Board certification and continuing certification are important elements of a physician’s career because they help practitioners stay up-to-date on current practices, guidelines, and processes. In this interview, David Joseph, M.D., discusses piloting changes to the American Board of Urology (ABU) Lifelong Learning Program and how they will help diplomates stay current without requiring as much time away from their families and practices. Joseph is the Lifelong Learning chair at the ABU, a professor and vice-chair of academic affairs in the Department of Urology at the University of Alabama at Birmingham and the Beverly P. Head Endowed Chair in Pediatric Urology at Children’s of Alabama.
Could you provide an overview of the ABU’s Lifelong Learning Program?
Joseph: Since 1985, all diplomates who have become certified have a time-limited certificate and automatically enter what’s called Lifelong Learning. That’s a process that continues today. Within Lifelong Learning, there are 2 levels, level 1 and level 2, and each span a 5-year period. Within each level, there are certain activities—we call them portfolio activities—that the diplomate must continue to do to remain certified. Some of those activities are similar from each 5-year period, such as doing peer review and CME [continuing medical education] credits, and there are others that vary. In the second set, some of the activities that are different include [having] to do a practice log [and] a complication and mortality narrative, and then you have a point-in-time secure exam that is used for knowledge assessment. That’s basically the process.
Several years ago, the ABU eliminated the high-stakes component of the exam and made it into more of an educational process, where gaps in knowledge are identified. If knowledge gaps are found, the board will assign the diplomate up to 3 CME activities to help close the knowledge gap. So the ABU doesn’t focus on the exam like many of the boards do as far as making a pass-fail decision on continued certification. The board places the exam in perspective with peer review, practice logs, and the mortality narratives and uses all those components to make the summative decision on continued certification.
What prompted the changes to be made in the program, and could you provide a summary of those changes?
The ABU is a member board of the American Board of Medical Specialties [ABMS]; there is a need to adhere to the policies and requirements of the ABMS. The ABMS has recently changed some of their standards, realizing that a 10-year cycle probably isn’t appropriate or practical to keep up with medical advancements and patient care. The ABMS moved to a 5-year cycle and required all member boards to shift from a 10-year cycle to a 5-year cycle that is based on a continuous formative type of educational process. One of the other components that the ABMS required is to remove the high-stakes aspect of any exam. Fortunately, that’s something the ABU had done years ago.
Equally important was what the ABU has learned from our diplomates by talking with them at the AUA [American Urological Association] Annual Meeting, section meetings, and [during] the “fireside chats.” The board recognized that the current Lifelong Learning Program creates a significant burden on the diplomates as far as taking time from their practice and from their families. Having the diplomate take the knowledge assessment exam in a secure environment is difficult. The board recognized that we now have tools we didn’t previously have that allow us to make some major changes. The board has created a program that adheres to ABMS requirements [while considering] our diplomate’s needs, Continuing Urologic Certification (CUC). CUC contains all the requirements in our current portfolio. The diplomate will not be doing more than they previously had done. Activities are now assigned to a year to provide direction to the diplomate, helping to distribute the activities and take the burden off the end of the cycle, when many diplomates leave activities to be completed.
A major change is replacing our 10-year point-in-time exam and moving away from a secure testing environment. The ABU has created a program that we feel is formative from an educational perspective and allows the board to make a summative decision over a 5-year period. There are 3 components to the CUC program: knowledge reinforcement, knowledge exposure, and knowledge assessment.
Knowledge reinforcement provides questions in a similar format to what had been asked on prior exams. This activity is a memory challenge and brings forward knowledge that the diplomate already has that is important for urologic management and care. Knowledge reinforcement occurs in years 1 and 3 of the 5-year cycle. There is a 4-month window when you’re allowed to undertake the activity, and the diplomate has 6 weeks to complete the process. Knowledge reinforcement is completely self-paced. There are 40 questions that will be answered within the 6-week period. The diplomate will do this on their own computer, and you can use absolutely any resource that’s available to you, [except for] talking with another urologist.
Results from our first year of the pilot shows that everybody was able to easily complete the process within 6 weeks. This can be completed by taking 1 question a day or answering all questions at one time. It’s totally up to the diplomate. There is no limit on the time that can be spent reviewing or researching a question.
The second and fourth years are called knowledge exposure. This activity brings the diplomate up-to-date on changes in guidelines or contemporary articles that have been published that are felt to have an important impact on providing urologic care. The knowledge exposure is an activity that the ABU has worked cooperatively with the American Urological Association. There are 8 articles that must be completed over 10 months. The diplomate can do 1 article a month or all at one time. Of those articles, 4 will come from core activities, basic urology, and 4 will come from any of the 4 practice modules. The AUA is providing optional CME credit at a reasonable rate for this activity for diplomates who are interested.
The fifth year in the cycle is knowledge assessment: a 90-question exam taken in your own environment. Gaps in knowledge will be supported by up to 3 CME activities. Diplomates who maintain an average score above a defined threshold for knowledge reinforcement and exposure can opt out of the fifth-year exam.
Could you talk a little bit more about the benefits of the proposed changes for the diplomates?
First of all, there’s an expectation of the patients. There was a survey done in 2018 by [the research organization] NORC of the University of Chicago. They found 95% of the public expectation that their physician is up-to-date in practice, that they’re participating in a continuing education program, and that they can show that they’re current with their certification. So fulfilling expectations to patients is important. But we also feel that this is going to be very helpful to the diplomate as far as improving their knowledge base and keeping them focused and moving forward. It’s going to better utilize contemporary educational tools and processes that we have available. Probably most important to many of the urologists is that we hope it’s going to decrease some of the burden that has been placed on their practice, their families, and their lifestyles.
Why alternate questions on basic urologic knowledge with questions that come from journal articles?
That brings in 2 different educational goals. The questions that come from the knowledge reinforcement are really the more traditional-type questions. They are designed to bring back knowledge that you already have in your mind. You just need to bring it forward and remember it and keep it current. The questions on the articles and the guidelines are to support the fact that you understand what you’ve just read, so they’re written in a little different fashion and they have a different purpose. There was a great effort and amount of work by the AUA as far as identifying what articles and guidelines were going to be used and with developing the questions. The AUA is providing CME at a nominal fee, so from a cost-effective perspective, it’s a nice way to get credit for work you’ve already done.
I understand these changes are currently being piloted. When do you expect full implementation for all diplomates?
We are now in our second year of the pilot. As I mentioned, the first year went very well, and we’re hoping that this year will be as successful. This year, the pilot includes new diplomates enrolled in knowledge reinforcement, and the diplomates who completed the first year will enter the knowledge exposure. Those 2 components will be working simultaneously. If we have another successful year, then we’re hoping to present our findings to the ABMS Committee on Continuing Certification. We would present our data on the pilot and request that we move to what’s called substantive change. If we’re granted that, then we’re allowed to roll this out to all our diplomates. Realistically, the earliest we could possibly do that would be 2024, if everything falls into line.
Do you expect any further changes to be implemented to the Lifelong Learning Program over the next several years?
That’s a great question. There will always be changes. I’m entering my fourth cycle of recertification, and I can tell you that none of the 3 prior cycles were similar. As our needs change and opportunities for education change, there’ll be changes in Lifelong Learning. I don’t expect that this is going to be the end product; it’s just part of the evolution.
Is there anything else that you think that our audience should know about this topic?
Working on Continuing Urologic Certification has been a group effort of the ABU staff and all the trustees. A great deal of effort by J. Brantley Thrasher, MD, and Lindsay Franklin went into this pilot. All the trustees are acting urologists, so any changes that are made are something that they adhere to also. They obviously take the mission statement of the board to act on the benefit of the public seriously. But there’s a second part of that mission statement about working with certified urologists. A lot of these changes came from comments that we heard from our diplomates. We appreciate when the diplomates have a question, concern, or a constructive comment on the direction we’re going. We really like to hear from the diplomates and encourage them to invest the time to tell us.