January 13, 2016

Lois M. Nora MD JD MBA
President and CEO
American board of Medical Specialties

Dear Dr. Nora,

CMSS is pleased to comment on the proposed ABMS Standards for Initial Certification. We have uploaded our comments electronically, but are putting them together here as an added resource for ABMS.

GS-1. Each ABMS Member Board’s Standards for Initial Certification will incorporate all six ABMS/ACGME Core Competencies: Practice-Based Learning & Improvement; Patient Care & Procedural Skills; Systems-based Practice; Medical Knowledge; Interpersonal & Communication Skills; and Professionalism.

We applaud ABMS for recognizing the need for a consistent set of standards across the 24 independent medical and surgical boards as these boards engage in a process to certify the competencies of physicians to practice medicine and surgery. These standards will equalize but not dictate “a rigorous and relevant process for Initial Certification that assesses the knowledge, skills, and professionalism of candidates…”

Integrating these competencies into graduate medical education and assessing their achievement through the application of the Accreditation Council for Graduate Medical Education (ACGME) Next Accreditation System’s milestone and entrustable professional activities (EPA) processes will move healthcare forward in the care of patients and establish a national threshold for the public’s trust.

 GS-2. Multiple methods of assessment, learning, and improvement can be utilized effectively within the process for Initial Certification and should include assessment of competencies other than Medical Knowledge by the program director and other faculty in the training environment.

We would caution ABMS and the 24 boards to respect and cooperate with other credible organizations, such as ACGME and specialty organizations, whose oversight is the training, assessment, and matriculation of physicians with regard to the individual physician’s successful demonstration of competence.

We believe that the primary certification process related to knowledge, skills and attitudes should rely on the concept of Entrustable Professional Activities (EPAs). EPAs delineate the tasks that define the profession and what is required after training for a clinician to be ready for independent practice. We do understand that after training there may be divergence in specialty and expertise but at the completion of training, in preparation for taking a certification test, we do believe that all trainees in a specialty should have competence in each of the EPAs for the specialty.

 GS-3. Each ABMS Member Board will determine criteria for eligibility, including the expiration date for the Board Eligible period. The expiration date must be no fewer than three and no more than seven years following the successful completion of accredited training, and in accordance with the corresponding Member Board requirements, plus time(if any) in practice required by the Member Board for admission to the certifying examination.

Whatever the criteria that a member Board determines will make a candidate eligible for initial certification, that Board should recognize the rigor and assessment performed during an ACGME accredited training program. The Board should not establish additional, onerous criteria on top of already established ACGME assessment milestones.  A rational period of time should be available to the physician to gain experience in patient care, prepare for certification, and become confident in her/his professionalism, skills, and judgment before engagement in the board certification process.

 GS-4. Each ABMS Member Board will work to maintain the value of Initial Certification to the Public and profession through systematic efforts to evaluate and improve their programs to reflect advances in medical practice and assessment methodology. These efforts should seek to increase program quality, relevance, and meaningfulness while remaining sensitive to the time, administrative burden, and costs (monetary and other) to candidates and training programs.

 We caution ABMS and Member Boards to respect and cooperate with other credible organizations which are in the training and assessment of physicians. Each Board should work to blend innovative processes and tools to maintain and increase the value of initial certification with better time management, creative administration, and reduced costs especially to candidates.

 PPS-1. Each ABMS Member Board will identify and convey that Board’s professionalism expectations to its candidates for Initial Certification.

 We support this standard.

 PPS-2. Each ABMS Member Board will have a process in place to consider the circumstances of an action taken against a candidate’s license by a State Medical Board or other determination of unprofessional conduct by an appropriate authority and to respond appropriately.

We encourage Boards to establish and announce their position on common actions taken against a candidate so that an adverse response to a candidate by a Board does not seem arbitrary or capricious.

 T-1. Each ABMS Member Board will establish requirements for training and document that candidates have met these requirements prior to awarding initial general or subspecialty certification. ABMS Member Boards’ training requirements should address duration and quality by specifically requiring that the total training time for general certification must be for a minimum of three years, training for subspecialty certification must be for a minimum of one year, and training programs must be associated with a residency accredited by the Accreditation Council for Graduate Medical Education (ACGME).

Boards should strive for compatibility with established training and documentation requirements rather than establishing requirements that are outside of the accepted training program requirements as set by ACGME. These additional requirements may add confusion, burden, and cost to training institutions and candidates.  As medical education moves from time-based training to competency-based training, it may be possible that a candidate will achieve these competencies in less than three years.  This standard should allow room for pilot programs of competency-based progression that are beginning to be implemented. ABMS should also recognize the validity of successful special research pathways which alter training time. Competency, rather than time, is key.

 T-2. Member Boards may choose to recognize alternate pathways to Initial Certification for candidates who have not completed residency training programs accredited by the Accreditation Council for Graduate Medical Education (ACGME).

 We appreciate ABMS’ recognition that one-size does not fit all. Boards may wish to consider working with the ACGME to identify and vet these alternative pathways in an effort to establish parity between the alternative pathway and an ACGME training experience. This effort should also support GS-4.

 KJS-1. Initial Certification by an ABMS Member Board provides patients, health care organizations, and the profession with a dependable mechanism for identifying specialists who have met standards for the specialty. This requires an assessment of candidates’ mastery of the core knowledge, judgment, and skills in the specialty.

The standard is reasonable in that ongoing review of the assessment program is essential.

The standard is good in that it includes language about how medicine can change with new knowledge, e.g. the KJS-1 annotation concludes “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.” “Evolve” is a great word to include.

 KJS-2. Examination procedures should reflect accepted educational standards for test design, development, administration, reliability, validity, fidelity, scoring, and reporting.

 We suggest that an analysis of practice is an opportunity to involve the broader educational community involved in training and assessment including specialty societies. A job analysis conducted by a single entity might not capture all the nuances of knowledge, judgment, and skills used by the physician specialist.

 KJS-3. Test administrations should be conducted in a manner that ensures that 1) the identified test-taker is, in fact, the person who is taking the test; 2) materials and other assistance used during the examination are limited to those provided or approved by the ABMS Member Board; 3) actual test content is protected and secure; and 4) information about test content is not shared by examinees, examiners, or anyone else associated with the examination unless specifically approved by the Member Board.

We support this standard.

Thank you for inviting input early in the process of adapting standards for initial certification to changing times. CMSS is pleased to comment on behalf of our 44 member societies which represent, in the aggregate, 750,000 physicians in the US.

Sincerely,

Dr. Kahn Signature

Norman Kahn, MD
Executive Vice President & CEO