After the establishment of certifying boards and the Advisory Board for Medical Specialties, the physician leaders of these organizations, appreciating their public accountability in issuing specialty certifications, considered best methods for ensuring the continued competence of a board certified practitioner.

For more than 75 years, board certification has been an evaluation performed by ABMS Member Boards and endorsed by the medical profession. This self-generated measure has provided assurance to hospitals and health plans, government and the public that the physicians identified as “board certified” have met specific criteria. Initial certification is based on a one time, snapshot assessment. Though very good, it is not the ongoing process of evaluation and quality improvement that demonstrates a physician’s continued competence and ability to practice state-of-the-art medicine in a specialty. Board certification remains at the heart of the competency movement and, through the years, its process has been studied and revised to incorporate a broader and more comprehensive evaluation of the physician and his or her practice.

At a meeting of the Advisory Board in June 1934 general qualifications were detailed and included statements on a candidate’s moral and ethical standing, possession of a license to practice medicine and membership in the American Medical Association (AMA). Educational requirements consisted of graduation from a medical school approved by the Council on Medical Education of the AMA (AMA/CME) at least one year of internship approved by AMA/CME and three years of study in clinics, dispensaries and laboratories recognized by AMA/CME. The period of special training had to include:

• Intensive graduate training in anatomy, physiology, pathology and other basic medical sciences that were necessary for understanding of the disorders and treatment involved in the specialty in question
• An active experience of not less than 18 months in hospitals, clinics and other diagnostic laboratories recognized by the AMA/CME as competent in the specialty
• Examinations in the basic medical sciences of a specialty as well as in the clinical laboratory and in public health aspects of the specialty
• Two years of practice

At the 1936 Annual Meeting of the Advisory Board, reference was made to a planned meeting of Board Secretaries. Though there are no formal reports of that meeting, one item on the agenda was “Reregistration at Stipulated Intervals.” In a report published by the Commission on Graduate Medicine in 1940, the following paragraph entitled “Time Limit on Certification” is included:

“Many persons argue that certification of a specialist indicates that he is up-to-date and competent at the time of examination but that this does not prove that he continues indefinitely thereafter to be competent and aware of all important new knowledge in his field. This is obviously true and, as the certifying Boards become established and as they complete the examination of the large group of physicians already practicing the specialties, they may find it desirable to issue certificates that are valid for a stated period only.”

In the late 1960s and early 1970s, it became evident that the public was demanding assurance of the continuing competence of physicians. Responses to this public attitude consisted of rather massive expansion of medicine, teaching hospitals and regional and national medical societies. State medical boards began to require attendance by physicians at recognized postgraduate courses or meetings in order to be relicensed at periodic intervals. State medical societies began to require a similar involvement in continuing medical education for continued membership. National medical societies developed self-assessment examinations that served as an educational enterprise to inform physicians of their deficiencies in knowledge in certain areas thought to be important in the practice of medicine at that time.

Recertification

ABMS and the specialty boards responded to the challenge of assuring continued competence by addressing the subject of recertification. In 1969 the Boards of Family Practice and Internal Medicine were the first to develop policies on recertification—the former mandatory, the latter voluntary.

In 1972, ABMS established the Committee on Certification, Subcertification and Recertification (COCERT) to develop general guidelines for a recertification process. Out of the discussions and workshops held by this committee, ABMS adopted a resolution urging the specialty boards to accept a policy that would make voluntary, periodic recertification of medical specialists an integral part of all national medical specialty certification programs and to establish a reasonable deadline for when this will become the standard policy of all Member Boards.

By 1973, the existing 22 boards had adopted the principle of recertification and, in 1975, ABMS provided guidelines on recertification to the specialty boards. By 1980, twelve Boards had received ABMS approval of their recertification plans and, by 1982, nine boards had administered recertification examinations. At this time, six Boards had established time-limited certificates, and by 1995, 21 boards had proposed time-limited certificates requiring recertification at intervals of seven to ten years.

Maintenance of Certification

Recognizing that clinical competence is more than the demonstration of knowledge on a test every seven to ten years or the accumulation of credits for attendance at educational meetings, ABMS began considering ways of restructuring the recertification process to be a more comprehensive evaluation and an ongoing process throughout the course of a specialist’s career.

David L. Nahrwold, MD

The answer revealed itself at the ABMS Executive Committee retreat in January of 1998, where David L. Nahrwold, MD presented a paper that encouraged the development of a system to address the public need for assurance of continued competence and enable all physicians, certified and non-certified alike, to improve the quality of medical care provided and document that improvement as needed for other accrediting and credentialing agencies and organizations.

In March of 1998, ABMS appointed its Task Force on Competence, with Dr. Nahrwold as chair. Under his leadership, the Member Boards came together to plan the implementation of such a system which, when fully functional, would become a better way of evaluating the continuing competence of a certified specialist because it included a method of documenting that the specialist maintained the necessary competencies to provide quality care. The system eventually came to be known as ABMS Maintenance of Certification® (ABMS MOC®), a program where all Member Boards’ certificates are time-limited and physicians holding them must meet a series of requirements during that cycle.

As the idea for ABMS MOC began to develop, it was necessary to establish some basic benchmarks. In 1999, the Description of the Competent Physician was approved by the ABMS Assembly. It stated that the competent physician should possess the medical knowledge, judgment, professionalism and communication skills to provide high-quality patient care which encompasses the promotion of health, prevention of disease and diagnosis, treatment and management of medical conditions with compassion and respect for patients and their families. The Member Boards agreed that maintenance of competence should be demonstrated throughout the physician’s career evidenced by lifelong learning and ongoing improvement of practice.

Being active stakeholders in graduate medical education, ABMS partnered with the Accreditation Council for Graduate Medical Education (ACGME) to develop a common set of six competencies important for all specialists to possess and maintain throughout their professional careers. These competencies are to be developed and/or refined during residency training, evaluated during initial certification and subsequently further refined, updated and reassessed as they participated in programs of maintaining certification.

Six Core Competencies for Quality Patient Care

The Task Force on Competence then concentrated its efforts on developing standards and methods to evaluate physician specialists after initial certification which became the basis of ABMS MOC which was adopted by ABMS and the Member Boards in 2000. ABMS MOC consists of four essential components embedded within the six general competencies. To maintain certification, a diplomate must provide: (1) evidence of professional standing; (2) evidence of commitment to lifelong learning and involvement in a periodic self-assessment process; (3) evidence of cognitive expertise; and (4) evidence of evaluation of performance in practice.

While ABMS guides the process, the Member Boards set the criteria and curriculum for each specialty. In 2006, all Member Boards received approval for their ABMS MOC program plans. The boards are currently implementing these plans.

By following ABMS MOC, physicians demonstrate their commitment to live the standards by which medical care is evaluated and demonstrate leadership in the national movement for healthcare quality and patient safety. Physicians must prove they have practice-related knowledge to provide quality care in the particular specialty. They must also assess the quality of care they provide compared to peers and national benchmarks then apply best practices to improve care.

The ongoing monitoring of certification through ABMS MOC will undoubtedly provide information of interest to everyone about whether a physician is keeping up with the standards of his or her specialty. It can also have dramatic impact on healthcare quality because of the frequency of evaluation and the inclusion of a practice assessment component.

Initial certification by an ABMS board, while necessary to assure the public that a specialist could provide medical care, was seen as insufficient to assure the public that certified specialists maintained the qualifications necessary to continue providing high quality medical care throughout the entire span of their professional lives. While there is little argument that there is an increasingly urgent call for measures of performance and physician accountability, ABMS MOC represents measured, thoughtful and proactive professional involvement in setting quality standards for medical practice. Principles such as those contained in the ABMS MOC program can be at the forefront of the quality medical care movement in the United States.

The information for this history has been compiled by ABMS staff through an examination of ABMS' records and documents. As with all historical reporting, the information we've provided is based on our understanding and interpretation of these records. If you find any factual inaccuracies, please advise us by contacting the Director of Marketing and Communications at (847) 563-4531.