JAOA • Vol 104 • No 11 • November 2004 • 485-492
Board Certification of Osteopathic Physicians
Armando F. Ramirez
Address correspondence to Armando F. Ramirez, Department of Education,
American Osteopathic Association, 142 E Ontario St, Chicago, IL 60611-2864.
As managed care's role has grown in recent years, board certification's
importance in the professional lives of physicians has grown correspondingly,
as most managed care organizations require board certification for physicians
participating in their plans. Hospitals increasingly are also making board
certification a prerequisite to obtain staff privileges. Many physicians, of
course, continue to become certified simply to obtain the professional
recognition that accompanies completing the intensive requirements of board
certification and to establish and legitimize areas of expertise. These are
all compelling factors motivating more and more physicians to begin the
process of certification.
The public's perspective of board certification continues to play a
significant role in certification's importance. As patients become more
knowledgeable about their treatment options, they increasingly view board
certification as a sign of quality and competence. The educated healthcare
consumer prefers to be treated by board-certified physicians, and board
certification, though a voluntary process, is becoming an indispensable
designation for physicians.
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The American Osteopathic Association's Board Certification Program
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The American Osteopathic Association's (AOA) board certification program
began in 1939. The official AOA's certifying body, the Bureau of Osteopathic
Specialists BOS), through its 18 approved specialty boards, has been the
primary certification provider for osteopathic physicians and has issued more
than 26,700 General, Special Qualifications, and Added Qualifications
certifications. (Figure
1)
As of the end of August 2004, a total of 18,816 osteopathic physicians are
actively certified by the AOA and hold a combined total of 21,883 active
certificates. In 2003, a total of 1030 certificates were awarded in specialty
and subspecialty areas (Table
1). In 2003, a total of 34 certificates of added
qualifications were awarded (Table
2).
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Reentry Into the Certification Process
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In February 1994, the AOA Board of Trustees directed all certifying boards
to establish a mechanism for re-entry into the certification process for those
physicians whose board eligibility had expired. Such a re-entry process may
include, for example, the completion of a specific amount and type of
continuing medical education credit before being allowed to sit for
certification examination, and may differ by certifying board. This process
does not re-establish board eligibility status, but does allow physicians to
meet the requirements for sitting for certification examination.
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Conjoint Examinations
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In July 1993, the AOA Board of Trustees directed the AOA Executive
Director, in conjunction with the BOS, in conjunction with the BOS (the
Bureau), to study the issue of creating a mechanism for the formation of
conjoint boards in areas of overlapping specialties. This action was prompted
by an application for the formation of a conjoint board of sports
medicine.
In its discussions, the Bureau noted that over time, there likely will
emerge new areas of overlapping jurisdiction in osteopathic medicine in
addition to sports medicine and that the formation of a new certifying board
each time would not be practical. Instead, it was recommended that a mechanism
for creating conjoint examinations be formed which would allow all appropriate
specialty boards to participate if they desire. The Board of Trustees accepted
this recommendation in February 1994 and approved the mechanism for creating
conjoint examinations.
The conjoint mechanism allows diplomates (those holding general
certification) from participating boards to establish eligibility to sit for
examination. To date, three conjoint examinations are offered (sports
medicine, addiction medicine, and dermatopathology).
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Recertification Gains Momentum in the Osteopathic Medical Profession
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Effective January 1, 1995, the AOA certifying boards were directed to offer
a recertification mechanism to its diplomates. In conjunction with
implementation of the recertification process, numerous boards have instituted
time-limited certificates (that is, new certificates are issued with an
expiration date). Effective January 1, 2004, AOA certifying boards that had
not yet implemented a certificate time-dating policy, were required to make
all newly issued certificates time-limited to 10 years or less. Fifteen of the
18 AOA certifying boards had already time-limited their certificates before
January 1, 2004. Certificates issued before the requirement to time-limited
certificates are valid for life. All diplomates are eligible to sit for
recertification examinations, even if they hold a lifetime certificate
(Table 3).
Table 4 summarizes
the current status of establishing time limits on the certificates issued by
AOA certifying boards.
As many of the early-issued, time-dated certificates are just beginning to
expire, in 2003, AOA recertification saw an increase of slightly more than
150% over the number of osteopathic physicians recertified in 2002
(Table 3). This
increase was driven primarily by the first large group of internal medicine
specialists and internal medicine subspecialists taking the various
recertification examinations provided by the American Osteopathic Board of
Internal Medicine. In subsequent years, it is expected that recertification
activity through the certifying boards of the AOA will continue to increase as
many more of the time-dated certificates continue to expire and as
recertification continues to become a requirement for managed care
participation/credentialing and obtaining hospital privileges.
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Psychometric Assistance
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As certification is so consequential, the certification process must be
legally justifiable and valid for credentialers to accept it.
Beginning in January 1994, the AOA began providing psychometric services to
assist osteopathic medical certifying boards in the validation of their
certification examinations. The AOA provides consultation and data analysis
services to certifying boards and assists them in creating, scoring, and
analyzing their examinations. These services provide psychometric guidance to
a board in any step of the examination process, whether for a written, oral,
or practical examination.
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Standards Review Committee Upholds High Standards of Quality
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From the early beginnings of the AOA's certification program, the AOA has
been concerned with the quality and standardization of its certifications. In
1992, the AOA Board of Trustees established a policy on uniform standards for
all AOA certifying boards for test construction, evaluation, and test use and,
in 1995, resolved that the BOS provide for rigorous statistical validation of
the examinations of all AOA certifying boards. In 1997, the Guidelines for AOA
Certification Examination Standards was formally approved, which describes the
psychometric standards that all AOA examinations must meet. From this
document, a plan for a formal evaluation process to assess the validity and
reliability of each AOA certification examination was devised and, in June
2000, the first official reviews of three AOA certifying boards were
conducted. This is an area that certainly brings value to osteopathic
certification and those holding it. The review process is in essence a
continuous improvement mechanism that in the end benefits not only the
certifying board but the current and future diplomates as well.
The format of the certifying board review is a self-study with completion
of a report. These reports are then reviewed by the Standards Review
Committee, which includes six elected members plus the BOS public member, two
alternate members, and the AOA psychometrician (nonvoting). After the first
cycle review, each board is reviewed again in 3.5 years. After the second
review, the time interval between reviews is 5 years. At each BOS meeting,
three certifying boards are reviewed and conjoint examinations are reviewed at
the last meeting of the evaluation cycle.
After review of the board's self-study report, the Standards Review
Committee may make recommendation of compliance to the BOS, or they may defer
making any recommendation at that time. Within 30 days of the Standards Review
Committee's evaluation, the certifying board will receive a written
evaluation, and examination activities found not in compliance with the
standards will be clearly described to the Board. In the first evaluation
cycle if the board was not approved by the BOS as compliant, the certifying
board has 120 days from the date of the written evaluation to respond in
writing with their action plan, specifying how the activities not in
compliance will be addressed. For second and later review cycles, the
submission of an action plan is not required.
For the first review cycle, at the next committee [D2]meeting, the board's
action plan is studied and any comments are forwarded to the certifying board.
Usually, the board's action plan is formally accepted at this time or further
information from the board may be requested. Within 1 year of the committee's
appraisal of the action plan, the board must submit an updated report to the
committee with evidence that shows the board is in compliance with the
standards.
For second and later review cycles, if any examination activities are found
not to be in compliance with the standards, the board must submit an updated
report within 1 year of the review date, along with acceptable evidence that
shows that all the examination activities are in compliance with the
standards. The board must submit its updated report at least 45 days in
advance of the meeting when the committee will study it.
The committee will then review the updated report and make a recommendation
to the BOS for action. If the BOS action finds the board not in compliance,
the BOS may impose a 1-year probation period and the practice affiliate will
be notified of the board's probationary status. Certifying board failure to
comply with the standards results in a BOS recommendation to the Board of
Trustees that the certifying board's directors and/or members may be replaced
and certification activities may be suspended until the board demonstrates
compliance with the standards. At the end of the probation period, the board
must then demonstrate compliance with the standards.
The Committee began meeting in conjunction with the BOS meetings (January
and June) starting in June 2000; the second review cycle began in January
2004. Subsequent review cycles start in January 2009 and occur every 5 years
after that. At each meeting, three certifying boards will be reviewed. The
schedule for the first and second evaluation is shown in
Figure 2.
In addition to ensuring the validity of the AOA certification process, the
BOS is also beginning to explore how to enhance the certification process
through incorporation of the seven core competencies into the process. The
seven core competencies, already espoused by AOA-approved residency programs,
are, and will be items of discussion at near future BOS leadership
meetings.
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AOA Board of Trustees Establishes Task Force on Certification
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In October 2002, the AOA Board of Trustees created a Task Force on
Certification to review the overall operational structure of the AOA's
certification program and to study future trends that may impact or change the
certification process and demand. The Task Force on Certification will
continue working closely with the AOA BOS on determining future steps to
safeguard and promote AOA certification. Additionally, the task force will
begin transitioning its functions to the newly created BOS Committee on
Financial and Administrative Board Matters, which will monitor existing and
upcoming certification trends in the osteopathic profession.
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Board of Trustees Approves New Certification Pathway for Accreditation Council for Graduate Medical Education–Trained/American Board of Medical Specialties Board–Certified Osteopathic Physicians
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In July 2004, the AOA Board of Trustees approved a new certification
pathway that provides a more streamlined and facilitative process for
Accreditation Council for Graduate Medical Education (ACGME-) trained/American
Board of Medical Specialties (ABMS-) board-certified osteopathic physicians to
enter into the AOA certification process. To be eligible, candidates must have
completed an ACGME residency program at least 5 years before application and
hold ABMS certification in a primary specialty. The pathway is for AOA
certification only and does not confer approval of first year of training as
equivalent to an osteopathic internship (provided through Resolution
42(A/2000). For complete requirements and eligibility information, and to
determine whether a particular specialty participates in this new pathway,
inquiries can be referred to the AOA Division of Certification at (800)
621-1773, extension 8266 or 8105.
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Board Certification: Dynamic and Ever-Changing
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As the needs of the health care environment continue to rapidly change, the
AOA and its specialty boards will continue to adapt to meet the needs of the
osteopathic physician and to protect the interests of the public. Board
certification no doubt will continue to play a key role in the professional
lives of osteopathic physicians well into the future.
Mr Ramirez is director of the Division of Certification, Department of
Education, American Osteopathic Association, Chicago, Ill.
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