Key words: American Board of Anesthesiology, policy: time-limited certification.
THE American Board of Anesthesiology (ABA) recently announced its plan for time-limited certification. All primary, subspecialty, and "Continued Demonstration of Qualifications" (CDQ) certificates issued on or after January 1, 2000, will expire 10 yr after the candidate passed the certifying examination. From its inception, the certificate of added qualifications in pain management was time-limited for 10 yr. This article discusses the rationale for this policy change.
In 1933, the Commission on Medical Education of the American Association of Medical Colleges concluded, "The time may come when every physician may be required, in the public interest, to take continuation courses to ensure that his practice will be kept abreast of current methods of diagnosis and treatment." In 1970, the Carnegie Commission called for formal recertification. The American Board of Medical Specialties (ABMS), of which the ABA is a member, responded in 1973 by passing its first formal resolution on recertification:
"That ABMS adopt in principle, and urge concurrence of its member boards with the policy that voluntary, periodic recertification of medical specialists become an integral part of all national medical specialty certification programs and, further, that ABMS establish a reasonable deadline when voluntary, periodic recertification of medical specialists will have become a standard policy of all member boards."
The purpose of primary certification is "to provide assurance to the public that a certified medical specialist has successfully completed an approved educational program and an evaluation including an examination process designed to assess the knowledge, experience and skills requisite to the provision of high quality patient care in that specialty." [1].
The ABA adopted a plan for voluntary recertification in 1977, to be implemented in 1984. Four arguments in favor of recertification were presented at that time: motivation for continuing education, motivation to maintain practice standards, the ABA's obligation to uphold the public trust through periodic evaluation of its diplomates, and the subtle but real pressure to comply with the 1973 ABMS resolution. In 1980, the ABA became concerned that it was premature to proceed with a recertification program because too much uncertainty persisted regarding the appropriate methods for revalidating the certificate. [2,3]Although the Board accepted recertification as a reasonable concept, three questions could not be resolved to its satisfaction. How is a cognitive recertifying examination structured for diplomates who have limited their practice to specific areas and have become expert in those areas at the cost of more generalized knowledge? How is the expertise and judgment that result from increased experience assessed? How frequently should recertification occur?
Since its establishment, the American Board of Family Practice has required mandatory recertification every 7 yr. Leigh et al. [4]studied the performance of family practice diplomates who were recertified on multiple occasions. A significant decline in performance occurred on each successive recertifying examination. The poorer performance may have been related to a narrowing scope of practice over time, although the individuals may have been competent in their restricted practice. Day et al. [5]compared the performance of physicians who were within 10 yr of completion of training with those who had completed postgraduate training more than 20 yr previously. Performance decreased over time primarily on questions testing new or changing knowledge and not on questions testing stable knowledge.
Several studies support the premise that certification means higher quality patient care and contribute to the view shared by the public and the medical profession that specialty certification represents the "gold standard" of competence. First, Norcini et al. [6]examined the validity of certification by the American Board of Internal Medicine at the time of residency completion. A quantitative clinical competence rating correlated with success in the examination process. Second, Slogoff et al. [7]established that board certification in anesthesiology, although still a surrogate for ideal assessment of clinical skills, correlates with other measures of competence in an anesthesiologist. In this study, all graduating residents considered by the evaluator in their training program to be competent to provide anesthesia care to that evaluator for increasingly complex procedures were 1.6 times more likely to achieve board certification than those who would be permitted to provide anesthesia care to the evaluator only for a less complex operation or none at all. Third, Tanguay et al. [8]reported that training directors predicted success on the written and oral certification examinations in child and adolescent psychiatry with a statistically significant degree of correlation. Finally, Silber et al. [9]studied 5,972 patients having prostate or gallbladder surgery in multiple institutions. Multivariate analysis demonstrated that, in any hospital, the likelihood of recovery or "rescue" from an adverse occurrence correlated most strongly with the proportion of board-certified anesthesiologists in that institution.
As a result of these and other studies, the ABA developed increasing confidence in the validity of certification and recertification processes from a quality of care perspective. The Board also became convinced that there is value in reassuring the public that an anesthesiologist continues to demonstrate the attributes of a consultant in anesthesiology.
In 1993, the ABA implemented voluntary revalidation of the primary certificate, CDQ. [10]The CDQ process includes two main components. The principal component is a credentialling review, which verifies the quality of the current practice of the diplomate. The second component is a secure written examination with two types of questions: one group that tests current, universal, and noncontroversial knowledge and a second group of subspecialty questions relevant to the individual's current practice. Questions outside a diplomate's area of subspecialization need not be answered provided a minimum number of questions are completed. To date, 99% of those taking the CDQ examination have earned certificates.
Confidence in the value of recertification and experience with the CDQ process have led the Board to implement a time-limited certification process for new diplomates of the ABA. All certificates issued by the ABA after January 1, 2000, will expire on December 31 of the 10th year after passing the certifying examination. The CDQ process will continue to serve as voluntary recertification, affording those holding primary certificates without expiration dates the opportunity to demonstrate current knowledge and quality of practice as a consultant anesthesiologist whenever local credentially or state or federal legislation so mandates. Although diplomates holding permanent primary certificates may choose to relinquish them for time-limited certificates once the recertifying process becomes active, no one will be required to do so. Those receiving certificates before January 1, 2000, will retain their primary certificate and may choose to enter the CDQ process at an appropriate interval only for their needs. In summary, those who will or have earned diplomate status before January 1, 2000, have the option of voluntary recertification.
The ABA believes time-limited certification is appropriate to reassure the public that the diplomate continues to demonstrate the attributes of a consultant anesthesiologist. Because continuing medical education (CME) focusing on current clinical practice issues represents a fundamental aspect of the voluntary CDQ and time-limited certification processes, the Board encourages appropriate CME programs to facilitate these activities. Certificate renewal will require credentialling and examination. A careful, rigorous evaluation process at the local level will be used to assess clinical experience, skills, and judgment requisite to the provision of high-quality patient care. A secure written examination, to be administered first in 2008 to allow several opportunities to pass before the time-limited certificate expires, will test knowledge of both the fundamentals of anesthesia practice and appropriate subspecialty material relevant to the individual diplomate's practice profile. To assist in providing a template for ongoing study, the examination will be based on a content outline focused on clinical topics published by the ABA and updated periodically.
The Board intends that this process will meet the goals of the ABA, the ABMS, societal expectations, and governmental and local practice mandates.
