ASA April 2003 Newsletter

Current American Board of Anesthesiology (ABA) issues encompass changing numbers of primary and subspecialty certification candidates and programs, ABA policies and administrative matters, transition to a “paperless” ABA office and the very significant introduction by all member boards of the American Board of Medical Specialties (ABMS) to the concept of ongoing Maintenance of Certification to replace episodic recertification.

Candidate Trends: The resident match articles in the ASA NEWSLETTER by Alan W. Grogono, M.D., regularly bring the ASA membership up to date on anesthesiology residency numerical trends. The smallest CA-1 entering class occurred in 1996 with the subsequent smallest CA-2 class, CA-3 class, ABA written examination cohort and ABA oral examination cohort following successively in 1997, 1999, 2000 and 2001, respectively. From 1994 to 1998, the overall pass rate on the ABA written examination varied from 61 percent-71 percent. In 2000, however, along with the lowest number of candidates, the written examination pass rate sunk to a nadir of 46 percent, climbing back to 55 percent in 2001 and then to 62 percent in 2002. Those who passed the written examination experienced similar overall oral examination pass rates to prior years — 70 percent-74 percent for the period between 1997 and 2002 with a consistent pass rate between 79 percent-83 percent for the subset of new American medical graduates.

In summary, because of low numbers of trainees and low written examination pass rates during the late 1990s, the number of newly board-certified anesthesiologists who became available to enter the national workforce pool went from an annual high of 1,536 in 1997 to only 705 in 2001. Subsequently, because of increasing numbers of trainees and improving written examination scores, which together are resulting in more candidates able to proceed to the oral examination, the number of new ABA diplomates per year finally started to turn upward with a total of 818 newly certified ABA diplomates in 2002. Nevertheless, this still represents only half of the number of new ABA diplomate anesthesiologists available annually five years earlier.

Examiner Selection Process Changes: An additional consequence of the multiyear trend of declining oral examination candidates is that ABA was forced to drastically change its system of maintaining and adding to its oral examiner pool. The prior “new oral examiner” waiting list was discontinued because of the lack of demand for new examiners and untenable waiting times to move up. Since potential examiners on the waiting list had been the source of in-training examination questions, the ABA/ASA Joint Council on In-Training Examinations initiated an entirely separate question-writer pool with specific training conducted by the National Board of Medical Examiners. This new written-question development team should be ready to actively contribute in the very near future.

Then, with the upturn in 2002 in the number of oral examination candidates, ABA was able to reopen nominations for a small number of new oral examiners in 2003. There will be no carry-over “waiting list,” and only enough new examiners as needed for the succeeding year will be selected annually. Interested parties should refer to the announcement on the ABA Web site <www.abanes.org> for nomination process details and should be certified or recertified within seven years prior to nomination.

Subspecialty Consequences of Changing Trainee Demographics: As expected, the smallest cohort of subspecialty trainees is following the smallest primary certification class by an additional year or more and may be experiencing additional delayed eligibility for the critical care medicine (CCM) and/or pain medicine subspecialty examinations because the reduced written examination pass rates may be delaying primary ABA certification, which is required to take any of the subspecialty examinations.

The number of CCM trainees registered with ABA peaked in 1998 at 86, fell to 46 by 2001 and remained only 49 in 2002. The number of candidates taking/passing the CCM certification examination has fallen from 120/104 (87-percent pass rate) in 1999 to only 36/24 (67-percent pass rate) in 2002. The numbers of anesthesiologist pain medicine trainees registered with ABA peaked in 1998 at 259 and was 215 in 2002. The numbers taking/passing the pain medicine certification examination were 414/294 (70-percent pass rate) in 2000 and 158/111 (70-percent pass rate) in 2002. The small numbers of anesthesiology CCM trainees as well as the meager numbers taking and passing the CCM certification examination jeopardize not only the viability of administering an annual CCM examination but also confirm that there is very low availability of new anesthesiology CCM subspecialty certified practitioners (only 24 for the entire nation in 2002).

Program/Examination Issues: A number of clarifications of ABA policies have taken place in recent years that may be of interest to the ASA membership.

1. The name used in the pain subspecialty certificate is now “pain medicine” instead of the former term “pain management” for all boards that issue pain subspecialty certificates, which includes ABA, the American Board of Physical Medicine and Rehabilitation and the American Board of Psychiatry and Neurology, Inc. The name change was approved by ABMS in March 2002.

2. Both ABA, which certifies individual physician anesthesiologists, and the Anesthesiology Residency Review Committee (RRC) of the Accreditation Council for Graduate Medical Education (ACGME), which accredits residency training programs, now permit the official residency program director (RPD) to be someone other than the academic anesthesiology department chair, although the academic anesthesiology department chair may remain the RPD. The RPD has final sign-off on issues such as resident competence, requests for exemptions to RRC and ABA training issues, oversight of training quality issues, etc.

3. Requalifying requirements were recently established for re-entering the pain medicine and CCM examination process, similar to those in place for the primary anesthesiology examination system. If an uncertified individual has completed subspecialty training more than 12 years prior or a second examination application was declared void, then the individual must re-establish his or her qualifications to enter the subspecialty examination system by completing four months (one-third of the original training period) in an ACGME-approved subspecialty training program.

4. ABA reserves the term “board-eligible” only for those candidates actively engaged in the examination system of ABA. Thus, if an anesthesiologist is not actively registered with ABA for an examination, ABA will reply to any status inquiries sent to it that the person is neither board-certified nor board-eligible. The “not-certified, not-eligible” designation applies to: a) those who have completed a residency at any previous time (including newly graduated residents) who have not yet/never applied for the ABA examination system, b) those further along who have dropped out for whatever reason from pursuing certification or c) those who have exhausted their second examination cycle and have not requalified to re-enter the examination system.

5. ABA has further clarified licensure requirements to apply for its primary certificate: a) applicants who are already in practice when they apply must provide ABA with evidence of a permanent, unconditional, unrestricted and currently unexpired medical license at the time of application, b) those applying while still a resident for the following July written examination must submit either a license or evidence of having qualified on examinations that provide eligibility for medical licensure (e.g., United States Medical Licensing Examination steps 1, 2 and 3) on or before the “standard” application deadline. Then they must provide ABA with evidence of a permanent, unconditional, unrestricted license prior to November 30 of the examination year, after which date, if no evidence of an unencumbered license has been submitted, that year’s examination will be declared void.

6. To permit J-1 visa holders who wish to extend their J-1 visas for training in non-ACGME accredited fellowships, the Educational Commission for Foreign Medical Graduates (ECFMG) has required a statement that the appropriate Board recognized those areas as relevant to the specialty. ABA recently sent a letter to ECFMG stating: “ABA recognizes that the anesthesiology subspecialties identified in its ‘Booklet of Information’ are an integral component of the discipline and practice of anesthesiology.” The required subspecialty rotations listed in the ABA “Booklet of Information” include pain medicine, CCM, pediatric anesthesia, obstetric anesthesia, cardiothoracic anesthesia, regional anesthesia, anesthesia for outpatient surgery and recovery room care.

“Paperless” ABA: ABA is transitioning to “paperless” administrative operating systems. At present, there is a continuously updated ABA Web site <www.abanes.org> that not only contains the annually updated ABA “Booklet of Information” with the ABA policies and requirements, but the Web site also includes other important information for training programs and examination candidates. Candidates may apply for any of the examinations online or download the applications to mail.

Maintenance of Certification (MOC): A very significant development for all ABMS certifying boards is the adoption of the concept of MOC, which holds that certification of physicians should not be a one-time event that could have occurred 10, 20, 30 or more years earlier and bears no relevance to that physician’s current quality of practice or knowledge base. MOC requires that diplomates periodically demonstrate four principal components: 1) current professional standing, 2) life-long learning and self-assessment, 3) cognitive expertise and 4) practice performance. ABA is in the process of establishing how this would function for anesthesiologists and is setting up the information technology infrastructure to be able to administer such a program on a continuous basis throughout each diplomate’s professional career. The MOC program has to be ready by at least 2004 so that ABA diplomates with time-limited certificates (those certified on or after 2000) can start meeting the MOC requirements to be ready to renew their certificates by 2010. However, any ABA diplomate who wishes to demonstrate MOC to an employer, a hospital medical staff, payers or patients will be able to participate voluntarily.

Many details remain to be determined for the 10-year MOC cycle. At this point:

1. current professional standing will be met with periodic confirmation of a permanent, unencumbered state license along with other local documentation.

2. For life-long learning and self-assessment, ABA, with input from ASA, has created the Council for the Continuous Professional Development of Anesthesiologists (CCPDA), consisting of two ABA members, two ASA members and five anesthesiologist members-at-large. CCPDA is currently establishing: a) the curriculum for life-long learning and self-assessment, b) which continuing medical education offerings will meet the curriculum, c) how many hours and in what distribution over the 10 years, d) ratio of formal programs versus self-administered education, etc.

3. For cognitive expertise, ABMS guidelines for MOC require a secure examination, i.e., no take-home or open-book testing. The current anesthesiology primary and specialty recertification examinations are already secure, being given in commercial computer testing facilities across the United States.

4. Professional standing will be met with periodic evidence of current clinical activity and local assessment of practice performance and perhaps also evidence of practice improvement.

The current proposal for the 10-year anesthesiology MOC cycle indicates that participants would need to register at least two years into the 10-year cycle and submit the periodic professional standing, practice performance and life-long learning and self-assessment documentation to the ABA office. Provided that the professional standing, practice performance, and life-long learning and self-assessment prerequisites are fulfilled, MOC participants could take the secure examination as soon as the seventh year into the cycle, which would still permit the traditional three opportunities to pass the examination. There would be professional standing, practice performance and life-long learning and self-assessment documentation needed up to the 10th year. That way, even if the secure examination was passed in the seventh year, the subsequent MOC renewal would not be granted until the 10th year, and one would not “lose” three years of potential MOC time.

Since the details of the MOC program are not all in place, CCPDA is proposing that individuals certified between 2000 and the MOC program’s availability have reduced LL-SA requirements for their first MOC cycle, in proportion to the reduced time remaining until the 10-year expiry of their current ABA certificate. Diplomates certified prior to 2000, possessing non-time-limited certificates, may continue to take a voluntary examination, without MOC requirements, leading to a 10-year recertification, through 2006. Pre-2000 diplomates may also elect to enter the MOC program at any time after it becomes available. MOC will be the only option after 2006.

ABMS and the Council of Medical Specialty Societies have charged their member boards and specialty societies (in this case, ABA and ASA) to work together to help their diplomates and members achieve the goals of MOC. ABA anticipates that ASA will be the leader among anesthesiology specialty organizations to actively continue current programs, modify existing educational offerings and/or develop new educational products to meet the curriculum needs of the life-long learning and self-assessment aspect of MOC as well as to assist MOC participants to constructively update their knowledge in preparation for the secure examination. ABA looks forward to working with ASA in this endeavor.

Patricia A. Kapur, M.D., is Chair, Department of Anesthesiology, Professor of Clinical Anesthesiology and Director of Perioperative Services, David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, California.

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