US Nephrologists Voice Opinions about Certification, Recertification, and ABIM

A recent survey of 1134 US nephrologists who are ASN members provided important insights that will help guide ASN’s assessment of approaches to initial certification, recertification, and physician assessment activities, as well as the relationship between the nephrology community and the American Board of Internal Medicine (ABIM).

The survey is part of ASN’s larger strategy to help nephrologists maintain career excellence.

About 90% of US nephrologists are ASN members. Nearly 1 in 5 nephrologists who received the survey responded. Most respondents were private practitioners (44.9%), followed by clinical educators (24.8%) and academic researchers (15.1%). Other respondents identified themselves as hospital-based physicians, industry researchers, and administrators (Table 1). Respondents also included those who identified as transplant nephrologist, interventional nephrologist, academic physician, among a few other designations.

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The majority of respondents (92%) were board certified through ABIM. For those who were not ABIM-certified, 3 respondents were certified by the American Osteopathic Board of Internal Medicine (AOBIM) and 6 were certified by the National Board of Physicians and Surgeons (NBPAS). Other certifying boards mentioned in the survey’s open comments section included the American Board of Pathology, American Board of Pediatrics, board eligible/not certified, and international certification.

“I was pleased to see the number of nephrologists who participated in the survey and provided their opinions about MOC, recertification, lifelong learning, and issues related to ABIM,” said ASN Councilor and Education Committee Chair Mark Rosenberg, MD, FASN. “Having this level of information will greatly assist ASN as the society examines options for helping nephrologists maintain career excellence and provide the highest-quality patient care possible.”

Board certification

When asked if initial board certification is important to the practice of nephrology, 1009 respondents (96.5%) answered “strongly agree” or “agree,” and 37 (3.0%) responded “disagree” or “strongly disagree.” Following are a sampling of comments made by those who agreed that board certification is important:

  • “Board certification has come to mean highly skilled; fulfills basic requirement to practice as a nephrologist.”
  • “Validation of knowledge base and a public record of achievement.”
  • “An objective test of the knowledge required to diagnose and treat disorders seen by nephrologists assures training programs have adequately trained fellows and fellows have retained and can apply this information.”
  • Among the 37 respondents who disagreed or strongly disagreed with the statement about board certification were the comments:
  • “Board certification is a poor reflection on the individual’s ability to be a good practitioner.”
  • “Board certification is a scam. All that should matter is if you completed a fellowship in an approved training center.”

Board recertification

Nephrologists were split in their answer to the question: “Is board recertification important to the practice of nephrology?” Forty-seven percent (491) responded “strongly agree” or “agree” with this statement, and 53% (553) responded “disagree” or “strongly disagree” (Figure 1). In more than 450 open-ended comments, nephrologists stated:

  • “[Board recertification] is high stakes with an all or nothing exam that does not reflect real life conditions and is written by people who do not perform the same type of job in a setting similar to most practicing nephrologists.”
  • “Practicing physicians recertify every day as they see patients and expand their experience and knowledge base.”
  • “We all need to maintain our knowledge and skills through lifelong learning to provide safe and effective care for our patients. However, the process for this should be completely different from the original certification, which is testing a one-time broad knowledge base and ability to answer test questions. We need to think of recertification as part of team-based practice.”

Figure 1 Survey responses to the question “Is board recertification important to the practice of nephrology?

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Board certification as a one-time event

When asked if board certification should be a one-time event, 589 (56.8%) respondents said yes, and 448 (43.2%) responded, “It is a credential that should be recertified at regular intervals.” Among more than 350 open-ended responses were the comments:

  • “A one-time exam to demonstrate achievement and an understanding of one’s training seems appropriate. Once you give me the license and certification the Hippocratic Oath takes care of the rest.”
  • “After my initial certification, I was opposed to mandated recertification; however, after having participated in the recert[ification] process twice now, I can say with reasonable confidence that the preparation (if not the test itself) has made me more current and probably more competent in nephrology. And I do a ton of inpatient consultative nephrology in an academic setting so it’s not that I lack for clinical exposure or sharp and helpful colleagues. So if it helps me, it must be helping others.”

What activities should count toward recertification?

In the survey’s section on recertification, several optional activities that might be part of a recertification process were listed, and participants were asked to select as many options as they felt applied. The results (in rank order) are shown in Table 2.

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In 350 open-ended comments, nephrologists stated:

  • “All are valid forms of evaluation.”
  • “I believe that additional research is needed to … determin[e] what techniques are needed to maintain competence, Also, what are the best practices to maintain competency?”
  • “I think the goal is lifelong learning. The high stakes exam [that] I just passed is not indicative of physician performance or capability. The practice assessments and performance improvement activities sound like busy work.”
  • “Most of us in nephrology (and in my case, also transplant nephrology) participate in all kinds of activities which require literature reviews, QAPI projects, etc. Most of us are exceedingly busy. These activities, which are demonstrative of clinical engagement and competence, should count as objective measures of … clinical engagement and competence.”

What role does CME play in certification?

The survey also asked, “Is documented CME provided by an accredited organization sufficiently rigorous to qualify as the only determinant of recertification?” About 60% (622) of respondents answered “yes,” and about 40% (411) answered “no.”

In more than 300 open-ended remarks, nephrologists stated:

  • “CME is a broad term, but yes, continued education should be the determinant. How to make it rigorous enough to qualify would be subject to some discussion. It should require one to fulfill a variety of areas within the specialty, like not doing all your CME activities on the same topic, say, anemia.”
  • “What ‘recertification’ should be testing is whether a doctor is making the effort to be continually exposed to what is new and innovative in the field. How he applies that to his practice is not the point. What you want to weed out [are] those doctors who have become out of touch with the current practice of nephrology.”

Time-limited certification

The survey addressed the issue of time-limited certification (“grandfathers and grandmothers”). When asked if nephrologists who earned initial certification before 1989 should participate in recertification, 676 (65.3%) of respondents said yes and 360 (34.7%) said no. In more than 400 open-ended comments, nephrologists stated:

  • “I am a grandfather and I feel being formally evaluated like my colleagues is reasonable (you have ‘street cred’). I also found participating in a med knowledge MOC activity was educational and worth the time. Online activities which can be completed over multiple sessions are optimal. Would be nice for MOC activities to count toward state licensure.”
  • “The longer you are in practice, the deeper your knowledge.”
  • “A deal should be a deal. Do we really want to drive our elder statesmen/women out of practice prematurely by making it even more of a hassle to take care of patients than it already is?”

ABIM and MOC

Finally, the survey asked, “Is ABIM the appropriate organization to recertify nephrologists?” In response, 427 US nephrologists (42.1%) said yes, and 587 (57.9%) said no. In more than 550 open-ended remarks, nephrologists stated:

  • “ABIM has betrayed the rank and file of physicians and unless it undergoes some major change it should not recertify any specialty. The American Society of Nephrology should be tasked with recertification.”
  • “With the caveat that they need to right their ship, since the current management and policies are out of touch and there has been a major erosion of trust in the organization, its leadership, and its interests across physicians.”
  • “ABIM would be perfectly appropriate, if they would reconsider the burdensome and expensive way they provide recertification. Otherwise, we should be open to alternative organizations.”
  • “I guess … I think the idea of breaking away from the “mothership” and doing our own thing doesn’t really solve the fundamental issue of what really makes and keeps a physician board certified and what doesn’t. I think we would end up re-inventing the wheel if we tried to do it on our own. As long as there is an ABIM that is receptive to positive change, we should put our stakes with a singular governing body and ensure our voice is heard and our ideas applied.”

ASN invited survey-takers to make additional remarks about any aspect of certification and recertification and received more than 475 comments; a sampling appears here:

  • “1. Stop re-certification/MOC. 2. Have practicing nephrologists more involved in policy or performance measure making. 3. Advocate for setting up oversight for ABIM or NQF, etc. 4. Advocate for legislation to prevent any interruption on physician’s practice.”
  • “For patients to get the best care, we need teams. We need to hold teams accountable for patient safety, satisfaction, and to an increasing extent, better outcomes. We should be thinking about these issues and how to do this better, not trying to make a better mouse trap to evaluate physicians’ knowledge.”
  • “Self-assessment programs that require testing are rigorous enough to meet the purpose of updating and refreshing knowledge.”
  • “I agree with the need for initial certification but not for recertification. I agree that physicians should continue CME education but not [be] re-examined. It is like getting your driver’s license; there is no need to be retested. Experience is something that books cannot test.”
  • “I strongly hope whatever organization takes the lead in the process, that organization takes into account the tremendous burden this places on the practicing nephrologist and attempts to incorporate the documentation into a meaningful practice with minimal oversight or [documentation] burden.”
  • “Nephrologists are internists—I want the ASN to continue to work with ABIM.”
  • “Recertification is useless, waste of money, waste of resources. [I]t does not help patient care. [D]oes not change patient mortality. [S]hould be abolished.”

Next steps

ASN is currently forming a task force to identify pathways available for nephrologists to renew their subspecialty board certification. The task force will analyze the MOC survey data, generate a decision matrix of pros and cons for the identified pathways, and report to the ASN Council on findings and recommendations for society actions. The survey results will help guide this process.

To discuss the survey or the task force, to provide comments about the survey, or to ensure your voice is heard concerning certification, recertification, or assessment, please contact ASN at education@asn-online.org, subject: Recertification.