Special Certification in Physical Medicine and Rehabilitation: Yesterday and Tomorrow

Article Outline

• Abstract
• Origins of board certification
• Certification components
  • Written and Oral Examinations
  • Maintenance of Certification
• Conclusions
• References
• Copyright

Abstract 

Smith BS. Special certification in physical medicine and rehabilitation: yesterday and tomorrow.

The Zeiter Lecture is given annually to honor Walter J. Zeiter, MD, the first executive director of the American Academy of Physical Medicine and Rehabilitation. In this lecture, I discuss the certification process for specialists in physical medicine and rehabilitation. I look at the history of initial certification, discussing the origins of both the written and oral examinations. I trace the development of these examinations and comment on potential developments in the initial certification process. I discuss the development of maintenance of certification in organized medicine and physiatry and comment on its future direction in physiatry.

Key Words:  Certification , Rehabilitation

IT IS AN HONOR AND A PLEASURE to present this distinguished lecture that celebrates one of the founding fathers of physical medicine and rehabilitation (PM&R), Walter J. Zeiter, MD. My career in physiatry began too late to allow me to meet Dr. Zeiter, but his accomplishments stand for all of us to follow as we pursue our beliefs for the future of our specialty.

Zeiter was the executive director of the Society of Physical Therapy Physicians from 1938 until 1945. In 1945, under his leadership and direction, this society was renamed the American Academy of Physical Medicine & Rehabilitation (AAPM&R). Zeiter continued as the executive director of the Academy until 1960. However, Zeiter and 13 of his contemporaries were not content only to have a medical society. They also believed that physiatry deserved to be recognized as an independent specialty within the medical community; and so in 1947 the American Board of Physical Medicine (ABPM) was incorporated. Zeiter received certificate number 10 from the ABPM in 1947. The ABPM was renamed the American Board of Physical Medicine & Rehabilitation (ABPMR) in 1949 and Zeiter served as its chair from then until 1953.¹ It is this dedication to our field of medicine that we honor today.

Each Zeiter lecturer is asked to select a topic of historical significance because Zeiter was known for his love of history. Yet the topic needs to be relevant to the current audience if it is to be successful and each lecturer needs to have a passion for his topic if the address is to be interesting. Having attended more than 20 of the previous Zeiter lectures, I tried to recall which stood out in my memory and why.

Several lectures seemed to have particular relevance to the listeners because the theme impacted medical practice or funding issues of the time. They included lectures by George Kraft, who, in 1991, discussed health care as it related to the anticipated percentage of the U.S. gross national product; Leon Reinstein, who, in 1995, intimated the likelihood of the United States adopting a single payer system to finance health care; and Randall Braddom, who, in 2004, outlined how adherence to the “75% rule” for payment in inpatient rehabilitation facilities (IRFs) could change the entire practice of physiatry. Other lecturers demonstrated a passion for the topic chosen. They included lectures by Arthur Abramson, who, in 1975, discussed the neurogenic bladder; Barbara deLateur, who, in 1996, demonstrated the research base for measurement of quality of life; and Nicolas Walsh, who, in 2003, advocated for the inclusion of American physiatry in world-wide initiatives.

Using these 3 criteria, I considered several areas in our field for discussion. They included the effort to establish an independent institute for rehabilitation research within the National Institutes of Health, development of a common musculoskeletal curriculum for all medical schools, modification of funding for patients admitted to IRFs, and the trend toward subspecialization within physiatry. Each has merit and I have a certain passion for them. However, the most timely topic for practicing board-certified physiatrists in the year 2005 is the impact of changes in the board certification process.

Board certification in PM&R has 2 components: initial certification, with both an oral and written component, and maintenance of certification (MOC), originally called recertification. I will attempt to trace the origins and development of both of these components of certification.

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Origins of board certification 

The concept of a specialty examining board was first introduced in 1908 by Derrick T. Vail, MD, in his presidential address to the American Academy of Ophthalmology and Otolaryngology. This address led to the incorporation of the American Board of Ophthalmology in 1917. This process of board development continued in various specialty areas and, in 1933, 4 initial boards (ophthalmology, otolaryngology, obstetrics and gynecology, dermatology), in conjunction with the Association of American Medical Colleges, the Federation of State Medical Boards, the American Medical Association, and the National Board of Medical Examiners, created the Advisory Board for Medical Specialties. The ABPM was 1 of the 14 specialty boards approved by the Advisory Board, now called the American Board of Medical Specialties (ABMS), between 1933 and 1948.²

The ABPM was incorporated February 27, 1947. The small group of founding members was apparently strongly dedicated to the principles of certification of physiatrists because it held the initial certifying examination on September 1, 1947. This initial examination consisted of 2 sections, written and oral. There were 130 applicants, each paying a fee of $75.

These initial applicants, who included the founding board members, were divided into 3 groups. Group A applicants were considered competent and capable. Their credentials and fitness for certification were acceptable. Those applicants in group B had completed the required training and were practicing in the field. However, they were not considered to be established as specialists. The physiatrists in group C either had not completed training or lacked 2 years of clinical experience in the field.¹

Although the exact number of physicians who were in each of the groups is uncertain, 91 people received life-long certification in physical medicine as a result of this initial certifying examination. Since that initial examination, 8110 physiatrists have received board certification. A total of 7424 of these diplomates are still living and 4086 (50.4%) of all diplomates were certified after 1992, receiving time-limited initial certification (Anthony M. Tarvestad, JD, written communication, September 2005).

The definition of initial certification has not changed over the years: one must show evidence of possessing requisite clinical skills or competency in physiatry at a defined moment in time. That moment is when the examination is successfully completed. Board certification is important to physicians because it is a clear recognition of expertise to our peers and to various “publics.” It functions as an entrance requirement into professional organizations and perhaps, more important, into medical staffs and physician-payer groups. However, the importance of initial certification has changed since 1947. In 1947, it was evidence of a step above the ordinary. Most physicians in that era were not certified specialists. Today, board certification is an expected outcome of medical training. Nearly all graduating medical students enter residency training and, in 1999, ABMS member boards certified approximately 89% of all licensed physicians in the United States.²

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Certification components 

I will now discuss the origin and development of each of the 3 current certification components: the written and the oral examinations for initial certification and the MOC process.

Written and Oral Examinations 

The first written examination consisted of 200 true-false questions, 69 multiple-choice questions, and 2 essay sections. The essays consisted of writing evaluations of prescribed therapies for a specific pathologic condition. It is fascinating to me that even in this first examination, the founding fathers wanted to validate the results. As discussed, the group A physicians were thought to be already competent in physiatry. Therefore for these 54 physicians the examinations were waived and they were granted board certification. However, each of these physicians who had not been involved in producing the examination was asked to volunteer to take the written examination serving as a control group for the group B physicians.¹

The composition of written examination has evolved over time. Those of us who took the examination between 1950 and 1977 remember taking the matching questions where 2 long lists were generated and data from the left-hand column had to be matched to relevant data in the right-hand column. During the late 1970s and early 1980s, the written examination contained a section of identified previous questions from a question bank that the candidates needed to answer correctly. An important improvement in the written examination process occurred in 1985 when the board initiated use of associates to help formulate the examination questions, bringing a wider knowledge base to the question bank. Beginning in 2002, the examinations were given by computer at multiple sites across the United States, making them available locally to candidates.

The current written examination consists of psychometrically valid multiple-choice questions. There is an examination blue print and each candidate is given extensive feedback about his/her performance. Looking to the future, the written examination will continue to be the cornerstone of initial certification. It has been well validated as the best measure of medical knowledge. Through the use of computer technology, question types will be enhanced. The board will work to continuously improve candidate feedback.

The initial oral examination given in 1947 must have been a fascinating experience. It was given in a single large ballroom, apparently with all the candidates present. The examiners were board directors. Each candidate received three 20-minute sessions on preselected topics, given by pairs of examiners. The only caveat was that examiners could not examine trainees from their own program.¹ Until recently, the form of this process did not change a great deal. Private examination rooms were added and the examinations were expanded to three 40-minute sessions. The sessions were converted to single examiners and, in 1967, the practice of having guest examiners was initiated.

In the 1990s, board directors, responding to concerns from the field, began to question the purpose, validity, and fairness of the use of the oral examination as a part of initial certification. From these deliberations came the decision to continue to use the oral examination as a part of the initial certification process, as do the majority of ABMS boards. However, changes needed to be made to assure the examination would be valid, reliable, and equitable to all candidates. The oral examination also needed to test areas of competency other than medical knowledge, the function of the written examination.

Work began on this initiative. Several consultants were hired and minor changes were made in the oral examination format, between 2000 and 2004, as the board prepared essentially a new oral examination format. The oral examination of 2005 was targeted for initiation of the examination new format. The examination was given in May 2005 and, for the first time, each candidate received essentially the same examination. The areas tested were data acquisition, problem solving, patient management, systems-based practice, and interpersonal skills. The examination had an overall reliability of .94, which compares very favorably with the written examination. In addition, the correlation to the written examination was .37, which strongly suggests that it measured different abilities than the written examination.³

This is only the beginning of our new process. In the future, it will be necessary to refine and further validate the oral examination. It will be necessary to assure it continues to measure competencies other than medical knowledge. Feedback to the candidates and the examiners will also need to improve. The necessity of continuing this process will have to be assessed as computer technology improves and other testing tools become available to help assess competencies other than medical knowledge.

As we look to the future, I believe initial certification will continue to be an important component of medical practice, the defining point of completion of training. It must assure practitioner ability in each area of clinical competence. It must be a valid estimate of each candidate’s ability at the moment of the examination. However, until better measures of competency are developed, program director assessment of resident performance will be a critical portion of this initial evaluation process.

Maintenance of Certification 

Every practicing physiatrist is beginning to face a new assessment—recertification or MOC. Initially, ABMS boards only offered initial certification. However, in the 1970s, many boards began to develop recertification processes and to require formal recertification for continued board certification. At the same time, boards began to issue certifications that were time limited rather than life long. The first of these recertifications were knowledge-based examinations. The impetus to recertification began to take on new importance as organizations external to organized medicine began to demand that medicine do a much better job of policing itself. Public awareness became heightened through the publication of the Institute of Medicine reports To Err Is Human and Crossing the Quality Chasm.⁴

In response to these challenges, the ABMS, through a joint task force with the Accreditation Council for Graduate Medical Education, developed and adopted the concept of 6 clinical competencies to guide life-long medical education. They are patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. Additionally, in 1998, the ABMS adopted 4 essential components for MOC: professional standing, commitment to life-long learning and involvement in periodic reassessment, and evaluation of performance in practice.⁴

As early as 1970, physiatry got involved in recertification and life-long learning, when the AAPM&R began publishing self-assessment study guides. In 1993 the ABPMR began to issue time-limited initial certifications and initiated a recertification program. This program included 10-year certificates, an ongoing continuing medical education (CME) program of 50 hours annually, an open-book cognitive examination, and the possession of a valid and unrestricted license to practice medicine. Of the 4086 physiatrists with time-limited certificates issued since 1993, 887 have been recertified and 3717 are enrolled in the current recertification program.

This initial recertification program has since been evolved into an MOC program containing all 4 of essential components suggested by the ABMS. As early information about this program has reached physiatrists, many holders of time-limited certificates are asking what all this means, other than more time and more money for me. I must admit that my first reaction was negative. My practice was unique and no process could properly assess it! However, as I became more knowledgeable about the program, I realized that a process like this would allow me to direct my own life-long learning. I needed to distinguish between directed self-learning, which is what I had really done, and self-directed learning, which would ultimately lead me to assess how well I did my own practice.

As each of us thinks about our own learning, it tends to be in areas of specific subspecialty interest, although most physiatrists have a mixed practice covering many areas, doing both inpatient and outpatient clinic practice. To me, an MOC program is simply an organized process to assure that my learning will stay organized and the end product will be maintaining my competence in all the areas of my practice. Realizing that MOC will happen, I think the real question is how to make it reasonable and affordable to all physiatrists.

The ABPMR has committed to an MOC program that I believe does just that.⁵ A 10-year cycle will be continued and it contains all 4 essential components of MOC. As a sign of ABPMR’s commitment to this process, all board directors have agreed to participate fully in MOC whether they have time-limited or life-long certificates. Achieving the essential components should not be unreasonable in either time or expense for physiatrists.

The component of professional standing will be met by holding a current valid unrestricted medical license. Life-long learning will continue to be met by accumulating 500 hours of CME. The self-assessment component will be met by demonstrating successful completion of 4 self-assessment instruments that meet ABPMR standards. These self-assessment instruments still need to be developed. This should be accomplished completely or in large measure by a partnership between the AAPM&R and ABPMR. Cognitive expertise will be demonstrated through a proctored medical knowledge examination once during the cycle at a computer testing center.

Practice performance assessment has been the portion of the MOC program that has raised the most concern for physiatrists. However, this will be accomplished by the physiatrist completing a continuous quality assurance (CQI) project and participating in 1 to 3 ABMS assessment tools, such as communication or professionalism evaluations, as they are developed by the ABMS. CQI projects were selected because they are adaptable to all settings—inpatient or outpatient as well as clinical, research, or administrative. CQI projects and training are already occurring in many institutions and practice settings. CQI projects have widely accepted performance standards.

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Conclusions 

As we look at MOC, the only portion of it that is completely new is the practice performance assessment, and the ABPMR has adopted a widely used tool to accomplish this component. Self-assessment tools are new to MOC but not to life-long learning. CQI processes are adaptable to any setting, so all physiatrists, regardless of practice type, can participate. Finally this MOC process will continue to evolve, especially as we learn more about accurately measuring competency. MOC will enhance practice and should assure life-long learning to maintain competency.

I believe the processes of initial certification and MOC are necessary parts of physiatric practice. They are evolving in a way that will enhance what we as physiatrists do. Done correctly, these assessment tools will give us the ability to demonstrate competence to all of our publics and to avoid any unwanted interference in the practice of PM&R.

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References 

1. In:  Martin GM ,  Opitz JL editor. The first 50 years (the American Board of Physical Medicine and Rehabilitation) . Rochester: ABPMR; 1997;
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2. American Board of Medical Specialties, Research and Education Foundation . In: Evanston: ABMS; 2002;2002;p. 54
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3. American Board of Physical Medicine & Rehabilitation. Statistics. Available at: http://www.abpmr.org/certification/statistics.html . Accessed December 22, 2005.
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4. Miller SH , Horowitz SD . Maintenance of certification (relation to competence) . J Med Licensure Discipline . 2003;89:7–10
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5. American Board of Physical Medicine & Rehabilitation. Maintenance of certification program. Available at: http://www.abpmr.org/certification/moc.html . Accessed December 22, 2005.
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