to do it. We will get started. Thanks for being here. This session is on the changing landscape of continuing certification and we'll of course give you some didactic presentations about what's going on in continuing certification and the evidence sort of backing up the decisions we've made about various aspects of it. But I think we're hoping that there's time for questions and comments and discussion toward the end of the session. We certainly welcome that. So don't be afraid to ask questions. My name is Carolyn Kinney. I'm the Executive Director of the American Board of Physical Medicine and Rehab and I'm also on the faculty at Mayo Clinic in Arizona in the Department of Physical Medicine and Rehabilitation. And my fellow presenters today are Dr. Jeffrey Johns who's an Associate Professor at Vanderbilt University and Vice Chair of the department there and is also Vice Chair of the American Board of Physical Medicine and Rehabilitation. So he's one of our directors. And Dr. Sherrilyn Driscoll who is currently our Chair of the American Board of Physical Medicine and Rehab and is also an Associate Professor at Mayo Clinic in Rochester and focused on pediatric rehabilitation medicine. The only disclosure worth noting is that I'm an employee of the American Board of Physical Medicine and Rehab and that's really the only disclosure. And I'll I think move the podium or move Dr. Driscoll to the podium to begin our presentation. Thank you. But what I'm going to do is a very small history lesson, because I would love to give you some background about why we are where we are, and sort of how we got here. So I'm going to race through, oh, I don't know, a decade, or I'm sorry, a century, of information here in the next few minutes, just to give you a sense of why the board exists, why the ABMS exists, who it is, what it does, and what our goals are, and what our purpose is in our existence as a board. So I will start back in 1916. The first board was founded. That was the Board of Ophthalmology. Back then, there was, I think, I mean, best I can understand from reading about it, turf wars. Ophthalmology needed to put a stake in the sand. We are specialists in eye diseases and eye surgery. This is our turf. We're keeping it. Everybody else, back off. And so they were the first board that was established. In 1947, so fast forward a few decades, the ABPMR was founded. So that was when we were recognized as a specialty amongst medical specialties. And you'll see there that since 1998, we've added a number of subspecialties that you all are probably well aware of, spinal cord injury, pain, PEDs, hospice, palliative care, sports, neuromuscular medicine, and brain injury. And I'm right in front of it, sorry. Is that okay? Yeah, fine with me. You guys, can you guys hear okay or is that bothersome for you? Okay. And so why did boards, other... I've mentioned sort of ophthalmology, but why did other boards come into existence? What was the reason behind it? One of probably the major reason was physicians started to feel like they needed to create some boundaries around a specialty so that a physician out there in the world didn't practice literally everything that some people could claim, look this is what I'm really good at. I want to market this. I do this. I will take care of my patients well with this. And so sort of putting boundaries around that content area that defined their specialty. They specifically wanted it to be independent of societies and academies. And what I mean by that is, as you know, the American Board of PM&R is a separate entity from the American Academy of PM&R, from our AAP, our academic partner in PM&R, and back then the idea was we want them to be separate because the societies or academies are looking after the physicians. They have the physicians back, but we need somebody to have the patients back. So the boards were set up separate so there was no conflict of interest between good care of the patient and looking after the physician's best interest. The system was set up as a national certifying body so that if you were in New York or if you were in California, you had the same certifying body, same certifying stuff going on across the nation rather than having no idea what a PM&R doctor in New York knew compared to a Californian PM&R doctor knew. And so they wanted to make sure that there were standards set for medical practice in any given specialty so that those standards were a sufficiently high level so that patient care and patient safety would be honored. The public would be protected with respect to minimally qualified physician in that particular field. That a hospital or a group or somebody setting up shop somewhere could be recognized nationally by their specialty expertise. And it also was a help to identify what was needed for graduate medical education for residencies and such. And so I'd like to share the American Board of Physical Medicine and Rehabilitation's mission, which will sound very familiar in that context. And that is to serve the public by advancing the quality of patient care in physical medicine and rehabilitation through a process of both initial and continuing certification. That part's kind of added. That fosters professional excellence and a culture of lifelong learning. And I share with you about the past decade of growth in our specialty. You'll see here that as of 2024 we are up to 15,536 total diplomats in physical medicine and rehabilitation from the board. That's all people since the beginning. Back in 1947 we certified 91 original physicians. Now we're up to 15,000 and some. Why did this... What about... Okay. So board certification. Why do that? One of the things that was really important at the beginning was this thing called a social contract. So let me back up a second. Back in the... Before the 80s, before the 1980s, most physicians were not board certified. Fast forward to the 1990s and beyond, most physicians are board certified. What happened in those years? Well there were several things that happened sort of in the 70s, 80s that made a difference and started pushing people towards board certification. One was, first there was a growing consumer movement in healthcare. Patients were like on it. Secondly, growth of hospital based and subspecialty surgical care and a hospital's wish to have credentialed physicians caring for their patients. And third, the growth of managed care and an associated desire to distinguish a group. And then as people were thinking about all of these things, there was a book that came along in 1984 by a person named Paul Starr. And it was called, The Social Transformation of American Medicine. And the idea was this social contract that I referenced. So that specifically, the social contract was an understanding that society had a willingness to grant physicians respect, autonomy, self-regulation, key, and financial rewards in exchange for competence, altruism, and promotion of public service. That was called a social contract, specifically the physician charter. It was endorsed by over 140 medical organizations at that time and it's something that basically we have lived with as physicians since then. So back in the 1990s, as those of us who were around back then knew, you got board certified and then you essentially... you were good to go. Once you passed your boards, you paid a dues, you got your CME, you maintained your license, and you were good to go for a lifetime certificate. But the thing is, the science and the practice of medicine change. I think we could all say that compared to the 1990s, things have changed a bit. The pace of change is accelerating. Patient safety became a huge issue, as you all may recall with all the articles, you know, a decade or two ago about mistakes in medicine and patient deaths related to our medical care and whatnot. And then it was also, I think, a lot more information about our ability to care for patients as we get on in our careers came to the fore and we realized that self-assessment of performance really doesn't correlate very well with objective external assessment and there might be some decline with age. So certification evolved. And in 1993, the American Board of PM&R phased out lifetime certificates. So anyone who was boarded 93 and beyond received a 10-year certificate. And so that was sort of the beginning of the system that most of us have known over the past couple of... a few several decades for recertification. Every 10 years you had to sit for your next, you know, your next test, prove that you know the material, you can take care of a patient, you have minimal competence in your area of practice. Other boards caught up to that. We weren't the first that did that doing the recertification every 10 years, but we certainly weren't the last, because it wasn't until 2002 that the American Board of Medical Specialties, which is our umbrella organization under which the American Board of PM&R lives... The American Board of Medical Specialties is an organization that houses the 24 medical specialties out there, you know, American Board of Pediatrics, American Board of Anesthesiology, etcetera. All of us, 24 of us under the ABMS, the ABMS came out with some shared guidelines for maintenance of certification in 2002. And so really it was then that pretty much every physician had to go to this recertification cycling over time. During this time I think that the board community also became very much aware of our accountability to the public in terms of patient safety and whatnot. We became more aware of some of the data related to maintenance of skills by physicians over time and just because of the understanding about adult learning, what's of value, what maybe isn't as much value for us. People decided, okay, it's time to rethink this. It's been a couple of... You know, it's been a decade or more. Let's rethink this. It might be time to evolve again. And so in 2018 the ABMS established a new group. This was called the Continuing Board Certification Vision for the Future, which has been affectionately known as the Vision Commission. And they got together to consider what might come next in continuing certification. I want to tell you just a little bit about that Vision Commission. It was a huge undertaking, really a big undertaking. Basically what they did was they put together a cross-section of physicians and a wide variety of stakeholders and those stakeholders included national specialty, society societies, state medical societies, hospitals, healthcare systems, healthcare organizations, ABMS member boards, general public, all kinds of physicians to basically get together and assess the existing standards, existing sort of science at the time that reflects our continuing certification and continuing ability to practice. And they recommended some changes. The goal was to better reflect the commitment to self-regulation, as I mentioned with the social contract before, and promote the highest standards of care. They had all kinds of task forces. They addressed various aspects of certification. They sought feedback from all of us, from a whole bunch of other people and stakeholders, and in 2021 they rolled out their recommendations for new standards for all boards and all people who are board certified with the expectation that we would all be meeting their standards by 2024. And so in 2024, January of this year, those standards were officially rolled out. All board certification sort of falls under that rubric now. Goals and the point of all of the continuing certification changes that were made, foster excellence in patient care, keep up with current and evolving medical knowledge, demonstrate professionalism, maintain your knowledge and skills over time, provide assurance to the public that that physician over there who's PMNR certified is the same basic knowledge as that physician over there, so they know there is some basic common knowledge to all of us, and continually make some small change to make our medical world a little bit better. So I will conclude with just a few thoughts and that is that to this day I would say board certification helps to fulfill the social contract that I mentioned. Certainly has changed over time and I guarantee it will continue to change over time and I recognize that sometimes it's hard to keep up. Provides a measurable degree of certainty about physician knowledge and professionalism and truly is intended, genuinely intended to help make us better doctors and improve the healthcare system. And with that I will turn it over. So my part in today's presentation is to convince you all that there's an underpinning of evidence for continuing certification, because we know people don't want to do it. If I ask this audience, how many of you want to do continuing certification and all that's entailed, raise your hands immediately. One person. I'm going to nominate you to the board, okay. So two people. But the truth is, people don't. And I get that. If you ask people, do you want to take a test? No. Nobody wants to take a test. We know that. Years ago, I spoke at one of these meetings. Actually, it was a town hall. And it was kind of in the, like, almost chaos related to continuing certification. A lot of pushback from all directions. And one of the accusations that was hurled, and that I heard repeatedly, you know, after that was, there's not a shred of evidence to support doing any of this. And at the time, you know, painful, though maybe that was, because we had made all these decisions about what seems to feel like it's the right thing to do, really didn't have a lot of support, evidence in support of it. But let me tell you, that has changed dramatically. And now there are lots of shreds of evidence about this being the right thing to do. That continuing certification broadly is the right thing to do. And some of the specifics about our particular design are also underpinned by evidence in support of some of the decisions we've made. So I hope I can convince you. I don't think I'll be successful in making you want to do it. But maybe you'll understand why it is the right thing to do, as Dr. Driscoll said, for the public. So firstly, we know that maintaining knowledge over time is hard to do. And there's abundant evidence that medical knowledge that physicians possess declines over time. Also, physicians are not good judges of what they don't know. And I'll show you some articles that reference this. Cognitive skills that are related to patient outcomes are increasing in number and do support testing as a means of assessing somebody's abilities to function as a physician. Even scores on examination, scores on examinations, including our examinations, are relevant to what the public would want to know about how competent their physician is. So I have the article by St. Onge listed there. It was an article that looked at family medicine physicians, both practicing physicians as opposed to residents. And they presented these groups with some clinical vignettes that were kind of prevalent kinds of cases, but some that weren't necessarily so prevalent. The younger physicians did better overall by a lot on judgment about treatment and things like that. The experience of the older physicians did not mitigate that difference. And it was found that the younger physicians were more likely to not pursue direction for treatment or diagnosis for things that had been disproved. Older physicians were reluctant to give up things that they had been practicing for a long time. So that was one article. The article by Gray is more recent and it looked at 455,000 Medicare patients and how they did, what their outcomes were. And they examined whether the physician ratings, milestones ratings related to what the patient's outcomes were. Outcomes like mortality, length of stay and that sort of thing. And the answer to that was no. But guess what did relate closely to how the patients did? Scores on the certification exams and the continuing certification exams. So that was a big study and a recent one. These are a series of articles that address what I said earlier, that skills and knowledge decline over time. This is not a theory. This is true and there's a lot of evidence to support this. The article, the systemic review of the relationships between clinical experience and care. Chowdhury's article from 2005 was in the Annals of Internal Medicine. Reviewed, it was an overall analysis of 62 studies looking at how old physicians were or years from the time they graduated from medical school and the performance of how they did adhering to guidelines for diagnosis, screening, treatment, that sort of thing. Again, younger physicians were much more likely to be adhering to current guidelines. Older physicians were more likely to be adhering to things they learned probably in residency where a lot of times there's kind of a hard stop in how people evolve their practices. In 2017, the Norcini article looked at outcomes that patients had, again, a Medicare population for admissions, Medicare admissions for things like myocardial infarction, congestive heart failure, GI bleeds, hip fractures, and pneumonia. And found, sadly, that every year, excuse me, every decade since medical school graduation translated into a 4.5% increase likelihood of mortality if you're admitted with one of those diagnoses, Medicare patient. So obviously there's tremendous variability within these groups, but it's pretty evident that acquisition and putting into practice new knowledge is something that people don't do, physicians don't do unless they're led to it, really led to it. And that's what most of these articles, you know, address through different mechanisms and there's quite a bit of evidence, as I mentioned. Well, a lot of people ask me, what about self-assessment? How come we can't just do self-assessment and figure out where our knowledge gaps are and, you know, we'll study up on those things? Well, again, it turns out we're not that good at self-assessment. Physicians are not that good at self-assessment. And we're not the only ones. I actually came across some kind of funny, unbelievable quotes from a long, long time ago. One of which was by Charles Darwin who said, ignorance more frequently begets confidence than does knowledge. That's an incredible quote from like 1871. And then another one related to that is, it is one of the essential features of incompetence that the person so afflicted is incapable of knowing they are incompetent. To have such knowledge would already be a remedy. And when we first rolled out the longitudinal assessment, some of you may remember, we used to ask people, well, how confident are you in the answer you're giving? And you could pick, you know, not so confident, a little bit, whatever for the answer you gave. And, you know, the most concerning always were the people who put really confident and the answer was wrong. And there's a body of literature about that as well, which, you know, we don't really have time to get into. Except I will say this, guess which gender is more likely to do that? Just a guess. And that's in the literature quite a bit, sorry. These articles all address the fact that self-assessment, there are so many biases that come into self-assessment. People tend to gravitate toward things they like or are interested in, things that seem easy. Sometimes they actually are looking things up and they mistakenly think that means they know the information, which they don't. And there's quite a bit of evidence that self-assessment is terribly biased and is probably not a good way for somebody to judge whether they're competent in a lot of domains, but, you know, specifically in medicine. This was sort of a depressing little curve and it's not a new one. It's something called the forgetting curve and it dates from studies that go way, way back, but it has been reinforced with a lot of literature about how quickly we forget things. You're going to forget what I said, except maybe the Charles Darwin quote, right away after this talk. You might remember that there was some evidence that seemed somewhat compelling, I hope, but you're not going to remember very many details of this. And that's just how we all are. You come to one of these, you know, the academy meeting or the AP meeting and we're coming for CME and we think we're going to learn things, and maybe we do, but so much is out the window almost immediately. There are things that help change that curve and a lot of that has to do with the things we're doing in longitudinal assessment. Testing itself is one of those things and the spaced repetition of testing of questions is another one of those things. So, this is about testing enhancing learning. The Roedinger study was in 2006 and it's, actually it looked at undergraduates, so young brains, and looked at whether letting them study twice, look at the material twice, and then try to remember, versus look at the material and then test them on it, and how did they do? Well, right out of the gate, like immediate recall, the first group did better. Immediate recall, because they saw it twice and they remembered, right? Further down the line, the group that tested did way better than the group that saw the material twice. And it's, you know, the other thing about the testing is that the testing should be consequential. It makes it different than saying, okay, everybody, we're going to offer you a test, but it's an open book test. All the answers are right in front of you and you all go. But again, will you remember any of that? No, is the answer, because that's not actually testing. It does a little something to focus your attention, but it really doesn't help retain. And, you know, educators have known this for a long time. It's why, you know, students are kids or whatever. They get tested a lot to make sure they know the material, and they get retested and retested. And like everybody, they don't like it, but it is how they learn and retain the information. So the space testing provides a boost to the learning. And that's one of the design features, as you know, for the longitudinal assessment. And when you get something wrong, you see it again. So there's a spaced repetition so that you have an opportunity to reinforce things that you didn't know the first time. Error correction is important, and that's one of the things that's addressed by the Metcalfe review, which is at the bottom of this page. It's obviously in a high-stakes exam, like initial certification, part one, part two, making errors is not good because, you know, it might affect your score, and you might not be successful. But in something that's much more lower stakes, like the continuing certification, the longitudinal assessment, making an error is not bad. It's what focuses you on what you didn't know. And you have the knowledge from us that you're going to see that question again, and you're going to have another opportunity to answer it. And if you do answer it correctly, that's a correct answer, you get full credit for that. So it's lower stakes, but it does require you to cognitively engage with the process. You can't just swim along and, you know, answer things incorrectly and think you're going to necessarily pass the assessment. But if you do engage and you learn from errors that you've made, that's actually a very powerful stimulus for learning that you retain, which is important and, again, one of the underpinnings of what we're doing. Well, what does the public want to know? What's like, what are the things that are important to them about any of this? They want to know their physicians are competent. Is there anything we can say based on, you know, these tests and everything we do that would be important for the public? One of the studies that we did and has been repeated by some of the other certifying boards has to do with disciplinary actions. You know, we unfortunately have people who get into disciplinary trouble with state medical boards for a variety of infractions. Some are minor, misreporting CME credits or something like that. But some are not minor and, you know, run the gamut from prescribing, you know, failure to document, boundary crossing, if you will, pill mills and all kinds of things like that. So those are real disciplinary actions and it's odd. You wouldn't think that board certification would have any correlation necessarily with that, but it's a proxy for professionalism. That's what it really is and it has a huge correlation, it turns out. People who are not able to pass the board certification exams or fail either one of the Part 1 or the Part 2 have like a more than five-time, five-fold likelihood of getting into trouble with one of these DANS reports. It was extremely significant finding. And moreover, not just the passing, but the actual scores also correlate. And I mentioned that earlier in another study. those who were in the lowest quartile for any of these tests were more likely than those in higher quartiles to run into trouble through their careers. So it's not that certification will definitely point out somebody who's likely to have this kind of trouble necessarily, but it is an association that's real and I think the explanation for it has to do with overall professionalism. The gray study here was in JAMA in 2021 and this had to do with Medicare patients presenting with low back pain and how quickly physicians were adopting the new guidelines for opioid prescriptions which were changing a lot during this time. And again, the scores on their continuing, this was internal medicine, continuing certification exam which they had one exam for continuing certification correlated very highly with how likely physicians were to adopt the new guidelines for opioid prescribing right along with or ahead of some of the big changes in what was recommended for opioid prescribing. One of the things that we hear a lot about is the aspect of continuing certification that has to do with quality improvement. And it is correlated with improved patient outcomes. Jim Sliwa, who's physical medicine and rehab physician and a former director of our board looked at our process improvement projects, all of them at that time, and kind of categorized them into patient outcomes and improved efficiencies. There are a variety of buckets that he put them in. But he really found that patient outcomes and patient experience improved, those projects represented real improvements in patient care and outcomes, so that was good. In the world of family medicine, both the Phillips article and the Peterson article looked at their experience with quality improvement and the Medicare population. They have a fairly robust quality improvement program including a registry and some modules for what we call PIPs, something very similar, and documented much better adherence to guidelines for blood pressure control, A1C, cholesterol management, and things that they could pretty easily target through the registry. We've recently included some research about the workforce in physical medicine and rehab. And because of the longitudinal assessment, we have the ability to ask people questions when they enroll every year. Most people are participating in the longitudinal assessment and as part of the enrollment, we're asking them, you know, what's your practice like? What are you doing? What are you seeing? Are you academic, et cetera, et cetera? And that information turns out to be really useful for not just what we do, although it is for the blueprints and the relevance of what we're producing for you all, but also for the ACGME, they're revising the training standards for PM&R residents. Right now it's good for them to know what it is people in practice are actually doing because they won't do this again for like another 10 or 15 years. And so right now this was a huge study. We had like 9,000 people respond. By far the biggest workforce study that was ever done in PM&R. And Dr. Sabarwal, who's here, also authored a study looking at subspecialty certification, which helps us decide, you know, what subspecialties we should continue, where are gaps in what patients need versus people entering subspecialties and things like that. The information can really help with strategic decision making. What matters to patients? Well patients think that we're being assessed regularly. And we are now, but there was a time when that was not happening. And I think patients, you know, a quote from one of the studies I saw said, you know, my lifeguard has to recertify every year in order to be the pool lifeguard for whatever it was. Actually shocked to think that physicians weren't being reassessed periodically. So they expect that we are. They expect that we're involved with improving the quality of care, their care. They expect to figure out, be able to easily find out if someone's certified, that we can display in a transparent way what that certification history is. They expect that we're addressing professional conduct and professional standing, which is increasingly one of, you know, part of what we're doing all along now to incorporate that more and more into our continuing certification. And they expect that we're going to continue to encourage, really require participation in continuing certification. Just a couple of reminders. You know, it is a higher standard than licensure. So somebody having a license, you can practice, but it doesn't necessarily mean that you're going to be board certified. It is a higher standard. A lot of the higher standard, part of it has to do with professionalism. But, you know, there's the continuing certification requirements, the testing, and so on. It is a voluntary process. You don't have to do it. But we know that, honestly, almost everyone at least attempts to get board certified after residency. Not everyone is successful, but everybody attempts. It does provide objective evidence for your knowledge, currency, I think your professionalism and your engagement in being the best that you can be, including improving quality. It does reflect your own commitment to knowledge, competence, and professionalism. And it's a credential that's trusted by the public and by health systems. Many of which, as you know, require it for being active within a health system. And that is my evidence. I hope I've convinced some of you that there's more than a few shreds of evidence and support. Thank you. And this is Dr. Johns. Thank you, Dr. Kinney. So with that historical context from Dr. Driscoll, with some of the evidence behind why are we doing this, why are we asking you to do it, why are we asking ourselves to do it, because we do. We're all required to do this. I'm just going to walk through some of the just details about the current process. As well as share some what should be very positive updates for you that many of you should have received emails about earlier or an email about earlier this week as it relates to the QI projects and I'll introduce you to some new terminology along the way. So this is a screenshot from the ABPMR website about the current five-year continuing certification cycle. So there are several components to this, professionalism, professional standing, licensure requirement. There are learning components, lifelong learning that includes CME, self-assessment, and now the longitudinal assessment and again I'll share some updates about that that are coming. And then the quality improvement and you see the requirements in the column to the right about over the five years what's involved for each of these components. So longitudinal assessment, there we go. So again as has been referenced here with like adult learning theory, this longitudinal assessment for primary certification began in 2020 to replace that once every 10 year MOC exam. And I think most people really received that well. We heard a lot of feedback prior to that time about the amount of time it took to study for that exam, taking time off of work, the investment to maybe travel to a testing center, these types of things rather than what we also know is a better way to learn with this adult learning theory of having information that can also be updated real time, new information that needs to be pushed out quickly to the specialty through the longitudinal assessment platform. So for several reasons this was determined to be a good decision and I think in general it's been very well received by the large majority of diplomats. We have also more recently included in the fourth quarter of each year article based questions, which again has been generally extremely well received and another way to push information out more quickly, especially with clinical practice guidelines, things that aren't just kind of a potentially one-off article, things that have enough evidence behind them that really should be considered new things that need to be implemented, diplomats need to be educated about. So in the fourth quarter of each year selecting these articles based on your own preference, based on your own practices to select those articles and answer questions about them in that fourth quarter. We did make a move this year that we're going to continue to try to evolve to release those articles sooner or at least let you know what's coming, because we've gotten some feedback and I have experienced it myself that the fourth quarter can be a busy time of year. So if I know what articles might be coming earlier in the year I can select those articles, I can read those articles sooner and not have to condense everything into a very busy time of the year. So we do want to continue to try to make this not just a better process, but also an easier process and so this should be hopefully a step towards making this easier and more accessible. In January of this year, if there are any brain injury medicine subspecialty board certified physicians here, the subspecialty for brain injury medicine rolled into the longitudinal assessment platform beginning January of 2024. We will also, beginning in January of 2025, begin pediatric rehab medicine and spinal cord injury medicine. So all three of the subspecialties over which we have direct oversight within PM&R, so it's not everything that PM&R physicians are subspecialized in, but everything that's within the primary purview of ABPMR will now be in the same platform and in longitudinal assessment moving forward. So the recertification for all three of these subspecialties will not require a 10-year exam. Uh, this is just a quick look at what the new platform is going to look like, because the other change that's going to happen in 2025 is we are bringing everything in-house essentially and it's something that you're probably not even aware of, but the platform that you currently use for LA-PM&R is not our own platform. Uh, LA-BIM is our own platform. So we are rolling everything primary and all three of the subspecialties into our own platform beginning in 2025. Why do you care? It will give us more flexibility and more, um, uh, the ability to make changes in a system that we now own and control internally, our IT team, um, because there are a lot of things that come up that we get asked, can we do certain things? And in a system that we don't control, the answer has been, unfortunately not. Now we have the ability to look at individual situations and make decisions, uh, and potentially make changes to the system. Um, so these are just screenshots. I think if you, you know, are brain injury medicine certified, you've seen this platform or know colleagues who are, uh, we've gotten really good feedback, um, as we did with primary LA-PM&R. We did a lot of beta testing up front. We're doing it now or we did it for the brain injury medicine. We're doing it now for the rest of the two subspecialties and primary that are about to go live. So that testing, maybe some of you in the room are involved with that testing, uh, that just got released I think in the last day or two. So we are testing it, make sure it's ready and operational, um, and we're very confident that it will be. So you'll still have the same flexibility to design your LA-PM&R just in the same way you do now, selecting percentages, um, and modifying this in a way that will, in large part, reflect your current practice while still recognizing that primary certification means that being board certified in PM&R does mean that you need to be, you know, current in knowledge across all areas of our field. So this last piece then that I already referenced, the quality improvement projects, that last bar on the bottom, uh, as also was referenced earlier, uh, we recognized that not everybody feels comfortable in this space. Not everybody likes to do this, but I hope you have also heard why it's important to do this. Uh, we are all in medicine to do the best for our patients at all times and we need and want to continue to improve that. Um, and I think similar to what we've been discussing about awareness and self-assessment of knowledge, unless you really look at your own practice, you may not realize where those potential gaps are. So studying particular areas that could be weaknesses, identifying problems, um, and then working to improve those and these aren't... Uh, they don't have to be high level, uh, you know, federally funded research studies. These are things of incremental changes at the practice level that will typically have pretty immediate impacts and improvements on patient care. So if there are any, uh, residents or fellows in the room, it's important to know that as we talk about QI projects or what you'll be introduced to, uh, here, this term IHHC, even during the time of residency and fellowship, this can be banked. So, uh, training programs also require that a quality improvement project be done. So if that's done as part of a training program, this can be banked and given credit during that first five-year cycle. So recognizing and rewarding and giving credit for work that has been done and allowing those early career, uh, physiatrists, uh, to check that box by work that they did even during their training program. So hopefully that's, uh, well received and we're seeing a lot of, uh, a lot better uptake about that and we're trying to get that message out and make sure that learners really know that this is an option. So walking through some of the things that have been available, this isn't new information, but it's just kind of a reminder about ways to satisfy this requirement. So there are currently 22 available templates on the ABPMR website. And so you can use this wizard, the QI project wizard or PIP wizard, you'll hear me use that term interchangeably. They're Quality Improvement Project, PIP, which you could think about as a Process Improvement Project, Practice Improvement Project. But this wizard can help guide you to say what's your practice setting, what type of patients do you see, and lead you down a path to say you might consider this template. You don't have to use one of those. You can always design your own project. This is just, again, a way to try to help make this process easier and more accessible and less intimidating to some. We do allow folks to work together on group projects. We are working on ways to improve this internally because if you submitted something to our system called Submittable, the current group project submission requires that each person on the project submit this thing, their project write-up, individually. We want to make this easier. So we are in the process of trying to figure out exactly how to do that so that one person could submit. It would then email, ideally, email the rest of the people on the group project to say, can you attest to the fact that you were on this project and which of these things might you have done as part of this quality improvement work? And once that comes back, we review the project once, assuming it's approved, then everybody gets credit. So making things easier. There are other options available in addition to the templated projects that I was just mentioning. So through AAPM&R, there are some free pre-formatted projects, free to members. There are also some available within AANEM, if any of you are members there. There are currently, I think, three pre-formatted performance and practice projects there. There is also available for those kind of part of larger institutions, there's an ABMS, that's the American Board of Medical Specialties we've been referring to, portfolio program. My personal experience with this is I think there's been pretty low uptake to utilize that to tap into these projects from PM&R diplomates, but the opportunity exists. So if you are at a medical system, academic medical center that's part of this, it might be an opportunity for you. So it's to kind of join in with ongoing work that's being done that's been given approval by ABMS to be considered at this portfolio program. Additional things that, again, not new information, just reminders. So there is such a thing called a patient-centered specialty practice recognition. This is through the NCQA. There's also an accreditation process, musculoskeletal ultrasound, through the American Institute of Ultrasound Medicine. So if your practice is accredited through the American Institute of Ultrasound Medicine for ultrasound-guided interventional procedures, you might be able to use that as your QI or IHHC credit if you were part of that improvement and quality work that went into that accreditation process. So Dr. Driscoll was talking about the vision commission and this is going to evolve now into some things that are hopefully what you'll receive as positive changes. These aren't going to be new requirements. These are new opportunities in addition to what I was just detailing as current and previous. These are new things because of these new standards, new information, new guidance. So the vision commission has really required member boards such as ABPMR to do a couple of things in this area of improving health and healthcare. New terminology that's from the vision commission and it's a shift or an evolution beyond just quality improvement work. It still contains quality improvement work, but it's improving health and healthcare. So it's a bit more broad you can think of this. So what they're asking member boards is to look at ways to align member board requirements for continuing certification with what you're being asked to do as part of your daily practice. Clinical care, administrative work that you might be involved with, maybe both, things that your hospitals are asking you to do, health systems are requiring you to do, payers, other things that are going on. So how can we align some of those things and give credit for that work again that you're already doing? The last thing and I'll come back to this, but this is from ABMS, is to recognize that diplomates do have varying degrees of knowledge and experience with actual quality improvement work. So hold on to that and I'll come back to it. So a couple of things that have been approved very recently. This one you might have seen announcements last year, I think right after the academy meeting, because we had discussions with our two main society partners, the AAP and AAP Menar, that if a poster is approved and presented at either of those two annual society meetings that are quality improvement projects, we are still working to optimize how we do this, but we will try to take the burden off of those on those projects and review and approve those projects separately. Not requiring another step of taking that work that was already done, you've already submitted it on an abstract, you've gotten it approved, you've made a poster, you've done a presentation. We felt like it was a good idea to say, well now you don't have to turn around and now put it in our submittable system as just another step and another hurdle. So we want to offload that and make this easier. You're doing the work. Let's try to make this process easier. So again, we're trying to work with our two professional societies to figure out better ways to do that internally, but we want to try to again remove that from you all. I think there are also benefits to that, just going back to that comment a minute. There are also benefits then, especially for those who want to share the good work that they're doing more broadly with other physiatrists, knowing that you can not only present and share your work at a conference, but make this easier to get to earn your QI or your IHHC credit may be another reason to think about going ahead and doing that submission and making the presentation at AAP or AAP Menorah. So another accreditation process, AANEM, the Electrodiagnostic Laboratory Initial Accreditation Process has baked into it a requirement for quality improvement work. So earning that accreditation, if you're a medical leader who's part of this lab accreditation process, if you submit that letter, that accreditation letter, and just a short attestation that can be downloaded from our website that says, I was part of this quality improvement work, I was involved as a medical leader, that's your credit. We don't need the details of what the project was. We don't need that submitted into a submittable system to review that quality work separately. We know it's part of this process. So again, aligning things that you're already doing. For those of you who are involved in training programs, be they ACGME fellowships or residency programs or both, if you serve on the program evaluation committee or clinical competency committee, again, those committees have part and parcel, very integral to them, quality improvement work. You're evaluating performance of residents. You're doing individualized education programs. You're trying to help with their learning process and improvement, and the overall quality and improvement work that's done at the program level. So serving on that for three years with a simple form that's downloaded and signed by the residency or fellowship program directors, that earns your IHHC credit. More accreditation work that has baked into it quality improvement work. CARF that also has an outpatient opportunity for those who are in outpatient settings that have CORF accreditation, whether it's at the hospital level or specialty level. Similarly for joint commission at the rehab hospital or joint commission disease-specific certification programs, those all require quality work, program outcome measures. That you're working towards. Your teams are working towards. This is ongoing work as part of your accreditation cycle. And again, not requiring that you then have to turn around and submit that quality work and what you did and what you tried to improve and your data analysis. CARF and joint commission are looking at those things. So if they come in and review what's been going on and you're a medical leader in one of those programs or hospitals and you've gotten your accreditation or reaccreditation, that letter along with a attestation form that says, I was a medical leader and part of this quality work, you got your IHHC credit. Aligning what we're asking of you with what you're already being asked to do at your hospital level. We also recognize that the work of our board for all of the reasons, especially that Dr. Kenney was talking about, about why is this important for quality and patient care and safety, this board certification work requires a significant amount of volunteer effort and hours, including the directors, but more so item writers and senior reviewers and longitudinal assessment item writers. So serving in one of those volunteer roles for three years will earn IHHC credit. We have also recently approved a new volunteer role that if anybody is really passionate about and experienced in quality improvement work, we are recruiting for quality improvement project reviewers. So that's a new opportunity that we have just started to socialize and publicize. So if it's not you, but you know somebody that's in your group or in your practice or your department, please let us know. So circling back to the comment that I made earlier that I said I was going to about recognizing that diplomats differ in knowledge and experience with quality improvement work. This is actually the opportunity that started us down this path about a year and a half ago to think about what things might we include that are beyond just the actual QI projects. And it's a developmental option. It's to help diplomats hone those skills, become more confident, learn about quality improvement processes. And now that we have article based questions as part of our longitudinal assessment in the fourth quarter beginning in 2025, so fourth quarter of 2025, there will be one quality improvement article as part of those fourth quarter articles. And if you select that once a year for four years, so it's four articles over four years, that should be educational and developmental or formative in helping you build your skills and your comfort with quality improvement work and earn that IHHC credit. Now because that's developmental and you're not really doing anything with it, it's something that we're not going to say, well you can just do this every five years from now until you retire. You need to do something with it. We're trying to help everybody be more comfortable in this space. So if you do this formative work, this developmental work for one five year cycle, we ask that you then do something else in the next five years. Ideally, you take what you've learned and you say, yeah, I'm comfortable in this. I can look at my practice. I can look for an opportunity. I can work with my team on what I might need to change and see if I've made any difference on that thing that I found an opportunity in. And that's my quality improvement work. And then if you feel like you still need to go back and hone some skills, you could then go back and do some more developmental work. But ultimately, hopefully launching from that and say, I don't need that anymore. I'm going to focus on how I can continue to make things change in my practice for the better health and healthcare of my patients. I think I just touched on all of that. So I'll pause there again. So improving health and healthcare is the broader term now. One option within that is quality improvement projects. But it's these other things now as well. We recognize there are probably other things out there that we need to consider. And we've had things brought to us as a board, as directors, to say, hey, what about this opportunity or this thing? And some of those we've reviewed and we say, yes, that absolutely fits. Others we've said, no, or we need more information on it before we can kind of make a determination. We have been changing a lot as you've seen. It's taken a lot kind of internal processes. We've gotten the website updated, tried to make this easier. So we have forms available online for these attestation letters that I'm talking about now. We need to make sure this is going well, but it doesn't mean we can't keep a running list of new opportunities. So I hope you receive all of this as good news. Making things easier, making things more accessible, these are not new requirements. Okay. I don't want you to look at this and say, no, I've got to do all of these different things. That's not what this is about. This is about better alignment with what you're being asked to do for continuing certification and things that you're already doing. So please do let us know if you know about other things that we want to keep on that list that we should explore or ask another accrediting body or certifying body or something to give us information. We're happy to start exploring those, but just know that we need to make sure these things are up and running because, you know, as we've started to publicize these things even informally a couple of months ago, we recognized that we needed to shore this up before we can continue to just kind of add things to this. But we recognize this is probably not the end of the list. So I think my final slide says some just general comments to get about the role of continuing certification. As was mentioned earlier, this does help to fulfill that physician social contract. This has changed over time during the course of probably many of the careers in this room, my career as well, and it's likely going to change again. So we hope that this has been helpful to understand the how and why and the current what and the way that we will approach this moving forward. And the role of continuing certification is genuinely intended to make all of us better doctors, to improve the care of our patients, and to improve overall health care. And with that, I thank you and we would welcome questions. So, the question is about neuromuscular medicine and a longitudinal assessment. As you probably know, we do not run that exam. We are a co-sponsoring board. The American Board of Psychiatry and Neurology doesn't have longitudinal assessment as part of its continuing certification. What they have is a program of article-based reading and questions, and it's a lot of articles. It's not like the articles that we have. It's like 25 to 30 articles every couple of years with questions, and you have to meet some sort of cutoff. They have a completely different system and different cycles for continuing certification than we do. So we're talking with them about, you know, is it possible for us to somehow blend these processes. Right now, if you take their test, it's still something that would only be required every 10 years, interestingly, and I don't know how long that will continue, because that's not sort of part of the guidelines that ABMS wants everybody to follow. But the article-based assessments are every three years, and it's a rolling three years. So you're having sort of a summative decision every three years. That's what the options are right now. We haven't embraced the article-based program because... Just because of the cycle differences. We also hardly have anybody that's going to be involved with that decision quite yet. It's not too many people are in neuromuscular medicine, and those who are not up for recertification, I think it's like one person or something like that. So stay tuned. We're looking into that. At this point, right now, the only option we have for PM&R is to take the 10-year exam. I'm going to add on to that, just kind of touching on the bit of variability. If you're familiar with any other specialties, other member boards, not even just the subspecialty level, but if you have colleagues, partners, who might be practicing in another area, there are variabilities across continuing certification programs. With the new guidelines, the new standards that have been implemented as of January 1st, 2024, there is an effort through ABMS to not necessarily standardize and say, everybody has to do this the same way, but just to make sure that everybody is, you know, evolving their programs in a way that will meet the standards because of the extensive work that went into the... through the Vision Commission, through all the stakeholders that Dr. Driscoll was mentioning, to make sure that these are being implemented. So I currently sit on a committee with ABMS called 3C, which is their Continuing Certification Committee, and we have begun this year to do some peer reviews of other member boards' continuing certification programs. So I've recently done that with two other member boards, and that's going to be an ongoing process now to have somebody external review, you know, with other member boards, reviewing continuing certification requirements to say, do we feel these are clear to their diplomats, and are they meeting these new standards, or do they have plans in place to get there? So it doesn't mean we're all going to look the same, but we do all need to be meeting the standards across member boards because board certification through ABMS needs to mean the same thing across any specialty, not just within peer. I had a little bit of trouble hearing you. I think what I heard you say is if your hospital requires you to do a quality improvement project, would there be a way for us to also use that project? Is that... So if the quality improvement project that you're referring to is part of work for CARF or one of the joint commission opportunities I mentioned for a rehab hospital or a disease-specific certification, that quality improvement work will be reviewed by CARF or joint commission when they do that reaccreditation and then it's the recertification or reaccreditation letter, that's what we need. We don't need the project, but if it's something different than that, I don't know that we have a way to automate that. So it won't... Is that on? It won't. So any work that you do for your hospital right now that doesn't have to do with CARF or JACO or anything, you're just doing it because your hospital says, please do this, just use that project as your independent project that you can put through on submittable anytime. And we want people to do that. We want people to do independent projects. So we developed those 22 project templates that are on our website a while back to give people some ideas about what they might do or for people that just were really stymied about how to do it. But what we really would love is for all of us to have our own independent quality improvement projects wherever we are out there in the world trying to make things better in medicine. And so I really would encourage you to use those independent, this was my project, didn't have anything to do with those templates, but this is what I did and then it'll be reviewed and get credit for that. But there is one situation which I think what you're asking about has to do with the portfolio program. And so if you... You know, in that program if you're doing a project, a quality improvement project for your hospital and the hospital is part of the portfolio program, that credit gets sent in seamlessly. You know, if you're on the project and the hospital is part of the portfolio program. So if you go to the ABMS website and you look up the portfolio program, big healthcare systems are part of it. I can tell you, I didn't even know about this. I was at Mayo Clinic and my very first cycle all of a sudden I got notified that I had credit. For a quality improvement and it's because Mayo Clinic is a sponsor, is involved with the portfolio program. So a quality project that I was on got the credit and I didn't even know. So you can look up to see if your healthcare system or is part of that. In that case the answer is definitely yes and it's seamless. Otherwise what Dr. Driscoll suggested and what Dr. John suggested would be other ways of getting credit for things you're doing at work, J-CO, CARF, and all of that kind of thing or submitting your project just... If it's a project you already did, just submit it as a PIP. We announced it. It's now. Well, yeah. CARF and JCAHO are now. So that means if you have a joint commission visit today, then why are you here? You don't get credit. Yeah. But let's say you get that recertification letter a month from now. You download the attestation form. It's on our website now. You send in a copy of the recertification letter, your attestation, and that's active. You identified a critical gap in practice and you implemented a system change that's going to have a great improvement and impact. So, the credit will be given for the cycle in which you did the work. Miss one what? The cycle. Oh, don't you have to do two in a 10-year period? Yeah. So, if you'll shift that to say I've got to do one in five years because it's a five-year continuing certification cycle, so yeah, so it's one every five-year cycle. Your dashboard has, did you do it? Right. So, in five years, that has to be checked in order to move on to the next cycle. But you can't use an old one, so if you had one in your last, you had a second one in your last cycle, you can't use that for your current cycle. It's still great work. We would encourage all of us to be doing quality improvement work all the time, but as far as taking the time to submit it, if you're doing that through the submittable process, it's one every five years. I think we're at time. I think we would all stick around and answer any additional questions, but we really appreciate your attention and your interest in this area. Thanks for coming and yeah, we'll stick around for questions. Thank you.

continuing certification

physical medicine

rehabilitation

longitudinal assessment

medical knowledge

quality improvement

subspecialty certifications

Vision Commission

pediatric medicine

spinal cord injury

patient outcomes