With so much controversy swirling around the changes in ABIM Maintenance of Certification, we thought it might be interesting and instructive to gain perspectives from so-called super certifiers — physicians who elect to maintain not just one but multiple subspecialty certifications throughout their clinical careers.

Jack Ringler, MD, specializing in pulmonary medicine at Berkshire Medical Center in Massachusetts, is one such super certifier, with multiple subspecialty certifications:

  • After completing his internal medicine residency at what was then Boston’s Beth Israel Hospital (now Beth Israel Deaconess Medical Center), he became ABIM board certified in 1986, placing him among the last to be “grandfathered in” with lifetime ABIM certification.
  • Following a 3-year fellowship at Beth Israel and Brigham and Women’s Hospital in pulmonary disease and critical care medicine, Dr. Ringler obtained his initial pulmonary disease specialty board certification in 1990 and his initial certification in critical care medicine in 1991.
  • After practicing and teaching for a decade at Berkshire, he recertified in pulmonary disease in 2000 and recertified in critical care medicine in 2001.
  • Dr. Ringler recertified again in pulmonary disease (2010) and in critical care the following year (2011).
  • As if two specialty board recertifications in 2 years were not punishing enough, he added a fourth certification in sleep medicine in 2011.

“It was a difficult 3 years,” Dr. Ringler says. And, while his motivation to pursue multiple certifications is, in part, an outgrowth of his career path — he describes pulmonary, critical care, and sleep medicine as “natural brethren” — he believes strongly in the principles underpinning both board certification and periodic, compulsory recertification.

The last thing I would want is be undercredentialed or undertrained for my specialty areas — to have somebody look at my record and question what I do professionally. While many pulmonologists train in programs that include critical care and sleep components — and many do fellowships that encompass all three — [the ABMS] still treats them as separate subspecialties, so we often feel the need to certify in each. In addition, I have chosen to practice in a smaller community setting. In large urban hospitals, you might have 10 pulmonology groups addressing various subspecialties, but here we have a single physician (or physician group) that wears more than one hat. I chose a community this size because I wanted to be more broad-based in my practice. But, if I am going to wear more than one hat, I want a badge on each one.

On Expanding MOC Burdens

With such a substantial recertification burden on his plate, Dr. Ringler takes a surprisingly philosophical view of the increasingly demanding changes introduced to Maintenance of Certification requirements over recent years.

Many of us pride ourselves on trying to be lifelong learners and reading to improve patient care, but we have not been compelled — until recently — into thinking about MOC throughout the entire 10-year cycle. In my experience, most of us would do the bulk of our recertification work in the last year, or perhaps 2 years, before our exams. I agree with the boards that it makes sense in terms of both pragmatic and substantive patient care to devote time more regularly to maintaining and updating our knowledge. Our fields move quickly, and making an effort to become current in just one or 2 out of every 10 years just isn’t good medicine.

With that said, Dr. Ringler does see room for improvement in certain components of MOC, especially the practice-improvement modules but also the clinical relevancy of exam content and related study aids.

The content I have needed to master to get through my board exams has not always been a perfect match for what needs to be mastered to treat patients effectively in the real world. While board exams are quite good at capturing rare diseases, they are less effective at capturing unusual presentations of common diseases.

Dr. Ringler cites obstructive sleep apnea as a good example of this.

Every day in my career I may see six or seven patients with this condition. Each case has its own unique flavor and characteristics — each patient presents a different set of comorbidities, coping styles, and social issues associated with the disease. I am reminded constantly that it is very difficult to generalize in real life. On board exams — perhaps understandably — one is more likely to be addressing cases of exploding head syndrome or Kleine-Levin syndrome, which would be unusual to encounter clinically even once during an entire career in this field.

On Preparing for Exams in Multiple Subspecialty Certifications

Having progressed through eight certification-recertification cycles (actually nine if you count the ABSM certification he did in sleep medicine before the ABIM began certifying that particular subspecialty), Dr. Ringler says he has typically relied on a combination of regular attendance at subspecialty board annual conferences, intensive board-review courses, and good old-fashioned cramming to prepare for his exams.

I will make a small confession here. When I was in my early 40s, I had three young children and life was incredibly busy. To prepare for the notoriously difficult ABSM exam, I developed a habit of studying until 2 or 3 in the morning in a room using a very bright light to simulate sunlight. I actually managed to delay my sleep phase and shift my circadian rhythm, which eventually led me to this very insightful moment where I understood that I was purposely developing the same disease I was studying. In many ways, I find it a relief that the ABIM has decided to spread out our recertification requirements over the full 10 years.

In response to the growing complexity of MOC requirements, Dr. Ringler suggests that it would be helpful to have a tool — a sort of digital coach — that would alert and prompt physicians when they need to meet specific requirements at various times.

We have all received emails telling us we have these expanded requirements to fulfill, but I am not sure that many [physicians] fully comprehend the details or the exact timing of what they need to accomplish. This creates a low-level but fairly constant state of anxiety around MOC. You have a sense that you will somehow get through and — if you start falling behind — you will receive some sort of reminder. But, most physicians are very good at taking lists of tasks, scheduling and completing them, so it would be great to have a tool that helps us to better understand and manage our specific requirements in order to relieve some of that constant anxiety.

On the Growing Controversy Over MOC

Although Dr. Ringler recognizes that some areas of MOC could be revised, he expresses great confidence that the ABMS member boards will continue to evolve and succeed over time.

Everyone is facing huge new burdens on their time, such as electronic record-keeping and learning software programs that are not yet ready for prime time. These things take huge amounts of the time we might otherwise spend maintaining our medical knowledge and certifications, so I can understand how practitioners become a little jaded. Still, the boards are taking on some highly complex and difficult challenges. I am sure that I don’t have better answers, and I maintain a high degree of trust that the people leading our boards both understand and respect the time burdens and challenges we face as physicians.

On His Next Recertification Round

While Dr. Ringler expects to recertify yet again in both pulmonary disease and sleep medicine, he suggests he may skip critical care medicine in the coming round.

I doubt that, at 64, I will be doing a great deal of critical care, so I may decide against pursuing that particular recertification.

Related reading from NEJM Knowledge+:
Changes in ABIM Maintenance of Certification: What Does It Mean for You?
To Recertify or Not? Making a Decision about ABIM Recertification
Preparing for the Internal Medicine Exam as a “Grandfathered” Physician
ABIM Internal Medicine Review Resources
What’s Your Study Style?

Are you a super certifier too? Or simply considering the idea of pursuing multiple certifications? Add your own perspectives either by commenting here or by getting in touch with our blog editors for a more formal interview.