Overview of Board Certification

Introduction:

While some physicians may think of Board Certification as just another complicated hoop they have to jump through in order to practice their craft, it can also be seen as a valuable way to demonstrate your commitment to the highest quality care, and to receive recognition for the many long years of work you have put into achieving expertise. Board certification sets you apart as a recognized specialist in the eyes of patients, hospitals, employers and insurers. Certification by an ABMS member Board is the gold standard for medical specialization in the US. Possession of a valid certificate reduces credentialing hassles, and is a required credential in many practice situations. This section will attempt to explain a bit about the background and process of ABOS certification.

Board Certification:

Board certification is a voluntary process on the part of any physician. It is different and distinct from licensure to practice medicine, a function regulated by state government. A valid medical license is required to be Board certified, but certification is not necessary for licensure. A Board certified physician has met certain standards and passed tests that are developed to assure the public that he or she has been adequately trained in a given specialty. By 2003, more than 85% of licensed physicians in the US were certified by at least one Board.

The American Board of Orthopaedic Surgery:

The American Board of Orthopaedic Surgery (ABOS) is a separate organization from the American Academy of Orthopaedic Surgery (AAOS), with a different purpose. Although many surgeons have held leadership positions in both organizations, they are not allowed to serve both simultaneously. You must be Board certified to become a fellow of the Academy, but AAOS membership is not a requirement to become Board certified. One major function of the Academy is to provide continuing medical education and training to orthopaedic surgeons. The Board role is to evaluate the knowledge, skills and practice of individual surgeons for the good of the public. To have the same organization providing both of these functions would be an obvious conflict of interest.

The ABOS was founded in 1934. It is a private non-profit corporation that exists to serve the public interest by examining orthopaedic surgeons and certifying that they have met certain standards of education, training and practice. There is no direct connection between the ABOS and the AAOS, American Orthopaedic Association (AOA), or any other orthopaedic subspecialty organization. The Board consists of twelve directors, 6 senior directors, 2 director-elects, and one public (non surgeon) member. Two new director-elects are selected by the Board each year from lists of practicing orthopaedic surgeon nominees submitted by the 3 founding organizations; the AAOS, the AOA, and the American Medical Association (AMA). The ABOS derives its legitimacy from the founding organizations and from membership in the American Board of Medical Specialties. Directors serve without pay. Many other orthopaedic surgeon volunteers serve the ABOS as question writers, test task force members, oral examiners, and site visitors.

The Process of ABOS certification:

In order to be allowed to begin the process of becoming ABOS certified, a surgeon must have met the following educational criteria.

1. Be a graduate of an accredited 4 year medical school
2. Have successfully completed a minimum of 5 year (60 month) accredited orthopaedic residency program in the US or Canada, and have appropriate yearly documentation from the program director. The final 24 months of the training must be obtained in a single program. The minimum acceptable content of the residency training program is available in the Rules and Procedures.

    

In addition, applicants for the part I (written) examination who are in practice, and all applicants for part II (oral), must have a full and unrestricted license to practice medicine, or work for the government in a position where a license is not required.

Board certification in Orthopaedic surgery requires that a candidate pass through a multistage process involving completion of an accredited residency, a written examination (Part I), a period of 22 months in practice, peer review, and an oral examination based on the candidate own practice (Part II). A surgeon who has passed the Part I written examination and is practicing while awaiting admission to Part II is deemed "Board Eligible". This term is not appropriate for surgeons who have not passed part I, or who have been refused admission to part II. The limit of Board Eligibility is 5 years; surgeons who have not passed part II within 5 years of taking part I are no longer "Board Eligible", and must re-take part I before moving on to part II.

Part I: The written examination. Orthopaedic surgeons who have completed an accredited residency, as attested by the program director to the ABOS credentials committee, may apply and be admitted to take the written examination. This examination, which is a timed, secure, paper and pencil exam, consists of approximately 320 multiple choice questions covering all of Orthopaedics. It is given at the Hyatt hotel in Chicago, on a single day in July. It involves 7 hours of testing divided into 2 sessions. The content outline for the most recent examination is available on this website.

The questions are produced through the work of over 70 volunteer practicing orthopaedic surgeons, with the help and professional guidance of the National Board of Medical Examiners (NBME). Each question submitted is required to be supported by at least 2 peer reviewed references, and is subject to review by at least 3 different groups of surgeons before appearing on a test: The Question Writing Task Force (QWTF), the Field Test Task Force (FTTF), and the written exam committee of the ABOS. Extensive statistics are kept by the NBME on the performance of each question and poorly performing questions (too hard, too easy, non-discriminating) are discarded. The passing score is set each year by the written exam committee based on an item by item analysis and the work of yet another group of volunteer orthopaedic surgeons, the standard setting task force. The overall pass rate in recent years has varied from 79% to 88%. The pass rate for US/Canadian medical school graduates taking the test for the first time is substantially higher. More information about the written exam is available here.

After passing Part I, candidates have a period of 5 years to apply for and pass the Part II oral examination. If they do not, they must re-take Part I to be admitted to the oral exam. It is each candidate responsibility to know deadlines and make a correct, complete application if they wish to be board certified. In order to be admitted to the oral examination, a candidate must have a full and unrestricted medical license, and have been in practice for at least 22 months, of which at least 12 are in a single location. The Board will obtain peer review of the candidate from certified orthopaedic surgeons who are familiar with their work, and get evaluations from the hospital chief of staff, chief of orthopaedics, surgery, anesthesia, and nursing staff in the operating room and orthopaedic wards. This information is reviewed by the Credentials committee of the ABOS, who will decide which applicants are admitted to sit for the Part II examination.

Part II: The oral examination. Once admitted to take the oral examination, a candidate must submit a list of all surgical cases performed during a defined 6 month period. The cases are submitted electronically, through a program called "Scribe". The case lists must be verified by medical records technicians at each facility in which the candidate operates. Those case lists are reviewed by volunteer certified orthopaedic surgeons, and 12 cases are selected. The candidate can choose 10 of those 12 to present during the oral examination. The examination is administered at the Palmer House hotel in Chicago in July of each year. The candidate must bring 3 copies of all pertinent medical records and one copy of imaging studies for each of the 10 cases. There are three 35 minute examination sessions conducted by 2 examiners each. The examiners independently grade each case presentation on 6 skills: data gathering and interpretation, diagnosis, treatment plan, technical skill, outcomes and applied knowledge. In addition, the case list is evaluated on surgical indications, handling of complications, ethics and professionalism. The Oral Board examiners are all volunteer orthopaedic surgeons who have been re-certified at least once. The panels are organized into subspecialty groups for general orthopaedics, trauma, spine, pediatrics, foot and ankle, sports, and upper extremity. More information about the oral exam is available here.

Candidates who pass the examination are notified in the fall. After passing Part II, a surgeon receives a certificate and becomes a "diplomate" of the ABOS for 10 years.

Recertification.

During its’ first 50 years, the ABOS issued certificates that were good for life. From the very earliest days of the ABMS, there was discussion of the need for periodic re-certification, based on the idea that medical knowledge and practice change over time. By 1972, the principle of recertification was adopted by all ABMS member boards. The first 10 year (time-limited) certificates were issued by the ABOS in 1986. In order to be recertified, a surgeon must apply and undergo a peer review process similar to that required for Part II, obtain 120 category I CME credit in the 3 years prior to application, and pass a secure examination. The process of re-certification is based upon the certification model, with CME credits taking the place of the residency education. A computer administered examination is offered for general orthopaedics. In addition, there are three practice profile (subspecialty) examinations consisting of 80 core general orthopaedic questions and 120 questions specific to either sports medicine, adult reconstruction, or spine surgery. Diplomates who have a Hand certificate of added qualification (CAQ) may recertify both the primary (orthopaedic) certificate and the CAQ by taking the Hand CAQ exam. That examination has 80 core orthopaedic questions and 120 hand questions. The new CAQ in Sports Medicine will likely function in a similar manner to the CAQ in hand.

In early 2000, the member boards of ABMS, agreed to evolve their recertification programs into a new concept called "maintenance of certification" or MOC. This path was taken in response to public and state legislative pressure to evaluate physician competence on a more frequent schedule. All ABMS Boards have adopted the MOC program and its implementation will be mandatory by 2016.

Maintenance of Certification.

Beginning with certificates that expire in 2010, all ABOS diplomates with time limited certificates who wish to remain Board certified will be allowed to do so by complying with requirements of the MOC program established by the ABOS. The MOC program has 4 components. They are:

1. Evidence of Professional standing, which will be assessed (as currently) with periodic peer review, confirmation of full and unrestricted licensure in all jurisdictions where a license is held and hospital credentials.
2. Evidence of Life-Long Learning and Self-Assessment, which will be addressed through two 3-year cycles of 120 credits of Category 1 CME that include a minimum of 20 CME credits of Self-Assessment Examinations (SAE).
3. Evidence of Cognitive Expertise, which will occur through the same secure recertification examination currently in place and required at 10 year intervals.
4. Evidence of Performance in Practice, which will focus on a quality improvement model and include a stringent peer review process. The process will involve submission of case lists and patient survey information. In addition, the Board will obtain peer review of the candidate from certified orthopaedic surgeons who are familiar with their work, and get evaluations from the hospital chief of staff, chief of orthopaedics, surgery, anesthesia, and nursing staff in the operating room and orthopaedic wards. This information is reviewed by the Credentials committee of the ABOS, who will decide which applicants are admitted to sit for the Recertification examination.

The requirements for MOC will be phased in. Diplomates with certificates expiring in 2010 will have to meet the CME and SAE standards mentioned above and submit case lists. The peer review component and secure examination will continue to be performed as is currently part of recertification. The final form of MOC, particularly component 4, Evidence of Performance in Practice, is being developed currently. More information about MOC is available here.