Three decades ago, the American Board of Internal Medicine (ABIM) announced the end of the “board-certified-for-life” status that had been in place since the Board’s founding by the American Medical Association and American College of Physicians in 1936. Beginning in 1990, ABIM required physicians to pass periodic tests to prove they were keeping up to date in their fields to maintain ABIM certification. “Grandparent” diplomates who had received their certification in 1989 or earlier could choose to take these exams but were not required to do so. Since that change, the organization has sought to find an assessment structure that physicians agree is both beneficial and minimally burdensome.
ABIM started Maintenance of Certification (MOC) by implementing a long, costly, high-stakes, every-10-year written exam, which switched from pencil-and-paper exams to computer-based testing in 2006. In 2013, ABIM began requiring diplomates to also accumulate 100 “MOC points” during each renewal period, as well as conduct a practice assessment and quality-improvement plan – changes that faced stiff criticism from individual physicians, as well as the societies that represented them, including the American Society of Hematology (ASH).1
Responding to this criticism, ABIM President and CEO Richard Baron, MD, admitted that the organization had “overreached,” and ABIM dropped the practice assessment and quality-improvement plan requirement but kept the 100 MOC point requirement. In 2018, ABIM began offering 2-year Knowledge Check-Ins (KCIs) in certain specialties in lieu of the 10-year test.
Although many practitioners welcomed the option to take a “less terrifying” KCI assessment at home or in the office – rather than at a designated testing center – many still argued these tests were too expensive, did not reflect practice diversity, the processes at testing centers are intrusive, and that MOC had never been shown to influence quality of care.
“The Knowledge Check-In was a major step forward for ABIM, but there was still work to be done,” said Marc Zumberg, MD, Section Chief for Non-Malignant Hematology at University of Florida Health in Gainesville, and member of the ABIM Hematology Board. “Physicians wanted different ways to keep up-to-date that actually sent them to where their knowledge gaps were. Still, some people didn’t like that they had to take time away from their practice even to do the 2-year exam.”
So, another shift came in August 2019, when ABIM announced plans to introduce a self-paced longitudinal assessment option alongside the traditional, long-form assessment. ABIM hopes to roll out assessment options specific to malignant or classical hematology within the next couple of years.2 While the longitudinal assessment option was advocated for and applauded by ASH as well as individual practitioners and other organizations that represent them, there is considerable confusion about how the changes will affect hematologists.3
The Original Exam
When ABIM started requiring diplomates to participate in MOC activities in 1990, it sought to create activities that ensured that physicians were continuing to stay informed about the latest developments in their fields. However, individual physicians and professional organizations have criticized these requirements, and the ABIM is now responding to the concerns.
“ABIM is striving to underscore the value of the different maintenance of certification aspects and tries to support physicians staying up to date,” said Beth Faiman, PhD, CNP, from the Department of Hematologic Oncology and Blood Disorders at Cleveland Clinic and Associate Editor of ASH Clinical News. Dr. Faiman also serves on the ABIM Hematology Board. “The ABIM has taken input from thousands of physicians in numerous specialties to create pathways so that physicians can stay current and maintain their certification.”
The 10-year MOC secure exam in hematology is offered twice per year, must be taken at a special testing center, currently costs $1,200, and takes about 10 hours to complete.
“Many were critical of the high-stakes exam, which yielded a lot of high anxiety,” said Dr. Zumberg. Moreover, many who took the exam complained that it did not represent the way they practiced medicine, a concern shared by ASH leadership. For example, when doctors are treating patients and questions arise, they can reference all types of materials to help them make diagnoses and decisions; however, the test did not allow them to reference any outside materials.
New Knowledge Assessments
When Rick Battaglia, MD, ABIM’s Chief Medical Officer, joined the organization in 2015, the association already had developed a task force to review its MOC practices. That same year, the task force released its report, and, Dr. Battaglia told ASH Clinical News, “that report was fairly clear in terms of its recommendations.” Chief among these “was to move away from sole reliance on the 10-year MOC exam,” he said. “Another was to recognize that physicians, as they move through their practices through the course of their career, tend to focus in certain areas and some specialties. Recognizing that specialization or informal focus within a specialty would be important.”
The KCI exams can be taken at home, work, or a testing center, last between 2 and 3.5 hours, include up to 45 questions, provide results and feedback more quickly than the traditional exams, and are “open book” using the UpToDate clinical decision support resource. KCIs in various specialties including hematology were introduced in 2019; the tentative rollout schedule anticipates expansion to all specialties by 2021.
ABIM has since sought to work with professional societies such as ASH and the American Society of Clinical Oncology (ASCO) to improve the assessment options. For example, starting in 2020, diplomates who are certified in medical oncology are able to take the ABIM/ASCO Medical Oncology Learning & Assessment, a flexible, lower-stakes MOC assessment program.4 This new tool offers physicians a choice between a general medical oncology assessment or disease-specific medical oncology assessments in breast cancer or hematologic malignancies. In the future, additional disease-specific medical oncology assessments will become available.
This assessment was designed with the support of ASCO, costs $240 every 2 years, is offered 2 to 4 times per year, is recorded by webcam to prevent cheating, and takes up to 3 hours. Unlike KCI exams, which provide immediate results, results of the ABIM/ASCO assessment are not available until 1 to 2 months from administration. The ABIM/ASCO assessment also provides relevant educational resources before and after the exam, which KCI assessments do not.
ASH also is committed to working with ABIM to ensure that existing and future hematology assessments meet the needs of general hematologists, as well as those who focus practice in classical hematology, malignant hematology, or transplantation/cell therapy. To do so, ASH is taking the lead in implementing a practice profile study in 2020, which will inform the new hematology longitudinal assessment option in 2022. For its part, ABIM is open to sharing data on assessment outcomes with ASH, so that the Society can develop individualized learning plans for diplomates based on the identified deficiencies.
Dr. Zumberg took the 2-year hematology KCI in 2019 and appreciated not only the ability to use UpToDate, but also the fact that his test results came immediately. “I was told in real time that I had passed the exam – I didn’t have to wait weeks and months to find out whether I passed or failed.”
The KCI option also relieves some of the pressure on physicians taking the test. If they fail, their board certifications are still valid for another 2 years. Diplomates only lose their actively maintaining certification status if they fail two KCI exams in a row; certification can be regained if they take a secure exam.
The Longitudinal Assessment
Still, Dr. Zumberg explained, physicians want different ways to engage with MOC and keep their knowledge current. They want feedback that provides resources to enhance their knowledge if the test reveals any gaps. Some believe even the 2-year exam requires them to take too much time away from their practice preparing and occurs too infrequently to ensure physicians are keeping up with new findings relevant to their patients.
The recently announced longitudinal assessment option will give physicians the opportunity to partake in assessment activities at their own pace.2 Rather than several hours at a time every 2 or 10 years, the more frequent short assessments are thought to better promote learning and retention. “Developing a longitudinal assessment option is part of our ongoing evolution at ABIM,” the organization said in its announcement. “We recognize that some physicians may prefer a more continuous process that easily integrates into their lives and allows them to engage seamlessly at their preferred pace, while being able to access the resources they use in practice.” Physicians who would prefer to maintain their certifications through the 10-year exam will still be able to do so.
Those taking the longitudinal assessment will be able to use “any external resource – other than another doctor – that the physician has access to,” such as journal articles, said Dr. Battaglia. “So, it will be even better in terms of being truer to how they practice, because they can use the type of point-of-care resources or educational references they would have access to while they’re answering the questions.”
“This new direction for MOC is a welcome change because it will better align with the needs of hematologists,” commented 2019 ASH President Roy Silverstein, MD. “For many years, the Society has advocated for assessment options that enhance medical knowledge through ongoing feedback outside of examination settings. We are thrilled to see this long-overdue reform being made.”
Preparations for the rollout of the new longitudinal option are beginning this year, but it is expected to take at least 2 years to complete. In November 2019, ABIM issued another update on the process of introducing the longitudinal option and responded to some of the more than 1,400 comments it received from diplomates after the initial announcement. The organization stressed its belief in the “value of co-creation” and pledged to “continue engaging with the internal medicine community to ensure the longitudinal assessment option will work for today’s practicing physician.”
In that vein, ABIM has opened several avenues for diplomates to share their insights and thoughts, such as through surveys and user tests on its online community “ABIM Engage.” ABIM also convened a Physician Advisory Panel that represents a range of practice settings, specialties, and geographies to provide input and feedback throughout the development and implementation of the project. As part of this effort, “ABIM staff are attending society meetings throughout fall 2019 and spring 2020 to offer physicians individualized guidance and collect feedback,” the organization explained.
Another goal of the new longitudinal assessment option is to create questions designed to better assess competence in individual specialties and allow doctors to take tests from more than one module to best represent their specific clinical practice. For hematologists participating in MOC, ABIM is working with ASH to address the different needs of those who focus in malignant hematology and those who focus in non-malignant hematology. “We have a goal of going live in as many specialties as possible by 2022,” noted Dr. Battaglia.
He also stressed that the cost for participating in either the 2- or 10-year exams would be about the same. Moreover, the more frequently diplomates participate in assessments, the less they will be required to complete other MOC activities. ABIM currently still requires physicians to earn 100 MOC points every 5 years to maintain certification, through a variety of continuing medical education or quality-improvement activities.
Building the new longitudinal assessment options will be a substantial challenge over the next 2 years, Dr. Zumberg said. For example, ABIM will need to build a large bank of questions that are both relevant and varied enough to ask people over time. ABIM has recruited many volunteers to serve on some of its Item Writing Task Forces but, in its November 2019 update, noted that there still are openings in several subspecialties. These questions will need to be vetted by the testing subgroups, and links to any educational materials to support will need to be kept up to date in real time. “There are a lot of issues that still need to get worked out,” he said.
- American Board of Internal Medicine. The Transformation of the American Board of Internal Medicine. Accessed February 10, 2020, from https://blog.abim.org/the-transformation-of-the-american-board-of-internal-medicine/.
- American Board of Internal Medicine. ABIM to Develop Longitudinal Assessment Option. Accessed February 10, 2020, from https://blog.abim.org/abim-to-develop-longitudinal-assessment-option/.
- American Society of Hematology. ASH Applauds ABIM Announcement on Maintenance of Certification Reform. Accessed February 10, 2020, from http://hematology.org/Newsroom/Press-Releases/2019/9871.aspx.
- American Society of Clinical Oncology. ABIM/ASCO Medical Oncology: Learning & Assessment (MOLA). Accessed February 10, 2020, from http://elearning.asco.org/pages/abim-asco-medical-oncology-learning-and-assessment.