Evolution of AOA Specialty Board Certification

History of OCC

A number of reports from the Institute of Medicine of the National Academies, including the consensus reports To Err Is Human: Building a Safer Health System¹ and Crossing the Quality Chasm: A New Health System for the 21st Century,² as well as its workshop report A Bridge to Quality,³ have expressed concerns related to the quality of health care in the United States. The reports call for reducing medical errors and improving patient safety. As a result of those reports, the BOS decided to reevaluate the osteopathic board certification process.

During this time, the BOS noted an increased focus on competency vs knowledge-based assessment and outcomes, evidenced in the Blue Ribbon Commission report, Building the Future: Educating the 21st Century Physician.⁴ Colleges of osteopathic medicine (COMs) use this type of assessment with osteopathic medical students through objective structured clinical examinations and standardized patient laboratories. Current COM graduates are very familiar with this type of assessment of their clinical skills.

The BOS reviewed what was being done within the osteopathic medical profession and paid particular attention to the continuous certification process that the American Osteopathic Board of Emergency Medicine (AOBEM) launched in 2005. The AOBEM's continuous osteopathic learning assessments provided the foundation of OCC.⁵

From the beginning, the BOS was committed to making the process cost effective and not onerous to stakeholders. The BOS met with osteopathic medical students—our future diplomates—to review the outline for OCC. The majority opinion was that, as noted previously, the practice performance component of OCC was similar to the way the students were already being examined in COMs.

Using this information, the BOS conceptualized and developed the OCC process over a 6-year period beginning in 2007.

OCC Today

Osteopathic Continuous Certification began on January 1, 2013. Since that time, no other osteopathic recertification processes existed. In February 2013, the Centers for Medicare and Medicaid Services recognized the quality of the OCC process, and it granted approval to all 18 AOA specialty certifying boards to use OCC to meet the maintenance of certification incentive of the Physician Quality Reporting System.⁶

The OCC process has 5 components, including licensure, continuing medical education requirements, cognitive assessment, practice performance assessment, and AOA membership.⁷

Uniquely Osteopathic

From the beginning, the BOS strove to create a certification system that was uniquely osteopathic. By virtue of the structure of the BOS, the final review process for each board's practice-performance module is done across specialties. By design, OCC is practice relevant, helping osteopathic physicians understand how they are practicing and whether they meet nationally established benchmarks. As the certifying boards' libraries grow in topic areas, osteopathic physicians will have the opportunity to take modules that best fit the way they practice medicine. For example, a family physician who primarily practices emergency medicine will, with the approval of the American Osteopathic Board of Family Physicians, be able to participate in emergency medicine practice-performance activities offered by the AOBEM.

Fluid Process of OCC

We are still in the infancy of OCC; what the process looks like today is not what the process will most likely look like 5 years from now, as osteopathic board certification is a fluid and continuous process that will evolve over time. Board certification has been fuid from its inception. When the BOS was created more than 75 years ago, certification did not look like it does today. Initial certificates were issued without requirements for maintaining board certification. Continuous medical education was added as a requirement to AOA board certification and certification maintenance in 1972. Recertification examinations were added in the 1990s.⁸

To maintain excellence in osteopathic medicine, one of the charges to the BOS is to monitor and update the certification process. As the BOS monitors OCC both internally from its impact on stakeholders as well as externally from the latest educational data, they will continue to conduct an ongoing review of the certification process. The BOS is already discussing how OCC may look in the future, including potential changes to the cognitive assessment and examination process.

OCC and Maintenance of Licensure

The difference in structure between the AOA and the American Medical Association (AMA) regarding board certification is relevant.

Although the AMA recently called for an independent evaluation of the certification systems using a third-party source, such as the Institute of Medicine of the National Academies,⁹ the AMA is not involved in board certification. The allopathic certifying boards make up the American Board of Medical Specialties; however, they stand alone and are independently incorporated organizations. Conversely, the AOA owns and oversees the work of all 18 AOA certifying boards.

In a parallel process, the Federation of State Medical Boards of the United States (FSMB) began discussing a maintenance of licensure (MOL). The FSMB's recommendation to state licensing boards interested in developing MOL programs involves 3 parts: reflective self-assessment, assessment of knowledge and skills, and performance in practice.¹⁰ The FSMB has repeatedly advocated to state medical boards that they consider osteopathic physicians participating in OCC as meeting the criteria for the state MOL process.

Certification Debate

The OCC process was debated during the 6 years prior to its implementation in January 2013. It has been a part of the AOA House of Delegates' and AOA Board of Trustees' discussion since that time. A sharp line of demarcation between education (continuing medical education, COMs, and osteopathic postdoctoral training institutions) and board certification (assessment) exists. All 18 AOA specialty certifying boards have worked tirelessly—often meeting weekly—over the past 6 years. The BOS assures osteopathic physicians that this process has been thoroughly discussed and thought through by many members of the osteopathic medical profession, psychometricians, and the BOS's public member. Compelling educational data support practice performance as a measure of clinical performance.

Conclusion

The AOA Board of Trustees is closely monitoring the OCC process and is mindful of the burden and the cost of OCC. The BOS is also attentive and continues to discuss, debate, and revise the OCC process to make our certification process one of excellence, one that is beyond reproach by any third party, and one that is relevant to the practice of osteopathic physicians. By keeping the osteopathic certification bar high, the AOA will be able to repel ongoing challenges to our profession.