Standards for Initial Certification

Initial Certification incorporates the six ABMS/ACGME Core Competencies of Practice-based Learning & Improvement; Patient Care & Procedural Skills; Systems-based Practice; Medical Knowledge; Interpersonal & Communication Skills; and Professionalism, and has an integrated three-part framework that addresses 1) Professional Standing and Professionalism; 2) Training; and 3) Assessment of Knowledge, Skills, and Judgment. The Standards for ABMS Initial Certification are common across the ABMS Member Boards while accommodating differences among the specialties.

In 1933, representatives from the founding specialties (of Dermatology, Obstetrics and Gynecology, Ophthalmology, and Otolaryngology) and the major physician, hospital, medical education, and examination groups of the time met to talk about the education and certification of medical specialists. Together, they were inspired to build a national system of standards for recognizing specialists and providing information to the Public.

Consensus was reached to establish a uniform system for specialty boards to administer examinations developed by experts from within the specialty. The group further concluded that the value of these boards would be maximized by establishing an advisory committee or counsel created by the representatives from the official specialty boards. The result was the formation of the Advisory Board for Medical Specialties (today’s ABMS) – which created the framework for standards of excellence in the various specialties that physicians pursue and upon which the Public relies.

In order to assure the Public of their ability to stay current in their knowledge and skills, physicians seek certification and continue to meet standards for continuous learning and assessment throughout their professional careers. The process of certification, once involving occasional continuing medical education courses and periodic assessment, now involves an ongoing cycle of learning and assessment. It places a greater emphasis on professionalism, patient safety, and performance improvement.

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The Six Core Competencies, adopted by ABMS and ACGME in 1999, are recognized as integral to quality patient care. The following are brief descriptions of the competencies.

The competency Practice-based Learning & Improvement refers to the candidate’s ability to investigate and evaluate patient care practices, appraise and assimilate scientific evidence, and improve the candidate’s own practice of medicine, the collaborative practice of medicine, or both.

The competency Patient Care & Procedural Skills refers to the candidate’s use of clinical skills and ability to provide care and promote health in an appropriate manner that incorporates evidence-based medical practice, demonstrates good clinical judgment, and fosters patient-centered decision-making.

The competency Systems-based Practice refers to the candidate’s awareness of, and responsibility to, population health and systems of health care. The candidate should be able to use system resources responsibly in providing patient care (e.g., good resource stewardship, coordination of care).

The competency Medical Knowledge refers to the candidate’s demonstration of knowledge about established and evolving biomedical, clinical, and cognate sciences, as well as the application of these sciences in patient care.

The competency Interpersonal & Communication Skills refers to the candidate’s demonstration of skills that result in effective information exchange and partnering with patients, their families, and professional associates (e.g., fostering a therapeutic relationship that is ethically sound; using effective listening skills with nonverbal and verbal communication; being mindful of health literacy; and working effectively in a team both as a team member and as a team leader).

The competency Professionalism refers to the candidate’s demonstration of a commitment to carrying out professional responsibilities; adhering to ethical principles; applying the skills and values to deliver compassionate, patient-centered care; demonstrating humanism; being sensitive to diverse patient populations and workforce; and practicing wellness and self-care.

ABMS Member Boards should integrate learning and assessment of the six competencies throughout their process for Initial Certification in a manner that best serves the needs of patients cared for by diplomates, and that is relevant to the practice of their respective specialties and to the specific type of practice of a candidate. As appropriate, the component parts of the process for Initial Certification should harmonize with each other.

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To achieve initial certification in a specialty, candidates must be in good standing professionally; they must have satisfactorily completed a rigorous program of education and training with assessment of competencies in the training environment, and they must have passed the Member Board’s assessment of knowledge, judgment, and skills. While the program director and faculty should assess all competencies, they have special opportunities to assess those competencies that can be observed in the workplace over time by multiple assessors.

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The eligibility of a candidate to become Board Certified by an ABMS Member Board is directly related to the recency of completion of an ACGME-accredited residency program (or its equivalent). It is not in the best interests of the medical specialty, the credentialing community, patients or the Public for the status of “Board Eligible” to remain open for an indeterminate period. Allowing an indefinite period of “Board Eligibility” denigrates the achievement of those diplomates who have already achieved Board Certification.

“Board Eligibility” only applies to the period of time between a physician’s completion of training and achievement of Initial Certification in a specialty.

In individual instances and for good cause (e.g., military deployment, acute illness), an ABMS Member Board may waive its Board eligibility rules for a candidate.

Additionally, Member Boards should establish well-defined, transparent, and equitable pathways for candidates to re- establish Board eligibility should they not achieve certification during their initial eligibility period.

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The ABMS Member Boards serve the Public through developing and implementing rigorous and relevant Standards for Initial Certification; these Standards also serve the Profession. ABMS Member Boards should be sensitive to advances in residency and fellowship training in their standards design and implementation.

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ABMS Member Boards will identify professionalism expectations for all candidates for Initial Certification. An ABMS Member Board’s professionalism expectations may be articulated in documents developed or adopted by the ABMS Member Board.

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Consistent with the ABMS Minimum Standards for Full and Unrestricted License Policy, at the point of application for Initial Certification, possession of a valid and unrestricted license to practice medicine indicates that the State Medical Board views a candidate’s behavior as consistent with the jurisdiction’s expectations for professionalism and provision of patient care, and has not identified any issues that justify taking an action against a candidate’s license. Hence, this is an appropriate screening mechanism. ABMS Member Boards may, but generally do not, act as the “first investigator” of complaints about a candidate. In some instances, actions taken against a candidate’s medical license by a State Medical Board should result in a determination of ineligibility for board certification. In other instances, actions taken against a candidate’s medical license by a State Medical Board should not necessarily preclude eligibility for board certification. ABMS Member Boards will appropriately balance their primary obligation to the Public with obligations of fairness and due process to candidates.

ABMS Member Boards with non-physician candidates should establish appropriate mechanisms to address actions taken against the professional licenses of these candidates.

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Each ABMS Member Board will establish training requirements for Initial Certification and determine which programs meet the Board’s requirements. Requiring association with the ACGME-accredited residency or fellowship program helps assure ABMS Member Boards that candidates have developed the skills, knowledge, and attitudes for proficiency in all the domains of clinical competency through the assumption of personal responsibility for the care of individual patients under the guidance and supervision of faculty members. Association with an ACGME-accredited residency or fellowship program also ensures that training environments include attention to patient safety and quality improvement.

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Among others, examples of common alternate training pathways to Initial Certification include acceptance of training at international graduate medical education programs deemed to meet the standards of the ABMS Member Board.

Member Board policies and procedures related to approval of candidates from alternate training pathways should not be perceived as arbitrary or capricious; they should be transparent, fair, objective, and equitably available to candidates with comparable credentials.

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The content covered by the components of the Initial Certification process should be clearly defined and justified in terms of the importance of the content for certification-worthy performance in the specialty, focusing on the knowledge and skills necessary for safe and effective practice.

Member Boards may choose to include more than one examination component (eg, a written and an oral examination; multiple written examinations taken at different stages of training). Design of the examination components should reflect careful consideration of the content and skills to be assessed, whether one or a series of examination components is to be used, when each component may be taken, and how scores on components are to be combined to reach an overall certification decision. To the extent possible, the examination components, taken together, should span the core content, judgment, and skills required for safe and effective practice of the specialty, demonstrating that successful candidates have mastered core knowledge of the specialty and shown they can apply that knowledge in patient care. Professionalism in development, administration, and scoring of all examination components is critical.

To ensure the appropriateness and currency of the certification program, a Member Board should review its examination program on an ongoing basis, revising the overall design for and content covered on individual examination components to reflect the evolution of medical knowledge and clinical practice. When substantial revisions are made to the overall examination or to an examination component, Member Boards should inform candidates about the modifications sufficiently in advance for candidates to prepare for the revised examination.

To aid in monitoring and improving the quality of examinations, Member Boards should track the performance of candidate groups over time (eg, counts and pass rates for first-time and repeat examinees from US/Canadian and international medical schools) and review those reports for trends, anomalous results, and outliers. From a similar perspective, Member Boards should adopt appropriate quality improvement procedures to ensure the appropriateness of content coverage on individual examination components and the relevance, accuracy, fidelity, and currency of test material as medical knowledge and clinical practice evolve.

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The purpose and content of each examination component should be defined clearly and justified in terms of importance for current and future practice. To provide an empirical basis for defining the content, Member Boards may wish to perform some type of job analysis, practice analysis, and/or surveys of training program faculty and the broader educational community, practitioners, or other groups; such studies should be coupled with expert judgments about the relative importance of different patient problems and clinical tasks in the practice of the specialty.

Procedures used to score the examination, as well as those used to combine scores on different parts of an examination component to determine overall pass/fail outcomes, should be well-defined and made available to candidates before test administration.

The level of performance required to pass an examination component should be determined by careful analysis and should depend on the knowledge and skills necessary for certification-worthy performance in the specialty. Generally, this will include a periodic review of the pass/fail standard and a structured standard-setting exercise. The pass/fail standard should not be determined to control the number or proportion of persons passing the examination. When alternate forms of an examination are used within or across administrations, the forms should be equivalent from content and psychometric perspectives, and the same level of performance should be required to pass each of the forms.

Each examination component for which a pass/fail decision is reported should be of sufficient length that the same pass/fail decisions would be made for most candidates if they were retested using an equivalent, but not identical examination; appropriate indices of reproducibility (e.g., reliability coefficients, standard errors of measurement, decision consistency) should be estimated for each form and each administration to ensure that this is the case.

Member Boards conducting oral and other subjectively-graded performance-based examinations should provide training to examiners participating in the examination. They should also ensure that each candidate is assessed on a sufficient number of cases by a sufficient number of examiners to obtain reproducible pass/fail decisions and should take steps to ensure that candidates are not disadvantaged based on gender, ethnicity, or other factors unrelated to examination performance.

When possible, to assist candidates in remediating weaknesses identified by an examination component, individual candidates should be provided with feedback on performance that provides meaningful information about areas of strength and weakness without compromising examination security.
Once scores are released, Member Boards should have policies and procedures in place for candidates to request score verifications and for handling appeals.

¹These are articulated in the 2014 edition of the Standards for Educational and Psychological Testing published by the American Education Research Association, the American Psychological Association, and the National Council on Measurement in Education. Chapter 11 on Workplace Testing and Credentialing is particularly relevant.

Test accommodations must be offered to candidates with documented disabilities (e.g., learning and reading disabilities; physical disabilities; visual impairments) to comply with the Americans with Disabilities Act; Member Boards may also offer accommodations in other situations (e.g., extra break time for nursing mothers). Applicants should be provided with information describing the documentation to be submitted with the request for accommodations and the timeframe within which an accommodation decision will be made. Procedures for responding to these requests should be equitable and consistent and should include a mechanism for handling candidate appeals of these decisions.

Member Boards should have well-defined policies in place for dealing with suspected irregularities in test administration. These should include a procedure for handling candidates’ appeals of these decisions.

²Additional information can be found in the 2014 edition of the Standards for Educational and Psychological Testing published by the American Education Research Association, the American Psychological Association, and the National Council on Measurement in Education.