The American Board of Otolaryngology is the organization responsible for certifying physicians who have met the Board’s professional standards of training and knowledge in otolaryngology–head and neck surgery. The American Board of Otolaryngology monitors the progress of residents through training and conducts examinations for board certification. Quality of care initiatives throughout medicine have stimulated the Board to develop a maintenance of certification process with a 10-year, time-limited certification. Maintaining certification requires participation in the Board’s process, which includes evaluation of professional standing, continuing education and self-assessment, cognitive expertise, and performance in practice. The ultimate goal of the American Board of Otolaryngology’s activities is improved patient care.
The mission
The mission of the American Board of Otolaryngology (ABOto) is to assure that, at the time of certification and recertification, diplomates certified by the ABOto have met the ABOto’s professional standards of training and knowledge in otolaryngology–head and neck surgery.
History
Shortly after the turn of the twentieth century, the American Academy of Ophthalmology and Otolaryngology established two committees to explore the concept of certification in these two specialties. The result of the deliberations was the development of the American Board of Ophthalmology in 1916 and the American Board of Otolaryngology (ABOto) in 1924. Initially, 465 otolaryngologists were invited to receive certification, and 354 were certified . Through 2007, 16,989 otolaryngologists have been certified by the ABOto. In addition to certifying individuals, the ABOto set the standards for and accredited otolaryngology residency programs until 1953, at which time the Accreditation Council for Graduate Medical Education assumed this function.
The certification process has evolved over time. Initially, the certification examination consisted of a written histopathology examination, a practical examination with real patients, and an oral knowledge examination, which was waived for “experienced” practitioners. The first written examination required essay-type answers but is currently in a multiple choice question format. The practical examination became the oral examination, which in its early format permitted a fair amount of individual examiner discretion in its administration. Currently, the oral examination consists of highly structured protocols that measures an examinee’s knowledge more effectively and consistently.
The written examination is considered a qualifying examination because a candidate must pass it before having his or her score on the oral certifying examination considered. If a candidate passes the written examination but fails the oral examination, he or she has 3 years to pass the oral examination and become certified before having to retake the written examination. Both examinations are administered annually in Chicago.
History
Shortly after the turn of the twentieth century, the American Academy of Ophthalmology and Otolaryngology established two committees to explore the concept of certification in these two specialties. The result of the deliberations was the development of the American Board of Ophthalmology in 1916 and the American Board of Otolaryngology (ABOto) in 1924. Initially, 465 otolaryngologists were invited to receive certification, and 354 were certified . Through 2007, 16,989 otolaryngologists have been certified by the ABOto. In addition to certifying individuals, the ABOto set the standards for and accredited otolaryngology residency programs until 1953, at which time the Accreditation Council for Graduate Medical Education assumed this function.
The certification process has evolved over time. Initially, the certification examination consisted of a written histopathology examination, a practical examination with real patients, and an oral knowledge examination, which was waived for “experienced” practitioners. The first written examination required essay-type answers but is currently in a multiple choice question format. The practical examination became the oral examination, which in its early format permitted a fair amount of individual examiner discretion in its administration. Currently, the oral examination consists of highly structured protocols that measures an examinee’s knowledge more effectively and consistently.
The written examination is considered a qualifying examination because a candidate must pass it before having his or her score on the oral certifying examination considered. If a candidate passes the written examination but fails the oral examination, he or she has 3 years to pass the oral examination and become certified before having to retake the written examination. Both examinations are administered annually in Chicago.
Examination development and process
The examination development process is detailed, costly, and time consuming. The items (questions) for the two multiple choice question examinations—the written and otolaryngology training examinations (in-service examination)—are generated by the Task Force for New Material, which consists of 36 item writers. Item writers are selected from a pool of individuals nominated by all of the otolaryngology specialty societies and by the ABOto directors and senior examiners; they serve 3-year terms. Item writers participate in the annual item writers’ workshop, during which they learn the nuances of writing effective multiple choice questions.
After the item is generated, it goes through a thorough and extensive editing and vetting process, which ensures that the medical information is accurate and refines the question wording and syntax. Finally, all new items are “field tested” on either the otolaryngology training examinations or written examinations. The statistical performance of each new item is carefully reviewed by the ABOto directors and a psychometrician. Items are evaluated as to whether they are too easy or too hard and how well an individual item’s performance correlates with how well the people who selected the correct answer did on the test as a whole. Items that do not meet the ABOto’s standards are either revised or discarded.
The items that are used for scoring on the otolaryngology training examinations and written examinations are selected from a pool of successfully field-tested items based on the examination blueprint, which is available on the ABOto Web site ( www.aboto.org ). The directors select the best items from the pool based on several statistical and other parameters. The protocols used in the oral and neurotology examinations are written by the oral examiners, which include the directors, senior examiners, and guest examiners. Each protocol is carefully reviewed and edited several times by the appropriate specialty-specific group before its use.
The results of all of the exams are analyzed by a psychometrician, who identifies any items that have an unusual statistical performance. These items are reviewed by the examination committee, and if the question is not thought to be valid, it is discarded from the examination and not used in scoring. The written and otolaryngology training examination scores are adjusted for annual variations in the “hardness or easiness” of the examination so that scores are consistent over time. Similarly, the oral examination scores are adjusted for variations in examiner leniencies and variations in the test severity for the 2-day examination period and year-to-year variations.
Before 1999, the passing score was set by failing a fixed percentage of examinees. In 1999, the ABOto switched to a criterion referenced standard, in which the directors participated in a psychometric standard setting exercise that determined a fixed pass/fail point. Theoretically, it is possible to have a 100% pass rate. This standard-setting exercise is repeated approximately every 5 years to ensure its validity.
Health care quality milestones
A few historical events have had a major influence on health care quality in the United States. Perhaps one of the most important was the 1910 Flexner report on medical school education . At the time there were many proprietary schools, many of which did a poor job of educating medical students. Commissioned by the Carnegie Foundation, the report summarized US medical schools and their curricula and provided recommendations on how to improve the quality of physician education. The establishment of medical specialty boards in 1916 was also a milestone because it not only provided a mechanism for evaluating physicians but also ultimately provided a mechanism for residency training accreditation. The public values board certification as a measure of quality .
Although quality of care has been an important subject for many years, the Institute of Medicine reports on quality of care in the United States have advanced this issue rapidly in many sectors, including the government, health care providers, insurers, purchasers of insurance, and public interest groups . As a consequence, many groups are exploring methods to improve all levels of the health care system. As an example, two organizations that have instituted quality improvement programs are the Joint Commission on Accreditation of Healthcare Organizations for hospitals and the National Committee for Quality Assurance for health plans. Similarly, the two groups that have the main responsibility for overseeing the quality of individual physicians are the state medical licensing boards and their umbrella organization, the Federation of State Medical Boards and the American Board of Medical Specialties (ABMS), which is the umbrella organization for the 24 medical specialty boards. The ABMS and the Federation of State Medical Boards are active in the invigorated national health care quality improvement movement.
Board certification continuum
Many people view the board certification process as simply passing the board examinations at the end of residency. The ABOto, however, views the certification process as a continuum that begins when residents are selected for training. The selection process is an important screen to identify the brightest, most capable medical students for otolaryngology–head and neck surgery training. Within the first few months of training, the new residents must register with the ABOto, which obtains and verifies information about the residents’ previous training.
The ABOto views the program director as a critical component of the certification process because the program director, along with the faculty, has the most exposure to the residents’ knowledge, skills, and behavior over the 5-year residency period. Based on the Accreditation Council for Graduate Medical Education’s six competencies ( Box 1 ), the board examinations have strengths in the measurement of medical knowledge and patient care (with the exception of surgical skills), but the program director is in a much better position to evaluate the other four competencies ( Table 1 ). At the end of training, the chairperson and program director must attest that the candidate is of “high moral character and worthy of examination by the ABOto” and is acceptable for the examination process.
