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Shaping the Future: Maintenance ofBoard Certification and Quality Care

Robert R. Hattery, MDa, N. Reed Dunnick, MDb

This review is a summary of a presentation at the 2005 Intersociety Conference on training for the future ofradiology. Certification by all 24 boards of the American Board of Medical Specialties, including the AmericanBoard of Radiology (ABR), has changed significantly. All primary and subspecialty certificates issued by theABR are currently limited to 10 years, and diplomates of the board must maintain their certification bycompleting the ABR’s maintenance of certification (MOC) program. The program consists of 4 components(professional standing, lifelong learning and self-assessment, cognitive expertise, and practice performance) and6 competencies (medical knowledge, patient care, interpersonal skill, professionalism, practice-based learningand self-improvement, and systems-based practice) that are the key elements to be incorporated within theconcepts of continuous quality improvement. The result, over time, is intended to have a major impact in thequality of patient care in terms of outcomes and best practices. How adults learn in the environment ofexpanding knowledge and the electronic distribution of content is a substantive question requiring research,data, and change. We must seize the opportunity to explore adult learning and the process of MOC. Time-limited certification and MOC can become catalysts for future training requirements, for the design of trainingpathways, and for certification methodologies. Shaping the future is a noble task requiring leadership, vision,patience throughout change, and creativity.

Key Words: Maintenance of certification, 4 components, 6 competencies, adult learning, change in trainingpathways

J Am Coll Radiol 2006;3:867-871. Copyright © 2006 American College of Radiology

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he topic of the 2005 Intersociety Conference, trainingor the future of radiology, was especially pertinent to thearadigm shift in lifelong learning and board certifica-ion. The quality of health care in the United States isnder intense scrutiny. In 1999, the report of President’sdvisory Commission on Consumer Protection anduality in the Health Care Industry [1], Quality First:etter Health Care for All Americans, recommended steps

o provide a national commitment to improving healthare quality. A study of hospitalized patients in New Yorktate found that 3.7% experienced adverse events, ofhich 13.6% led to death and 2.6% to permanent dis-

bility [2]. Approximately one fourth of these eventsere due to negligence.The 2000 Institute of Medicine [3] publication To Err

s Human extrapolated data from 2 reports and suggestedhat between 44,000 and 98,000 Americans die fromedical errors each year. Even if the lower number is

American Board of Radiology, Tucson, Ariz.

University of Michigan, Ann Arbor, Mich.

Corresponding author and reprints: Robert R. Hattery, MD, Americanoard of Radiology, 5441 East Williams Blvd, Tucson, AZ 85711; e-mail:

lhattery@theabr.org.

2006 American College of Radiology091-2182/06/$32.00 ● DOI 10.1016/j.jacr.2006.03.011

sed, medical errors would be the eighth leading cause ofeath in the United States [4]. In its 2001 publicationrossing the Quality Chasm: A New Health System for the1st Century, the Institute of Medicine [5] urged funda-ental change to close the quality gap.These problems in the quality of health care delivered

n the United States are not due to inadequate funding.n 2003, the United States spent 15.3% of its grossomestic product on health care, far more than is spent inestern Europe and Japan [6] and about twice what is

pent on education [7]. Furthermore, these health carexpenses continue to rise and are expected to reach8.7% by 2014 [6].The focus on the quality of health care is widespread.rganizations such as the Joint Commission on Accred-

tation of Healthcare Organizations and the Nationalommittee for Quality Assurance are actively promotinguality initiatives. Third-party payers are consideringechanisms whereby physicians who demonstrate qual-

ty are rewarded with increased reimbursement (“pay forerformance”) [8], and the Federation of State Medicaloards is considering the maintenance of certification

MOC) as a part of a discussion of the maintenance of

icensure. To maintain the privilege of self-regulation, we

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868 Journal of the American College of Radiology/Vol. 3 No. 11 November 2006

ust evaluate and improve our educational and certifi-ation processes so that the public has confidence in ourrofession. The public and our patients want better ac-ess to care, competent physicians, fewer medical errors,mproved quality, and less variation in the quality of carehey receive.

The mission of the American Board of RadiologyABR) is “to serve patients, the public, and the medicalrofession by certifying that its diplomates have ac-uired, demonstrated, and maintained a requisite stan-ard of knowledge, skill and understanding essential tohe practice of diagnostic radiology, radiation oncology,nd radiologic physics.” Primary certification and sub-pecialty certification, licensure, and the maintenance ofime-limited board certification are recognized by ouratients, hospital credentialing committees, private prac-ice groups, and the public as essential elements that arendicators of quality care provided by diplomates of theBR [9]. However, the processes of adult learning and

esting used in the past are no longer considered satisfac-ory. The paradigm shift in certification of physiciansow underway in American medicine is being fueled byomplex forces that demand change.

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he goals of the ABR’s MOC program are to ensure thatnitial board certification and the maintenance of thatertification will serve as indicators of quality and will beccepted as such by third-party payers, organizations thatonitor the quality of care, and the public; support the

uality improvement model; facilitate and documentontinuous professional development and patient caremprovement; recognize the diversity of practice; fosterelf-direction related to diplomates’ practice and self-ssessments; and encourage formal and informal lifelongearning and continuous practice improvement.

The American Board of Medical Specialties has man-ated that all 24 of its member boards issue time-limitedertificates and develop MOC programs. All have agreedo participate and have MOC programs either approvedr contingently approved. All certificates awarded by theBR are now time limited. Subspecialty certificates haveeen time limited from their inception. Time-limitedertificates for primary certification were initiated in995 for radiation oncology and in 2002 for diagnosticadiology and radiologic physics. The ABR is a uniqueoard, because primary certificates are issued in 3 differ-nt disciplines: diagnostic radiology, radiation oncology,nd radiologic physics. Each discipline has a distinct setf skills and core knowledge, yet the focus is the same:atient care.The description of the MOC program in this article

mphasizes the requirements for diagnostic radiology. m

urther details for radiation oncology, radiologic phys-cs, and diagnostic radiology can be reviewed at theBR’s Web site (http://www.theabr.org).The MOC program of all member boards of the

BMS are based on the 4 components (professionaltanding, lifelong learning and self-assessment, cognitivexpertise, and practice performance) and 6 competenciesmedical knowledge, patient care, interpersonal skill,rofessionalism, practice-based learning and self-im-rovement, and systems-based practice) [10]. Thisodel is the framework for the development of theOC program by the ABR. We must find a way to

mbed the principles of these components and compe-encies in the education of medical students, residents,nd fellows and throughout the careers of diplomates inhe ABR’s MOC program.

The expectation of the ABR’s MOC program is toddress each competency via the components through-ut the 10-year cycle of time-limited certification. Theethodologies will consist primarily of unrestrictededical licenses, continuing medical education (CME),

elf-assessment modules (SAMs), cognitive examina-ions, and practice performance quality improvementrojects. All diplomates with time-limited certificates iniagnostic radiology, radiation oncology, and radiologichysics must successfully complete the 10-year cycle ofhe ABR’s MOC program to maintain their status asoard-certified physicians or physicists.Professional standing, the first component, requires a

alid, unrestricted license in all states in which a diplo-ate holds a license. Professionalism, a competency, is a

ogical complement to professional standing.Lifelong learning and self-assessment is the second

omponent of the ABR’s MOC program. In diagnosticadiology, this consists of a total of 500 CME credits thatre required in the 10-year cycle, 250 of which must be inategory I. At least 70% must be in specialty-specific or

elated areas. The choice of the specific educational ac-ivities is directed by a diplomate’s specific practice, needsssessment, and SAMs. Many states require CME creditsor licensure. Continuing medical education credits re-uired for licensure can also be counted to meet theBR’s MOC requirements. Also, SAMs earn CME Cat-gory I credit and can be used to meet the annual activityf 50 CME credits. Fifty CME credits are not requiredvery year, but CME activity needs to be obtained on aontinuous basis throughout the 10-year cycle, and aotal of 500 credits must be achieved.

The professional societies in radiology, radiologichysics, and radiation oncology are doing an outstanding

ob in providing CME credits to members of our profes-ion. The societies are developing SAMs as part of theirnnual meetings, as well as online SAMs and enduring

aterials. The societies play an important role in enhanc-

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Hattery, Dunnick/Shaping the Future 869

ng SAMs’ effectiveness by (1) encouraging and guidinghysicians and physicists in preparing, updating, andulfilling their personal educational plans; (2) helpinghysicians and physicists select the SAMs most congru-nt with their educational plans and patterns of practice;nd (3) using authentic assessments and detailed feed-ack as the essential SAM infrastructure. Self-assessmentodules should include clear standards of quality, “self-

vident” criteria, time for application to one’s practiceith appropriate feedback, and a reflection on one’s ownractice, both personal and from colleagues.A cognitive examination is the third component ofOC. The examination is computer and case based,

roctored, and secure. Efforts are being explored to ad-inister the examination at various testing centers and

ertain radiology society annual meetings. The contentill be relevant to lifelong learning, SAMs, and contem-orary practice. Because subspecialty certificates were al-ays time limited, the ABR began administering the

ubspecialty MOC examination in 2004. The cognitivexamination for time-limited primary certificate holdersn diagnostic radiology will be available beginning in010.In the shifting paradign, we must find ways to create

ew models of adult learning, make lifelong learning andelf-assessment relevant to quality care, and develop per-onal educational plans and practice performance plansn the basis of continuous quality improvement princi-les. The ABR must undergo the same paradigm shift inesting and measuring the right things. Examinationseed to be relevant to practice and linked to the learningrocess. The milepost approach must be replaced by anmprovement approach that recognizes that the cognitivexamination is only one component of MOC and certi-cation.Proposals for practice performance (the fourth com-

onent) have been reviewed for approval by the Ameri-an Board of Medical Specialties beginning in 2006 forll 24 member boards. The ABR has conducted a practiceerformance summit (PQI) in Chicago in August 2006.iagnostic radiology has proposed the following practice

erformance projects (1) practice guidelines and stan-ards, to include communication; (2) referring physicianurveys; (3) patient safety; (4) double reading/accuratenterpretation; and 5) report turnaround times. TheBR has proposed patient safety as 1 of 5 practice per-

ormance programs since the Institute of Medicine’s [3]eport identified patient safety, in the broadest sense, asn important issue in health care. It seems intuitive tossume that every radiologist should be committed touality and safety as a fundamental premise of the prac-ice of radiology. Issues such as quality control and assur-nce procedures, radiation risk, radiation damage and

ffects, radiation safety measures, and ways to keep pa- t

ients safe in the clinical environment are our domain.he public and our patients should depend on us to be

he experts in providing safe and effective health care.he future will depend on many things. Radiologists andhysicists must aggressively grasp the need for outcomesesearch, work to develop consensus measurements, andreate database repositories that permit physician-spe-ific and group aggregate data to be compared. Evidence-ased appropriateness criteria, best practices, and out-omes data will influence future educationalethodologies and testing.

DULT LEARNING

ducational processes have traditionally consisted of aeries of mileposts, that is, undergraduate education,edical school, clinical training, residency training, and

ften one or more fellowships. It was unusual for a stu-ent or teaching faculty member to link one milepost tohe next. We now see the potential of connecting thehreads via the 4 components, the 6 competencies, andime-limited board certification. Students, faculty mem-ers, the Accreditation Council for Graduate Medicalducation, the American Board of Medical Specialties,nd the specialty boards are challenging the methods ofearning, teaching, and testing relevant to patient care,utcomes, and evidence-based decision making.

How adults learn best is an important question beingaised by educators, societies providing educational ma-erials, and physicians facing an explosion of new knowl-dge. Jennifer Bosma, PhD (personal communication),resented a series of points at the 2005 ABR Summit onelf-Assessment modules relative to findings from studiesf effective adult instruction. Gelderman [11] and Dixon12] have promoted the concept of a self-assessing cul-ure, with the focus not on criticism but on continuousuality improvement, which most readily occurs whenarticipants are expected to evaluate their own perfor-ance on the basis of evidence, and self-assessments are

ctually used to make informed decisions and actionlans. Creators of SAMs have a unique opportunity toncorporate these aspects of adult learning.

The Radiological Society of North America’s Adultearning Program was summarized by Linda Bresolin,hD (personal communication), as follows:

n April 2005, the Radiological Society of North America (RSNA)onvened 55 individuals, representing 15 organizations, to discussodern educational methodologies and to identify what the implica-

ions were for radiologic education and how radiologists learn. Overhe course of two days, participants considered how they learn cur-ently and how they would prefer to learn in the future. They listenedo experts from the fields of IT-assisted learning, education theory,erception, and medical simulation. They also discussed presenta-ions by experts from nonmedical disciplines, other medical special-

ies, and the Canadian Continuing Medical Education system.

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870 Journal of the American College of Radiology/Vol. 3 No. 11 November 2006

The participants brainstormed about the significance of this infor-ation for how radiology should be taught and how educationalaterials and programs should be developed. Major recommenda-

ions coming from the conference included: enhance web-based edu-ation to support point-of-care and distance learning; broaden resi-ency training to include teaching, research, and leadership skills;apitalize on medical simulation in radiology education; train radiol-gists in continuous quality improvement; and explore models forommunities of Learners.

There are several effective ways for adults to learnnd transfer core knowledge in the MOC cycle: activeparticipatory, reflective), longitudinal (building onrior experience), transferable to the practice setting,entored by excellent colleagues, standardized mod-

ls with which a learner can compare, individualizedusing authentic real-practice-based dilemmas withhe exposure of common misconceptions), and bench-arked (using feedback, comparisons with normative

ata, and appropriate guidelines and standards). Therimary concept that underpins MOC is continuousuality improvement [13-16].

AST, PRESENT, FUTURE

n the early 1900s, the Flexner report [17] resulted in aramatic improvement in medical school education [18].imilarly, the creation of specialty boards established cre-entialing requirements and standards of care that had aignificant impact on quality. The emphasis on the qual-ty of health care, physician training, and board certifica-ion has a history of more than 100 years. In his presi-ential address to the Academy of Ophthalmology andtolaryngology in 1908, Derrick T. Vail, MD, included

he following comment: “and if he is found competent letim then be permitted and licensed to practice ophthal-ology.” Subsequently, the American Board of Oph-

halmology was organized in 1916.The ABR was formed in 1934 [19]. The opening

aragraphs in A History of the American Board of Radiology934-1964 by E. L. Jenkinson [19] read,

ith increasing specialization in medicine, as the nineteenth centuryave way to the twentieth, there sprang up across America innumer-ble groups of “specialists,” looking to improve the quality of practicen their respective fields. The American Roentgen Ray Society wasrganized in 1900, the Radiological Society of North America in915, and the American Radium Society in 1916. Just what consti-uted a “specialist” was, however, open to a variety of interpretations.ny Doctor of Medicine was entitled to a listing in the Directory of

he American Medical Association as specializing in the field in whiche considered himself best qualified. In other words, he was the judgef his own qualifications.

The situation posed a problem. The medical profession had, forany years, considered that there should be minimal standards of

reparation for the practice of any medical specialty in order to pro-ect the public, the profession in general, and the specialists them-elves. [Jenkinson also noted that unless some centralized process wasstablished, each state would develop its own specialty board.] In view

f this possibility, it appeared that the practical solution would be for

ach group to set its own house in order and place its mark of approvaln those qualified to practice predominately in that particular field.

The mission of the ABR has not changed significantlyince 1934, but certificates, residency training require-ents, administration, and examination content have

volved. The past 4 decades have included incremental asell as innovative changes. The ABR awarded certificates

n Radiology (1934 to 1996), Diagnostic Roentgenology1934 to 1968), roentgenology (1934 to 1964), thera-eutic roentgenology (1935 to 1953), and so forth. Theertificates changed, but so did training requirements.ertification in diagnostic radiology, radiation oncology,

adiologic physics, and the subspecialties of vascular in-erventional radiology, neuroradiology, pediatric radiol-gy and nuclear radiology replaced the previous certifi-ates. The length of training has increased from 3 to 4ears, a clinical year has been added, and the timing of thexaminations has changed. These changes were made inhe context of lifetime primary certification.

Training pathways have been developed to help meetome of the challenges ahead. Currently, the ABR has ap-roved the Holman Research Pathway, the Diagnostic andnterventional Radiology Enhanced Clinical Training Path-ay, the Pediatric Emphasis Diagnostic Radiology Alterna-

ive Pathway, and combined programs. Residents now canhoose to take 12 months of training in a single specialty.iscussions are ongoing about alternative models of train-

ng and certification for primary certificates. Are trainingnd certification in a steady state? How can time-limitedertification become a catalyst for future change in trainingequirements and pathways to certification?

ESHAPING THE FUTURE

he maintenance of certification and quality provide a hostf possibilities. The concept of board certification was in-pired in 1934 by a desire to serve individual patients andhe public, with a focus on education, skills, and quality ofare. The ultimate translation of the process of certifications quality patient care. The quality of health care, includinghysician quality, was the focus in the beginning, 72 yearsgo, and remains the focus today. We must seize the oppor-unities to revitalize training, teaching and learning, contin-ous quality improvement, and board certification.

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