CME, lifelong learning, and/or career development. The minimum of 100 questions can come from multiple self-assessment activities. When the ABPN Maintenance of Certification Program is fully implemented in 2017, the first of the two required self-assessment activities must be completed during years one to three of the 10-year maintenance of certification cycle and the second during years six to eight. This will help ensure that self-assessment activities guide diplomates’ continuous cognitive development and CME activities.
Beginning in 2007, diplomates will be required to complete an average of 30 specialty or subspecialty Category 1 CME credits per year over the 10-year maintenance of certification cycle (Table 2
). To be accepted by the ABPN, CME activities must be accredited by the Accreditation Council for Continuing Medical Education (ACCME) or the Royal College of Physicians and Surgeons of Canada, and CME activities must be relevant to the specialty in which a diplomate is certified. Diplomates certified in more than one area will still only need to accrue an average of 30 CME credits per year, as the same CME credits can be used to satisfy the maintenance of certification requirements for multiple ABPN subspecialties. When the ABPN Maintenance of Certification Program is fully implemented in 2017, 150 CME credits must be earned during each 5-year block of the 10-year maintenance of certification cycle. This will help ensure that diplomates attend to their cognitive development in a continuous manner. Considered together, self-assessment and subsequent CME can be viewed as a quality improvement cycle focused primarily on medical knowledge (Figure 1
).
3. Performance in Practice. This component of the ABPN Maintenance of Certification Program is designed to encourage diplomates to incorporate the principles of quality improvement into their clinical practices. Each Performance in Practice Unit consists of two parts, a clinical module and a feedback module. Over the 10-year maintenance of certification cycle, diplomates will be required to complete three Performance in Practice Units, and this requirement will be phased in beginning in 2013 (Table 2
). When the ABPN Maintenance of Certification Program is fully implemented in 2017, the first of the three required, two-part Performance in Practice Units must be completed during years one to three of the 10-year maintenance of certification cycle, the second during years four to six, and the third during years seven to nine. This should help ensure that diplomates demonstrate their ongoing attention to clinical quality improvement. As with self-assessment and CME, Performance in Practice Units implement quality improvement cycles, but here the focus is on clinical activities (Figure 2
).
To be accepted by the ABPN, Performance in Practice Clinical Modules must require that diplomates collect data from at least five of their own clinical cases in a similar category (e.g., diagnosis, type of treatment, location of service) over the previous 3-year period; compare that data with published best practices, practice guidelines, or peer-based standards of care (e.g., hospital quality improvement programs); identify opportunities for improvement in the effectiveness or efficiency of their clinical activities; take steps to implement the suggested improvements; and, within 2 years, collect the same data on another five clinical cases in the same category to see if improvements in clinical activities have occurred. The specific focus of the category in the Performance in Practice Clinical Modules and the comparison standards selected (e.g., practice guidelines) are chosen by the diplomates themselves and not by the ABPN.
To be accepted by the ABPN, Performance in Practice Feedback Modules must require diplomates to solicit the opinions of at least five peers or five patients concerning their clinical activities over the previous 3-year period; identify opportunities for improvement in the effectiveness or efficiency of their clinical activities; take steps to implement the suggested improvements; and, within 2 years, solicit the feedback of at least another five peers or five patients to see if improvements in clinical activities have occurred.
4. Cognitive Expertise. Once they have satisfied all of the other ABPN Maintenance of Certification Program requirements that are in effect at the time that their certification is due to expire, diplomates are qualified to take the ABPN Maintenance of Certification Cognitive Examination (Table 2
). Diplomates must be able to provide records documenting completion of self-assessment, CME, and Performance in Practice requirements, and some of those applying to complete the Maintenance of Certification Cognitive Examination will be audited by the ABPN.
Similar to its predecessor, the ABPN Recertification Examination, the Maintenance of Certification Cognitive Examination in psychiatry, is a multiple-choice, computer-based test. At this point, it is administered at Pearson VUE Professional Centers located in over 200 sites around the country. The Maintenance of Certification Cognitive Examination is practice relevant and focuses on the clinical application of knowledge. A specific content outline for the examination is available on the ABPN website (www.abpn.com). To maintain certification without interruption, diplomates must pass the Cognitive Examination prior to the expiration date on their ABPN certificate, and a passing score extends certification to December 31 of the tenth year after the date of the examination. As has historically been the case for all ABPN recertification examinations (Table 3
), it is expected that the pass rates for the Cognitive Examination will be high. This prediction is based on the fact that the examination places particular emphasis on patient-based questions that clearly reflect the "real world" of clinical experience and that all diplomates taking the examination will have already completed general, and sometimes even subspecialty, residencies and passed the ABPN certification examinations. It is also probably true that most of these diplomates are relatively young yet experienced clinicians at the heights of their professional careers and that most view their certification to be important enough for them to put forth their best efforts to maintain it.
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Preparation of ABPN Maintenance of Certification Products for Diplomates
As the different required components of the ABPN Maintenance of Certification Program are instituted (Table 2
), diplomates will need to have available options for their fulfillment. Unlike some of the other American Board of Medical Specialties member boards, the ABPN has decided at this point not to undertake the preparation of maintenance of certification products other than the Maintenance of Certification Cognitive Examination itself and some model forms available on the ABPN website (www.abpn.com) that might assist diplomates with the completion of their Performance in Practice Units. This decision partly represents the ABPN’s long-standing philosophical position that processes and products to help prepare diplomates to meet its certification and maintenance of certification requirements should be developed, if possible, by non-ABPN organizations and individuals. It also embodies the belief of the ABPN that the entire maintenance of certification process should be a collaborative venture with its affiliated professional organizations, and that this approach stands the best chance of encouraging diplomates to participate in the Maintenance of Certification Program. To that end, the ABPN has already endorsed several products for CME (e.g., APA meetings), self-assessment (e.g., the American College of Psychiatrists’ Psychiatrist in Practice Examination, APA Focus Annual Self-Assessment Exam, and APA Practice Guidelines), and Performance in Practice (e.g., Net Outcomes developed at the University of Arkansas for Medical Sciences).
The ABPN Maintenance of Certification Program is a work in progress, and a number of questions about it remain to be answered completely. First, will diplomates voluntarily participate? If the program is relatively convenient, reasonably priced, and broadly recognized as a legitimate measure of physician competence, then we expect a high rate of diplomate participation. The only maintenance of certification fee charged by the ABPN will be for its Cognitive Examination, and that fee will be reduced from $2,125 in 2007 to $1,900 in 2008.
Second, will organizations that license, credential, privilege, and reimburse physicians accept diplomate participation in the ABPN Maintenance of Certification Program in lieu of their own specific requirements? We believe that the success of this effort may well depend upon how specific maintenance of certification components are designed and implemented. For example, some organizations may require physicians to demonstrate their competency in specific areas (e.g., patient safety, professionalism, adherence to certain practice guidelines), through specific requirements (e.g., total numbers of self-assessment, CME, and Performance in Practice activities), in a relatively continuous manner (e.g., number of self-assessment, CME, and Performance in Practice activities per year of the maintenance of certification cycle), or according to specific time frames (e.g., length of the entire maintenance of certification cycle). The ABPN plans to ensure that its program has the flexibility to respond to these or other similar requirements that may evolve over time.
Third, will diplomate participation in the Maintenance of Certification Program satisfy the public and political pressures for documentation of continued physician competence? We expect that the continuous involvement of diplomates in maintenance of certification activities that demonstrate their ongoing competence will be especially important in this regard. This effort would certainly be strengthened by rigorous research that links maintenance of certification activities to positive patient outcomes and by auditing requirements that ensure that diplomates participate in meaningful maintenance of certification activities.
Fourth, will professional organizations affiliated with the ABPN (e.g., APA or the the American College of Psychiatrists) develop sufficient maintenance of certification products to meet diplomate needs? If this does not occur, the ABPN may be forced to take steps to develop its own maintenance of certification products, as it obviously cannot find itself in the unfortunate situation of requiring diplomates to fulfill requirements that they have no means to accomplish.
Fifth, will diplomates whose clinical activities only involve narrow subspecialty areas be required to complete all aspects of the more broad-based ABPN Maintenance of Certification Program? Like some of the other American Board of Medical Specialties member boards, the ABPN is currently in the process of developing specific maintenance of certification cognitive examination modules that will enable diplomates to maintain their ABPN certification in psychiatry, the subspecialties, and perhaps even limited foci of clinical activity by passing a single examination tailored to meet their individual needs (
18).
Sixth, will diplomates who do not practice clinical medicine be expected to participate in the ABPN Maintenance of Certification Program? The current American Board of Medical Specialties Maintenance of Certification guidelines and the ABPN Maintenance of Certification Program require that the Performance in Practice component of maintenance of certification can only be completed by using data relevant to a diplomate’s own clinical activities. For that reason, diplomates who do not actually provide care for their own patients would not be able to complete the required Performance in Practice activities. The current ABPN plan is to designate those diplomates who do not see patients but who do complete the remaining components of the ABPN Maintenance of Certification Program as having maintained their ABPN certification but also as being "not clinically active." Subsequent conversion of a diplomate to "clinically active" status is possible under the current ABPN plan if that diplomate resumes enough clinical practice to generate sufficient data to complete the Performance in Practice component of maintenance of certification.
Seventh, will ABPN diplomates whose certificates are not time-limited be required to participate in the ABPN Maintenance of Certification Program? When the ABPN Recertification Program began, all diplomates certified before 1994 were exempt from having to complete the Recertification Examination. These diplomates were told that, upon completion of all requirements then in effect for ABPN certification, they would hold a "lifetime" certificate as long as they maintained an unrestricted license to practice medicine. It was believed to be legally untenable to attempt to subsequently modify that implicit agreement between the ABPN and those diplomates by requiring them to become recertified. Likewise, these same diplomates are also exempt from having to participate in the ABPN Maintenance of Certification Program. Despite this policy, all current ABPN directors are required to participate in the Maintenance of Certification Program, and some diplomates with "lifetime" certificates are also choosing to do so voluntarily. If maintenance of licensure programs become a reality around the country, the number of diplomates with "lifetime" certificates electing to participate in the program might well increase significantly.
In summary, the ABPN has tried to develop its current Maintenance of Certification Program in a manner consistent with its underlying philosophical beliefs, the American Board of Medical Specialties guidelines, public and political concerns, diplomate needs, and the anticipated requirements of organizations responsible for licensure, credentialing, privileging, accreditation, professional development, and physician reimbursement. It is likely that the ABPN will have to modify its Maintenance of Certification Program in the future to respond to evolving expectations of all of those constituencies. Diplomates should regularly consult the ABPN website for the latest Maintenance of Certification Program requirements. As always, the ABPN will attempt to balance the sometimes conflicting factors that underlie its Maintenance of Certification Program in a manner that best meets the needs of its diplomates, the patients, and the public they serve.
Dr. Faulkner and Ms. Tivnan are full-time employees of the ABPN. Drs. Winstead, Reus, Andrade, Brooks, Colenda, Mrazek, Reifler, and Schneidman are each ABPN paid consultants. Dr. Reus receives research funding from Nabi Pharmaceuticals, Dr. Mrazek has intellectual property interests in an AssureRx product, and Dr. Reifler serves on the Professional Advisory Board of Senior Bridge.