Board Recertification

Author: Harold J. Burstein MD, PhD
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A recent article in The New England Journal of Medicine (N Engl J Med 2010;362:948–952) centered on the pros and cons of board recertification for United States clinicians. A clinical vignette described a middle-aged internist and endocrinologist “grandfathered” by his initial board certifications and asked whether he should register to recertify. The article contained well-crafted arguments for and against recertification.

In favor of recertification are the arguments that maintaining clinical skills is valuable and leads to better care; that the recertification process and content differs from other CME programs; and that the requirements are not unduly burdensome or expensive. The contrary opinion suggests that data proving the worth of recertification as a way to maintain or improve clinical outcomes are lacking; that standardized testing is a weak surrogate for clinical skills or judgment; and that the American Board of Internal Medicine has a functional monopoly on testing programs, feathering the nest of its own foundation by charging clinicians lots of money for the privilege of maintaining a paper (or online) certification.

The journal invited readers to reply, and more than 2000 did. By a 2:1 majority, readers from the United States, United Kingdom, and Australia recommended that the clinician not recertify. In Canada, the vote was 50:50. However, even that tepid endorsement for recertification if grandfathered was vastly in excess of actual practice. American Board of Internal Medicine (ABIM) data suggest that fewer than 1% of clinicians who are grandfathered bother to participate in maintenance of certification.

I have been thinking about all this, because I am in the process of recertification in medical oncology. Alas, I am not grandfathered in and thus must undergo this decennial exercise in board review. My employer requires board certification as a criterion for clinical privileges, so there really is no choice for me, my contemporaries, or my junior colleagues.

I have several observations on maintaining certification in medical oncology. First, it is both time-consuming and expensive. No one has much free time these days, and the task of participating in online review modules and board preparation takes many hours. The costs are high (though the fact that other organizations, such as ASCO, have entered the market to provide services may be reassuring). Second, the process is unnecessarily complicated. You must earn points in 2 separate categories (medical knowledge and practice performance); I had to sit down with an ABIM representative stationed at an educational booth at the ASCO meeting—and then ask multiple colleagues—to clarify how to earn the points. Finally, the practice performance component is unwieldy and of unclear impact.

That said, the process also has obvious strengths. The educational content of board review clearly differs from regular CME as conventionally encountered. Board review has far more emphasis on treatment principles, side effects, symptom control, and data analysis, while, in my experience, CME programs often focus on “what's new?” Provocative phase I data for drugs not yet approved loom large in many CME presentations, even though the study findings may be clinically irrelevant or premature. Board review appropriately minimizes fads. Also, I have found it valuable to “bone-up” on diseases that I don't usually treat and treatments that I don't usually give. As a breast cancer specialist, I can all too easily lose sight of advances in other areas of oncology, and I appreciate the chance to see the progress that has happened elsewhere.

So, put me in the camp that says there is educational value to board recertification but that the process needs ongoing refinement. As to whether someone who is grandfathered should take the test, I vote “yes.” In fact, I cannot see the ethical or professional stance that supports the existence of grandfathering as an option. If recertification is required for anyone, it should be required for all.

Just wish me luck on the test.

The ideas and viewpoints expressed in this editorial are those of the author and do not necessarily represent any policy, position, or program of the NCCN.

Harold J. Burstein, MD, PhD, editor-in-chief of JNCCN, is an Associate Professor of Medicine at Harvard Medical School and a medical oncologist at Dana-Farber Cancer Institute and Brigham & Women's Hospital. He is a clinician and clinical investigator specializing in breast cancer.

Dr. Burstein attended Harvard College and earned his MD at Harvard Medical School, where he also earned a PhD in immunology. He trained in internal medicine at Massachusetts General Hospital and was a fellow in medical oncology at Dana-Farber before joining the staff.

Dr. Burstein's clinical research interests include novel treatments for early- and advanced-stage breast cancer and studies of quality of life and health behavior among women with breast cancer. He has written widely on breast cancer in both traditional medical journals and on the web, including New England Journal of Medicine and Journal of Clinical Oncology. International committees focusing on cancer treatments that he has or continues to participate in include the NCCN Clinical Practice Guidelines Breast Cancer Panel, St. Gallen Breast Cancer Panel, CALGB Breast Cancer Committee, ASCO Health Services Research and Clinical Research Committees, the National Quality Forum Breast Cancer Technical Panel, and other ASCO expert panels.

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