What Do American Board of Internal Medicine Recertification Exams Measure?

The American Board of Internal Medicine (ABIM) was founded in 1936 by the American Medical Association and the American College of Physicians. Initially, testing after training provided lifelong certification. However, beginning in 1990, ABIM required physicians to pass periodic tests to prove that they were keeping up-to-date in their chosen fields of practice. Initially, a high-stakes, every-10-year written or (after 2006) computerized exam at a central location was required to maintain ABIM certification. This type of exam is still important and required for initial certification. Additionally, in 2013, ABIM also began requiring 100 Maintenance of Certification (MOC) points during a renewal period, which could be obtained by a variety of educational or practice requirement methods. Initially, a practice assessment and quality-improvement plan were required, but these were later eliminated due to difficulty with the methods.

An every-10-year exam for MOC left a lot of time between assessments. In 2018, ABIM began offering the 2-year Knowledge Check-Ins (KCIs) in Oncology in lieu of the once-per-decade exam. This method was developed in conjunction with the American Society of Clinical Oncology and was available in general oncology as well as in some specialty areas, including breast cancer and hematologic malignancies. This exam could be taken at the central computer center or at a monitored computer. The plan was to develop additional subspecialty KCIs to address the issue of specialization in many oncology practices, such as academic centers and larger practice groups. This option was discontinued after 2021, apparently due to criticism that it was too difficult and time-consuming to cover the material every 2 years that would be necessary to pass the area-specific tests. However, this method did address a frequent criticism of the test, which was that it should not cover very broad areas of practice that are not used by disease-specific subspecialists.

The latest shift, in 2019, was the addition of the computerized Longitudinal Assessment (LA) option as a more practical way to maintain certification. This option includes a 5-year cycle with questions being answered from any location using any resources used for practice (except another person). The LA has a total of 600 questions, with 30 questions required every quarter, or 120 per year. Each question must be answered within a 4-minute limit. Additionally, this method has built-in flexibility; a physician can skip up to 100 questions over 5 years and still meet the participation requirements. However, the current method does not address the issue of subspecialization and needless time spent answering questions for conditions or diseases that the physician has not treated for many years, in some cases.

The process is extensive with a large bank of questions required for this process. Many of the questions are “tested” on the exam takers for validity. The cost of either the 10-year or every-2-years LA (over 10 years) is approximately the same. In either case, the cost is fairly high and not always paid for by the physician’s employer.

As a physician who has now taken the recertification exam by all these methods—the every-10-year exam, the KCI for hematologic malignancies, and most recently the LA in hematology—my wish would be to see a hybrid of the specificity of the KCI for subspecialty physicians, with the flexibility of the LA using online methods for information. Without the subspecialization option, it becomes a test of who is the best at finding answers in UpToDate or similar online repositories of information. Don’t we really want a recertification test that challenges knowledge of the conditions that the physician actually manages?