Recertification: Nobody asked me!☆☆☆

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Abstract 

Am Heart J 2002; 143:946-7.

See related Editorials on pages 943 and 945.

As I write this, there are 5 American Board of Internal Medicine self-assessment booklets for recertification in internal medicine sitting somewhere in my office vying for my attention. I ordered them a year ago. I powered through the cardiology sections. I was enthusiastic and determined. Then I opened a general medicine booklet. The first question related to optimal antibiotic choice for treatment of an uncommon infection. The second question involved detailed knowledge of chemotherapeutic agents. The fifth question was about glomerulonephritis. I closed the booklet. I haven't opened it since.

As the sunset of my 10-year internal medicine board certification approaches at breakneck speed, I have resigned myself to not seek recertification. Why? Because reacquainting myself with the various aspects of general medical care in a finite amount of time seems insurmountable. Because time away at review courses—spent with textbooks and at the examination—means more time away from my children (which is already at a premium) and time away from my practice (which cuts into precious vacation time and needs to be carefully coordinated with multiple individuals). Because valid internal medicine board certification is not a requirement for my hospital appointment or practice status. Because I no longer treat patients in general internal medicine unless their problem is specifically related to the cardiovascular system. Because the idea of failing the examination is so humiliating (and so likely at this point) that simply “opting out” seems, in a perverse way, more palatable.

I have rationalized this decision at length. We practice in a system where consultation for issues outside of our immediate comfort zone are encouraged—perhaps a contributing factor to the downward spiral in general medical knowledge among specialists. So, lack of a current general internal medicine board certificate will not affect my day-to-day practice. It will not affect my interactions with my colleagues. It will not make me any less of a passionate and motivated cardiologist. It will only make me angry that by some coincidence related to the timing of fellowship completion I will have to shed the recognition of a hard-won past accomplishment, while most of my cardiology colleagues will be able to maintain their certification with just as little current knowledge of general internal medicine as I possess.

Which brings me to cardiology board recertification. Valid board certification (or at least board eligibility) in cardiology is a prerequisite to employment as a cardiologist, whether in the outpatient or hospital setting. Therefore, the maintenance of current certified status is vital to maintaining an income stream. Valid board certification also represents an easily measured, objective minimum standard by which institutions, colleagues, and patients can identify those practitioners who have demonstrated competency in our subspecialty. Board certification is a rite of passage that brings with it a “stamp of approval,” which (initially anyway) substitutes for the trust that can only be nurtured through repeated interactions and thoughtful care. Board certification indicates that we are considered well versed in our specialty to manage our own patients and to provide up-to-date, sound management advice to our noncardiology colleagues.

Do we need recertification examinations in cardiology? On the one hand, ongoing demonstration of interest and competence in our subspecialty is vital. On the other hand, passing an examination does not guarantee skill and does not substitute for a passion for professional excellence. Nevertheless, a measurable standard is advantageous because it provides a way of ensuring a minimum acceptable quality. Making the duration of certificate validity finite is also appropriate because—as my experience with general internal medicine illustrates—knowledge is not time unlimited. Furthermore, the progressive sub-subspecialization within cardiology has resulted in the same estrangement from general cardiology of the sub-subspecialist as the estrangement of the cardiologist from general internal medicine.

All that being said, the process must be realistic. It must also be uniform. Recertification requirements should be applicable to all cardiologists—not just those who were too young to have a voice on the committees that decided who would need to be recertified. The recertification process should aim to ensure ongoing familiarity with all areas of cardiology, regardless of personal practice patterns, sub-subspecialization, or interests. Criteria for recertification should be applicable to real-world experiences and realities. The formal, every-10-year, multiple-choice examination requirement should be abandoned and replaced with educational modules (which could be completed in an open book fashion) and credits for specific Continuing Medical Education (CME) activities to demonstrate commitment to maintenance of certification. Time duration of certification should be finite—valid for 10 years after the initial examination but then renewable subsequently through the above process every 2 or 3 years. This would mimic the procedure many of us already go through to maintain our state licenses. The modules and CME activities would be dictated by the American Board of Internal Medicine, rather than individually, but enough choice could be built into the system to make it reasonable and approachable for most practitioners. And the credits earned could be used toward state license maintenance as well. The cost and time commitment should be reasonable and geared toward practitioners with frantic schedules and rising overhead. Feedback on the modules should be meaningful and prompt. If desired, physicians could voluntarily participate in the modules (with or without the CME requirements) before the initial 10-year deadline.

Perhaps it's wishful thinking, but I can't help wonder if such a system would have made the maintenance of my general internal medicine certification more approachable and made me a more rounded medical practitioner in the process. After all, the point of all of this is to ensure some standardized ongoing learning and updating of our knowledge in our quickly changing fields, to keep the bar of professional excellence raised. Board certified once, we have all proved our test-taking abilities. Now we just need to demonstrate ongoing interest in what we do, regardless of when we attained our certificates.

Oh, and thanks for asking!