The Value of Board Recertification Among Physicians

Introduction

An ongoing challenge among healthcare certifying organizations is identifying an effective manner of evaluating a physician’s competency. Maintenance of certification and specifically, recertification exams, are used to verify that a high standard of care is consistently met across all medical specialties. However, different countries, like Canada and the US have different structures in place to ensure physicians are kept abreast of the latest medical knowledge. While maintenance of certification re-examination is mandatory in the US, the same structure and exam is not required in Canada. This contrast puts into question the value of the recertification exam in medical professional development programs. We outline the rectification situation in Canada and the US and provide recommendations regarding further research evaluating the potential redundancy of a recertification exam.

The Importance of Board Certification

Historical changes with regards to technology, hospital positions and public involvement in healthcare has led to more and more physicians becoming board-certified since the early 20th century. Although board certification is not a requirement for practicing physicians, it is the primary way specialists can be distinguished. Certification is not like medical licensure, which legally permits a physician to practice medicine. It is the highest form of accreditation a physician can achieve and is a testament to their knowledge, skill and competence. It assures patients and the public that their healthcare providers are sufficiently skilled and capable of offering high-quality care. External parties also view these certifications as benchmarks for a physician’s ability. Insurance companies, hospitals and quality assurance organizations take certification into account when evaluating or working with a specialist. Businesses also hold healthcare to the same value purchasing standard as other commodities, thus emphasizing a need to provide quality medical care.¹ As the “board-certified physician” became a more recognized achievement and the public developed a consumerist attitude towards healthcare, accreditation became more important.² For example, anesthesiologists in British Columbia can submit different billing codes depending on whether or not they are board certified.³ The American Board of Physician Specialties (ABPS) reports that certified emergency physicians receive a higher salary than uncertified ones and that the gap between pay is increasing.⁴ Advancements in technology and limited numbers of hospital positions also meant that physicians had to find a way to distinguish themselves as competent and knowledgeable professionals with respect to their peers to receive hospital privileges and good insurance coverage. In the early 2000s, certification for most specialties was no longer unlimited and recertification was introduced. Therefore, board certification and recertification is an important accreditation for modern physicians to maintain to practice.

Recertification in the US versus Canada

In the US, physicians are required to participate in a maintenance of certification program. The primary organization in the US that offers specialist accreditation is the American Board of Medical Specialties (ABMS) which encompasses 24 specialty boards.⁵ These 24 specialty boards require Maintenance of Certification (MOC), whose main goal is to ensure public’s confidence in healthcare. MOC requires certification to be limited to 6–10 years. Each specialized board functions autonomously within the framework of the ABMS. While the ABMS provides overarching guidelines, individual boards possess significant discretion in implementing them. The ABMS generally requires their member boards conduct periodic assessments of knowledge, judgment, and skills where assessment results are used to make certification decisions with an emphasis of lifelong professional development.⁶ Physicians in the US are required to undergo a formal examination every six to ten years to maintain board certification. Alternatively, the Longitudinal Knowledge Assessment (LKA) option was introduced by the Board of Anesthesiology (Maintenance of Certification in Anesthesiology Program^®) in 2014–2015 and then the American Board of Pediatrics (ABP) in 2015–2016.^7,8 The American Board of Internal Medicine (ABIM) recently began offering this module in 2023 after years of program development. In 2016, ABIM unveiled plans to create an alternative to the decade-long exam.⁹ Two years later, ABIM introduced the Knowledge Check-In (KCI) in internal medicine and nephrology, influenced by input from over 30,000 physicians through surveys and focus groups. This new assessment option allowed physicians to regularly assess their medical knowledge, provided flexibility in testing locations, and included access to external resources like UpToDate, while also offering immediate feedback upon completion.⁹ The LKA path offers physicians more flexibility to complete their MOC requirements and is promoted as a more relevant and convenient way to maintain certification.¹⁰ In this program, physicians are continually evaluated over five years and complete a minimum of 500 out of 600 questions to maintain their credentials and will have to meet specific performance thresholds after five years to maintain their certification. MOC is different for Canadian physicians. In Canada, the Royal College of Physicians and Surgeons of Canada and the College of Family Physicians of Canada (CFPC) are the main governing bodies responsible for tracking MOC. The MOC requirements are set by each province or territory’s registrar’s office. Like in the US, MOC in Canada is required for all physicians. It consists of a similar structure where physicians must earn a certain amount of credit hours by attending continuing medical education (CME) activities every year.¹¹ Physicians must also be board-certified by either the College of Family Physicians of Canada (CFPC) or the Royal College of Physicians and Surgeons of Canada (RCPSC). However, there is no recertification exam every 6–10 years. Whether or not this exam is a valuable part of MOC is unknown.

The Canadian MOC program is still in reform, with the RCPSC recently amending their recommendations in January 2024 and the CFPC to release new guidelines in December 2024. The RCPSC has reduced credit requirements from 400 to 250, reduced annual minimums from 40 to 25 and completely abolished minimum credit requirements for Sections 1 and 2, making attaining MOC requirements easier.¹² The CPFC, in response to physician feedback, has altered their program to include optional enhanced activities, a simplification of the quality criteria framework and most importantly, extended certification periods to favour longitudinal professional development activities.¹³ Recertification exams remain excluded from the new requirements.

Time-Limited vs Unlimited Board Certification

Several studies have identified that a single examination is not advantageous to continuous learning and knowledge acquisition in physicians.^14,15 A scoping review revealed that gradual testing is more beneficial for long-term knowledge acquisition compared to a comprehensive exam.¹⁶ In addition, several studies have identified that longitudinal assessment is more practical, applicable to clinical practice and can help identify knowledge gaps.^16,17 Assessments interspersed between learning activities have been shown to improve knowledge retention by strengthening memory associations between different concepts. Continuous learning and longitudinal assessment are already implemented in the MOC program, as physicians must complete educational activities throughout the year to achieve credits toward their CME. Although physicians must still maintain a certain standard to “pass” the LKA, the use of a formal examination on top of these ongoing assessments is questionable. Studies report that among board-certified internists with time-limited and unlimited certifications, no differences in patient health outcomes existed between both groups.¹⁸ Patients did not differ in clinical outcomes such as blood pressure control (OR, 0.99 [95% CI, 0.69–1.4]), thiazide use (OR, 1.0 [95% CI, 0.8–1.3]) or post-myocardial infarction use of aspirin (OR, 0.98 [95% CI, 0.58–1.68]). Other research reveals that MOC was not associated with an increased number of ambulatory care-sensitive hospitalizations¹⁹ but was associated with an overall improvement in the quality of care and physician performance scores on Healthcare Effectiveness Data and Information Set (HEDIS) outcomes.¹⁸ Additionally, the time-consuming nature of these examinations is also of concern to examinees, as studying for these exams takes time away from their patients and practice. In addition, the high cost and complexity of the study materials and examination itself are of concern to physicians who are preoccupied with other clinical and research responsibilities.

Conclusion

The maintenance of clinical skill, acquisition of knowledge and improvement of leadership is essential to the preservation of a high standard of care. Currently, research evaluating learning outcomes using longitudinal assessment appears to favour this type of education over intermittent comprehensive evaluation. Thus, the need for recertification exams as a part of the MOC process is questionable. To maintain certification, physicians might benefit from a continual practical assessment rather than cumulative exams. Future program reform should focus on integrating longitudinal assessment in continuing medical education.