Pathology is one of the few medical specialties that
does not require continuing education to maintain certification over time.
That will end in 2006 for newly minted practitioners—and perhaps
effectively end for all others—when the American Board of Pathology
begins issuing time-limited, 10-year certificates.
The goal is to ensure that all board-certified physicians "meet the highest
standards of patient care and accountability throughout their careers,"
says the American Board of Medical Specialties, which launched its Maintenance
of Certification, or MOC, initiative in 2000. The ABMS is a 24-organization
umbrella group of approved specialty boards that includes the ABP. (Pathologists
do have to document continuing education by state licensure requirements,
but these are variable and not pathology specific.)
The CAP’s Education Committee has spent the past year working to make
pathology-specific the ABMS’ general specification of the competencies
needed to maintain certification, and the committee has begun to explore
how its education programs will help fill the gaps between what’s offered
now and what will be needed.
The College has shared its thinking about the competency categories and
specific skills in a paper submitted in January to the Archives of
Pathology & Laboratory Medicine, and will begin rolling out new education
programs targeted to the competency categories later in the year, starting
with its annual meeting curriculum.
The ABMS defined six general competencies integral to quality care: medical
knowledge, patient care, interpersonal skills and communication, professionalism,
practice-based learning and improvement, and systems-based practice. It
specified that four general methods would address these competencies:
evidence of professional standing, evidence of lifelong learning in the
appropriate categories, evidence of cognitive expertise (recredentialing
examination), and evidence of performance in practice. Each specialty
board must define what each of these general methods will be for its members.
The ABP is doing so now and has indicated that it will collaborate with
pathology education providers like the CAP in this effort.
"The American Board of Pathology is looking to pathology education providers
to create education to meet the ABMS requirements for lifelong learning.
That’s not a simple task," says Elizabeth Hammond, MD, chair of the Education
Committee and a pathologist at Intermountain Health Care. First, she says,
committee members had to understand what the requirements were, make them
concrete in terms of what is required for pathologists, and then develop
knowledge and skill statements that adequately specified each competency
"The short story of what the College has been doing to address MOC,"
says Constance Filling, vice president of the CAP Division of Education,
"is to identify and proactively start the development of some education
programs that are going to meet these needs. But there are steps to do
that. It’s not just sitting down one afternoon and saying, ’I think we
College staff began by bringing the Education Committee up to speed on
the ABMS requirements, including the time frame, implementation plan,
and what was expected of specialty societies including the ABP, Filling
"The second step was actually getting down to work and saying, ’OK, if
ABMS has defined these six general competencies across all medical specialties,
we have a responsibility to contribute to defining that specifically for
our specialty,’" Filling says. "Or, at least, to understand it for our
specialty in such a way that we can identify potential areas of need from
an education point of view—so that we can try to offer education
programs in those areas."
Pathologists who become board-certified in 2006 and
thereafter will need to be recertified within 10 years. They can take
the exam, which the ABP is likely to offer twice each year, as soon as
eight years out from their certification date. In addition to taking the
examination, these pathologists must provide documentation that they have
fulfilled continuing education requirements for each of the six ABMS categories
to demonstrate the maintenance of their competence.
Those in practice now will have the option to take continuing medical
education, as they have previously, says Loretta Morrison, CAP’s director
of education design and development, but "for many of the pathologists
out there, at least right now, these requirements won’t apply to them
unless there’s some change in the thinking."
But that may be from the standpoint of what only the ABP would require.
"It is likely that hospitals, payers, and perhaps malpractice insurers
will make "maintenance of competence, or eligibility for recertification,
a de facto requirement for everyone,"Dr. Hammond says.
According to recent Gallup Organization findings, more than 75 percent
of patients surveyed would choose a board-certified physician over a physician
who was not board-certified but was recommended by a trusted friend or
family member (Brennan TA, et al. The role of physician specialty board
certification status in the quality movement. JAMA.
2004;292:1038-1043). Eighty percent of those surveyed would be likely
to seek another physician if their current physician’s certification had
lapsed. Most patients believe, then, that the quality of health care is
closely linked to the competence of physicians as indicated by specialty
board certification (Folberg R, et al. Competency-based residency training
in pathology: challenges and opportunities. Hum Pathol. 2002;33:3-6). Education committee members realize that
insurance companies are likely to follow suit, Dr. Hammond says.
The Centers for Medicare and Medicaid Services is already talking about
pay for performance and sponsoring the development of care measures by
such agencies as the National Quality Forum. Since almost all physician
groups already have requirements for documenting maintenance of competency
and maintenance of certification, the CMS is likely to look to this documentation
as an added measure. "Pathologists will probably have to show documentation
of maintenance of competency requirements to receive compensation for
services provided to Medicare patients at some point in the future," Dr.
Hammond says. "Our goal is to provide relevant education that is documented
as painlessly as possible for pathologists right now, so they will be
ready when and if this occurs."
The CAP has developed an education-tracking system that can catalogue
the education of individual pathologists. This year, the tracking includes
the competency category that the educational offering fulfills. "Pathologists
and residents can use this tool to track all of their education, not just
that offered by CAP," Dr. Hammond says. (To see and use the tool, visit
the section on education at www.cap.org.)
The broad implementation outline from the ABMS contained
the six competency categories, a working definition of each, and sketched-out
competencies along with specific associated skills. The CAP Education
Committee and staff refined the category definitions to make them more
specific to pathology and fleshed out and tailored the competencies and
associated skills, the CAP’s Morrison says.
"We had a very good starting point from ABMS," she says. "In some cases
we saw there was very little change to the definition—it was just
adding a word or two. In other cases, and this might have been only one
case, we simplified it as well." As for the specifics, she adds, "For
each of those competencies, we developed these more targeted and very
specific and behavioral knowledge and skill statements—all toward
the end goal of making these specific to what a pathologist does."
The 12-person committee first met as a large group, then divided into
subcommittees that worked on the respective competency categories. At
various points in the process, Filling says, "we asked for input and comments
and feedback from targeted individuals outside the committee."
"We spent an awful lot of time doing this, and did a lot of homework,"
says Education Committee member Peter J. Howanitz, MD, a pathologist at
the State University of New York Downstate Medical Center, Brooklyn. "We’ve
read a lot of articles and have some imaginative things about how we’re
planning to disseminate this information."
What’s resulted to date is a list of 17 competencies and 87 specific
skills under five of the six competency categories (excepting medical
knowledge, which will divide naturally into subspecialties such as anatomic
pathology and clinical pathology and their specific disciplines). For
example, under "practice-based learning and improvement," the committee
identified three competencies: practice analysis, assimilation of external
data, and process and outcome improvement.
And under the latter competency—process and outcome improvement—for
example, the committee listed as skills the ability to identify processes
requiring improvement, analyze root causes (underlying problems) to appropriately
target changes, create a process improvement plan or new process, and
measure results or improved outcomes by using statistical tools or external
benchmarking or both to demonstrate improvement. (The full set of competencies
and knowledge and skills statements for each MOC category is provided
in the paper submitted to the Archives of Pathology & Laboratory Medicine.)
"The interesting thing about the ABMS competencies is that they are much
broader, across all six of them, than many specialties—certainly
pathology—had thought about previously," Filling says. "When you
ask pathologists what they need to learn and keep up with, their initial
answers would generally be focused within the medical knowledge and patient
To explore where potential needs might exist, the committee has conducted
a survey of nearly 2,500 CAP Fellows, to which about 14 percent responded,
the results of which were compiled in fall 2004. Respondents were asked
to rate, from a low of one to a high of five, how important each skill
was to their overall effectiveness and how proficient they were in performing
The survey covered competencies and skills under practice-based learning
and improvement, systems-based practice, and patient care; the other three
competency categories will be surveyed soon. "They were either areas where
we thought the College might be able to provide CME programs relatively
quickly and/or where we thought there was very little already available,"
The largest gaps between the importance and proficiency level of the
general competencies, on average, were in the areas of practice economics
and practice and system integration. The largest gaps for specific skills
were in applying "knowledge of health care trends in economic/strategic
decision-making" and applying contracting and negotiating skills.
When it comes time to explore the other three areas, Dr. Howanitz has
one prediction on a competency that will rate highly as a need. "Communication,
I think, is one of the most important. One of the most important ways
we communicate is as teachers," he says. "We’re always asked to teach
at every conference, in every department."
While the College hopes its efforts in defining the
competency categories and fleshing out the competencies and skills will
be helpful to the ABP in setting the requirements for pathologists, that’s
not the CAP’s chief aim, Filling says.
"We’re doing this for our own purposes in figuring out what the best
thing is for us to do from an education point of view," she says. "We’ve
mapped the current curriculum the College has to the MOC categories, based
on our best assessment of where they would fit, and identified the areas
where we think we have gaps." Adds Dr. Hammond, "Using the information
about the gaps in our offerings, we can more carefully select courses
for the national meeting and plan other educational offerings that will
better suit the needs of our members."
The committee examined courses from the 2004 annual conference to see
how and where they would fill the Maintenance of Certification requirements,
and they’re doing so in advance for the 2005 conference. "We’re planning
to look at what’s offered and work with the speakers," Dr. Howanitz says.
"They’re expecting to hear back from the Education Committee about exactly
what’s expected of them in the description of their program."
Says Filling: "It’s already having an impact in terms of the kinds of
courses we’re selecting. From an education point of view, it’s useful
to have things broken into skill- and knowledge-based behavioral statements
because then you can identify the purpose of the course and the objectives
you want to achieve."
She encourages CAP fellows to send their input to staff or committee
members and says surveys of education needs will continue. "It’s our intention
to do this on an ongoing basis and to upgrade the competencies with the
ABMS and ABP as information becomes available. This isn’t something you
do once and you’re done," she says.
Ed Finkel is a writer in Evanston, Ill. Send comments to firstname.lastname@example.org or to M. Elizabeth Hammond, MD, chair of the Education Committee (email@example.com).