Maintenance of Certification in Emergency Medicine

Joel M. Bartfield, MD FACEP, Associate Dean for Graduate Medical Education, Albany Medical College

The intention of this article is to give a brief overview of the new program for maintenance of certification as outlined by the American Board of Emergency Medicine (ABEM) under the direction of the American Board of Medical Specialties (ABMS). Much of the information contained in this article can be found on the websites of ABEM at www.abem.org and ABMS at www.abms.org.

The first specialty board to be approved by ABMS was Ophthalmology in 1917. Since then ABMS has approved a total of 24 specialty boards. In 1976 Emergency Medicine became the 24th (and last to date) specialty board to be approved by ABMS. Historically board certification was viewed as a one time event. In other words once a physician passed specialty board certification and became a diplomate of his/her board, (s)he was approved for life. The term time-limited certification refers to the requirement for re-certification at some point following initial passage of a specialty board certification exam. In 1970, Family Medicine became the first specialty board to issue time-limited general certification. They were followed by Surgery and Thoracic Surgery in 1976. In the 80s and 90s many specialty boards followed suit. Emergency Medicine adopted time-limited certification as early as 1980 (4 years after becoming incorporated). The last board to adopt time-limited certification was Pathology in 2006.

As medicine has become more and more complex and the American public expects greater and greater proficiency from its physicians, ABMS has moved toward a process to ensure ongoing competency throughout a physician’s years of practice. The program that has thus been adopted is named maintenance of certification. This program, adopted within the last several years by ABMS has four principal components including:

1. evidence of professional standing
2. evidence of a commitment to life long learning and involvement in a periodic self assessment process
3. evidence of cognitive expertise
4. evidence of evaluation of performance and practice

Each specialty board has been charged with creating assessment tools which assess each of these components.

The American Board of Emergency Medicine created a program named Emergency Medicine Continuous Certification (EMCC), which addresses these four components. The first component (evidence of professional standing) requires that “all diplomats hold at least one medical license in the US, its territories or Canada that is active, current, valid, unqualified and unrestricted throughout the time they are certified.”1 This policy extends to all of the diplomate’s licenses during the entire period of time in which (s)he maintains or attempts to regain certification (in other words diplomates are allowed to have inactive licenses which have voluntarily lapsed but are not allowed to have licenses which have previously been revoked by a state licensing board). Diplomates must demonstrate that their active licenses comply with ABEM criteria each time they take the LLSA and ConCert examination (see below).

The second component (evidence of a commitment to life long learning and involvement in a periodic self assessment process) is the life long learning and self assessment (LLSA). The primary goal of the LLSA is to promote continuous learning through the review of an annual set of LLSA readings selected by ABEM. Each year twenty articles are selected by the board, half of which relate to designated content areas as outlined by ABEM and published on the ABEM website. Diplomates are expected to read the twenty articles and are then invited to take an online examination which consists of forty multiple choice questions. This component of certification is designed to be an “open book” testing experience. Diplomates are allowed to consult with colleagues and take the exam in small groups. Although ABEM does not issue continuing medical education it has condoned other organizations to set up review courses built around the LLSA reading list and teach to the content of the articles. The New York State Chapter of the American College of Emergency Physicians (NYACEP) offers such a course. The NYACEP course has been offered since the inception of the LLSA program in 2004. It is offered at multiple locations throughout the state at multiple times throughout the year. Further information can be obtained from the New York ACEP website, www.nyacep.org.

Each LLSA test remains available online for a total of three years. Diplomates are allowed three chances to pass the LLSA exam before having to re-register. Diplomates are required to achieve a score of ninety percent (36 of 40 correct) in order to pass the exam.

The third component (evidence of cognitive expertise) is the continuous certification examination (ConCert). The ConCert examination will replace the former written re-certification examination. The year that a diplomate was scheduled to take the old style re-certification examination will be the year that (s)he will be required to take the ConCert examination. This examination is a “closed book” examination which is similar to the former re-certification written examination. Important changes include the fact that it is administered at approximately 200 professional computer based testing centers throughout the country, it is a shorter examination with approximately 205 multiple choice questions, and an increasing number of questions will be taken from the LLSA readings. The style of the test questions is identical to the previous re-certification examination (single best answer multiple choice questions). A passing score of 75% is required for the ConCert examination. Ultimately 40% of the questions on the ConCert examination will be based on the prior years LLSA readings. This percentage will be slowly increased as LLSA readings are incorporated into ConCert examinations given throughout the first ten year cycle of the continuous certification program. Diplomates will be required to pass a ConCert examination once every ten years.

In order to be eligible to take the ConCert examination, diplomates must have completed the required number of LLSA equivalents (an LLSA equivalent is defined as either passing an LLSA examination or taking but not passing a ConCert examination). As stated above, the goal of the LLSA component is to assure continued learning and improvement throughout a physician’s career. Diplomates are therefore expected to take and pass each LLSA examination. However, since each LLSA examination is offered for a total of three years, diplomates are required to have completed all available LLSA equivalents minus two in order to register for the ConCert examination. A chart outlining the exact number of LLSA equivalents that are required in order to register for the ConCert examination is provided on the ABEM web site (www.abem.org).

Physicians who have not completed the required number of LLSA equivalents prior to certification expiration will not be eligible to register for the ConCert examination, nor will they be eligible to regain certification through the Emergency Medicine Continuous Certification program. Physicians missing one LLSA equivalent will be required to re-take and pass the ABEM written examination and those missing two or more will be required to re-take and pass both the ABEM and written and oral examinations in order to regain certification.

The fourth component (evidence of evaluation of performance and practice) is still being developed. The implementation date is anticipated to be sometime in 2007. As described by the ABEM, “Assessment of practice performance will take advantage of current practice improvement programs that meet ABEM standards and are in place through a diplomate’s institution. The assessment of practice performance will be focused on practice improvement and patient care, interpersonal and communication skills and professionalism”.1

The American Board of Medical Specialties and the American Board of Emergency Medicine should be applauded for their efforts to assure that today’s practicing physicians maintain competency. Our patients have every right to except nothing less. To date the states of Nevada and South Carolina have implemented processes which mandate physicians applying for re-licensure to document continuing competency to practice medicine. Many other states including New York are considering similar legislation. New York ACEP is proud to offer yearly CME courses addressing the LLSA component of maintenance of continuing certification to help our members and our physicians maintain competency to practice emergency medicine.

1. American Board of Emergency Medicine, www.abem.org