Gerald K. Arnold

Who Is Maintaining Certification in Internal Medicine—and Why? A National Survey 10 Years after Initial Certification

Context Maintenance of certification (MOC) by the American Board of Internal Medicine (ABIM) requires participation in its Continuous Professional Development program. Understanding the attitudes and perceptions of internists regarding the MOC process would be helpful in increasing participation in quality improvement efforts. Contribution Diplomates whose ABIM certificates were dated to expire by December 2002 were surveyed regarding reasons for participating or not participating in the program. The most common reasons for participation were to improve professional image and to update knowledge. Nonparticipants perceived MOC as too time-consuming. Implications In general, physicians seem to value the MOC process for its effort to improve quality of care and patient safety. The Editors Improving the quality of patient care dominates the health care agenda (1-4). Recently, a great deal of attention has focused on redesigning health care delivery systems to make them more fail-safe, but there is no denying that state-of-the-art knowledge on the part of the individual physician remains a key factor in ensuring quality care (5). Professional societies and certifying boards exist to improve and assess the quality of health care provided by an individual physician. Professional societies, such as the American College of Physicians (ACP), provide continuing education to translate medical knowledge into best practices and strive to foster excellence and professionalism in the practice of medicine. The 24 certifying boards of the American Board of Medical Specialties (ABMS) now issue time-limited certificates to physicians who meet rigorous standards through a process that recognizes that medical knowledge and practice must be renewed to demonstrate ongoing competence in an environment with rapidly changing medical information and technology (6-9). The American Board of Internal Medicine (ABIM), the ABMS certifying board that issues the largest number of certificates, offers certificates in general internal medicine, 9 subspecialties, and 5 areas of added qualifications. In 2002, the ABMS adopted a framework in conjunction with the Accreditation Council for Graduate Medical Educations Outcome Project (10) and the General Competencies Project (11) for all boards to evaluate physician competence at the conclusion of training (initial certification) and throughout their careers (Maintenance of Certification [MOC]). The overarching goal for certification and MOC is to protect the public and patients by attesting to the quality, safety and effectiveness of U.S. medical practitioners (6). In the 1970s and 1980s, the ABIM had a program for voluntary recertification of lifetime certificates, which drew relatively few participants. Consequently, in 1990, the ABIM began issuing certificates with a 10-year duration. These certificates must be renewed through the MOC program to remain valid. The ABIMs MOC program, called Continuous Professional Development (CPD), began in 1995. As of December 2003, 77% of physicians holding 10-year certificates in internal medicine only (general internists) had enrolled in the program. Eighty-six percent of physicians with 10-year certificates in both internal medicine and a subspecialty or added qualifications (subspecialists) enrolled in the program for their subspecialty, and 60% of this same cohort enrolled for their internal medicine certificate. Because board-certified physicians (called diplomates) lose their certification status after 10 years, both the ABIM, who administers the program, and ACP, whose membership encompasses approximately 119000 internal medicine generalists, subspecialists, and students, wished to understand why 23% of general internists and 40% of subspecialists are not renewing their internal medicine certificate and why 14% of subspecialists are not renewing their subspecialty or added qualifications certificate. Because little is known about the forces that drive participation in MOC, the ABIM and ACP conducted a national survey of ABIM diplomates who earned certificates in internal medicine, a subspecialty, or an area of added qualifications in 1990, 1991, or 1992. This group represents an early cohort of diplomates with 10-year certificates who had had sufficient time to renew them. This study aimed to identify factors that influence participation in MOC and explore how diplomates perceive the value of the MOC process. We describe practice characteristics, perceptions, and attitudes about MOC and reasons for maintaining or not maintaining certification. We compare attitudes of general internists with those of subspecialists and of diplomates who have completed, have enrolled in but have not completed, or have never enrolled in MOC. We conclude with implications for MOC programs and the quality movement. Methods Program Description The ABIMs MOC program has 3 components: 1) verification of credentials, 2) proctored examination, and 3) self-evaluation (12). Verification of credentials means physicians must have a valid and unrestricted license and provide a recommendation from an officer of a hospital or health care organization about their professional standing in the community. The proctored examination measures medical knowledge in a discipline, requires a passing grade, is given at computer testing sites, and may be taken as early as 5 years before a certificate expires. Self-evaluations encourage lifelong learning in medical knowledge or skills and practice-based performance and improvement. During the period of the study, most diplomates completed self-evaluations consisting of open-book, take-home modules of 60 multiple-choice questions in internal medicine, a subspecialty, or an area of added qualifications. As the MOC program evolves, there are a greater number of options and more flexibility. Physicians are encouraged to complete the program over 10 years. Continuing medical education (CME) credit accompanies successful completion of the proctored examination and self-evaluation modules. On average, diplomates receive 120 CME credits for completing the program requirements (ABIM internal report, November 2004. Unpublished data.). Study Design and Participants The sampling frame of 23108 diplomates included those initially certified by ABIM in 1990 or afterward whose certificate would expire by December 2002. These diplomates held a total of 24344 time-limited certificates as of 24 February 2004. To ensure a representative sample of participants who completed the MOC, each diplomate was assigned to 1 of 39 internal medicine, subspecialty, or added qualifications groups on the basis of the certificate or certificates earned in 1990, 1991, or 1992; the kind of MOC sought; and status in MOC at the time of the survey. The 3 kinds of MOC include 1) general internists eligible to renew a time-limited internal medicine certificate5898 diplomates who earned an internal medicine certificate in 1990, 1991, or 1992 and no other certificates in later years; 2) subspecialists eligible to renew a time-limited internal medicine certificate7367 diplomates who earned an internal medicine certificate in 1990, 1991, or 1992 and a subspecialty or added qualifications certificate in later years; and 3) subspecialists eligible to renew a time-limited subspecialty or added qualifications certificate9843 diplomates who earned a subspecialty or added qualifications certificate in 1990, 1991, or 1992 (most possess an internal medicine certificate without an expiration date). Status in MOC was also divided into 3 categories: 1) 13455 physicians who completed the program, 2) 3656 who enrolled but had not completed the program, and 3) 5997 who had never enrolled. Diplomates who could have enrolled for multiple areas (for example, diplomates who earned an internal medicine and 2 different subspecialty certificates) were randomly assigned to 1 of their possible groups. A stratified random sample of 3500 diplomates was selected so that percentage-point estimates within each kind or status group would have only a 5% margin of error. Some subspecialty groups were oversampled to ensure a 95% probability of collecting responses from at least 2 physicians in each group. Those not enrolled in MOC were oversampled because they were regarded as being less likely to respond. Sample size requirements and oversampling rates were determined by using the Power Analysis and Sample Size (PASS 2000) software (13) and the PROBHYPR (cumulative hypergeometric function) in SAS, version 9.0 (SAS Institute, Cary, North Carolina). Detailed analyses of the 95% CIs for all estimates show that the accuracy of the primary estimates was within the range limits originally planned for the study. (Sample size calculations used in the planning stage of the study were based on the assumption that survey percentage estimates around 50% would have 95% CIs of 5 percentage points [that is, 10% of the estimate]. As expected, the median 95% CI for estimates between 45% and 55% [n= 88] was 5% with a range of 2% to 12%. For estimates ranging between 25% and 75% [n= 552], the median 95% CI was 6% with a range of 2% to 18% based on an estimate of 50%. Of primary concern was precision of estimates related to the major objectives of the study. These estimates [n= 478] were taken from the questions related to the reasons why physicians did or did not participate in the MOC program [questions 4, 5, 11, and 12] and whether physicians planned to participate in future MOC programs [questions 6 and 13]. The median 95% CI for these survey objectives estimates based on a sample estimate of 50% was 6% with a range of 1% to 85%.) Survey data were collected between mid-March and 6 August 2004. A prenotification letter was sent to the entire sample on 2 March 2004. A 4-page self-administered questionnaire was mailed on 12 March 2004, followed by a postcard reminder on 19 March, second and third questionnaires on 22 April and 7 June, respectiv

The comprehensive care project: measuring physician performance in ambulatory practice.

OBJECTIVE To investigate the feasibility, reliability, and validity of comprehensively assessing physician-level performance in ambulatory practice. DATA SOURCES/STUDY SETTING Ambulatory-based general internists in 13 states participated in the assessment. STUDY DESIGN We assessed physician-level performance, adjusted for patient factors, on 46 individual measures, an overall composite measure, and composite measures for chronic, acute, and preventive care. Between- versus within-physician variation was quantified by intraclass correlation coefficients (ICC). External validity was assessed by correlating performance on a certification exam. DATA COLLECTION/EXTRACTION METHODS Medical records for 236 physicians were audited for seven chronic and four acute care conditions, and six age- and gender-appropriate preventive services. PRINCIPAL FINDINGS Performance on the individual and composite measures varied substantially within (range 5-86 percent compliance on 46 measures) and between physicians (ICC range 0.12-0.88). Reliabilities for the composite measures were robust: 0.88 for chronic care and 0.87 for preventive services. Higher certification exam scores were associated with better performance on the overall (r = 0.19; p<.01), chronic care (r = 0.14, p = .04), and preventive services composites (r = 0.17, p = .01). CONCLUSIONS Our results suggest that reliable and valid comprehensive assessment of the quality of chronic and preventive care can be achieved by creating composite measures and by sampling feasible numbers of patients for each condition.

Where Have All the General Internists Gone

ABSTRACTBackgroundA shortage of primary care physicians is expected, due in part to decreasing numbers of physicians entering general internal medicine (GIM). Practicing general internists may contribute to the shortage by leaving internal medicine (IM) for other careers in and out of medicine.ObjectiveTo better understand mid-career attrition in IM.Design and ParticipantsMail survey to a national sample of internists originally certified by the American Board of Internal Medicine in GIM or an IM subspecialty during the years 1990 to 1995.Main MeasuresSelf-reported current status as working in IM, working in another medical or non-medical field, not currently working but plan to return, or retired; and career satisfaction.Key ResultsNine percent of all internists in the 1990–1995 certification cohorts and a significantly larger proportion of general internists (17%) than IM subspecialists [(4%) P < 0.001] had left IM at mid career. A significantly lower proportion of general internists (70%) than IM subspecialists [(77%) (P < 0.008)] were satisfied with their career. The proportion of general internists who had left IM in 2006 (19%) was not significantly different from the 21% who left in 2004 (P = 0.45). The proportion of general internists who left IM was not significantly different in earlier (1990–92; 19%) versus later (1993–95; 15%) certification cohorts (P = 0.15).ConclusionsAbout one in six general internists leave IM by mid-career compared to one in 25 IM subspecialists. Although research finds that doctors leave medicine because of dissatisfaction, this study was inconclusive about whether general internists left IM in greater proportion than IM subspecialists for this reason. A more likely explanation is that GIM serves as a stepping stone to careers outside of IM.

A three-part model for measuring diabetes care in physician practice.

Background To assess the psychometric properties of the three components of the Diabetes Practice Improvement Module, to compare reliabilities of composites to individual measures, and to identify associations among practice-based and patient-based measures. Method Data include practice systems surveys of 626 physicians, 13,965 chart audits, and 12,927 patient surveys. Quality composites were identified using factor analysis. Means with reliabilities (intraclass correlation coefficient [ICC] and Cronbach’s α) are reported. Associations among patient-based quality measures and practice measures with case-mix adjustments were estimated via hierarchical models. Results Composite ICCs range from 0.11 to 0.54, and single items range from 0.05 to 0.49. Staff communication, efficiency, care access, and patient knowledge correlate with patient satisfaction (P < .001). Clinical outcomes are associated with clinical processes (e.g., annual foot exam) and appropriate treatment (P < .001). Patient adjusters (e.g., overall health or factors limiting self-care) are important for the models; physician characteristics used (e.g., age, practice size) seem less important. Conclusions Composites require smaller patient sample sizes and result in more reliable measures than do individual items. Additionally, the data show meaningful relationships between composites; physician-directed components (i.e., clinical processes and treatments) are related to clinical outcomes, and patients are clearly more satisfied with care if it is easily accessible and if communication about care is good.

Does Having Open Access to Care Improve Patient Experience? A Case-Control Study

This study investigated whether primary and specialist care practices utilizing open access to care (OA) receive better patient experience scores than propensity-matched control practices without OA. From March 2010 to December 2014, 711 physicians classified as having OA in their practice, indicated by scoring 15 or higher on the OA checklist, were propensity matched to practices without OA. Patient experience was measured with 5 composites: timely care, communication, staff quality, care coordination, and overall physician rating. Minimally important differences in patient experience ratings were calculated between OA and control practices to determine optimal OA checklist scores. OA positively affected most composite domains for specialist practices, except physician rating, but minimally affected primary care practices. Practices scoring 19 or higher on the OA checklist had significantly higher patient-experience scores than matched controls. The authors recommend practices strive for 20 or higher on the OA checklist to see significant improvements in patient experience ratings.