 Our next speaker is Dr. Lois Nora. Dr. Nora is president and CEO of the American Board of Medical Specialties. The American Board of Medical Specialties is an organization that is devoted to improving quality of care for patients and works in collaboration with 24 medical specialty organizations to maintain and improve professional standards for physician certification. Dr. Nora received her MD from Rush Medical College and trained as a neurologist. She also received her JD here at the University of Chicago and her MBA from the University of Kentucky. Before joining the American Board of Medical Specialties, Lois had served as president and dean at the Commonwealth Medical College in Scranton, Pennsylvania and later as president and dean of Newcombe, the Northeast Ohio Medical University. Throughout Dr. Nora's career, she's focused on improving medical education, improving professional development and on issues at the intersection of law and medicine. Today, Dr. Nora's talk will be entitled Continuing Board Certification Focus on Opportunities. Please join me in giving a warm welcome to Dr. Lois Nora. Good morning. I'm delighted to be with all of you and thank you for the opportunity. Let me acknowledge my continuing debt and deep appreciation to Mark Siegler, the McLean faculty and the McLean family for what that particular experience meant to me in my professional formation and continues. In addition, because I need to leave at noon, please let me acknowledge Carol Stocking, who I had the privilege of being a student of and found to be one of the persons who combined wicked intelligence with incredible kindness in a very remarkable way. I am going to be talking about board certification and continuing certification, known by many in the audience, I know as maintenance of certification. I am a salaried employee of the American Board of Medical Specialties. Board certification is a key component of our system of professional self-regulation. And demonstrating part of the social compact where physicians professionally self-regulate in order to continue to deserve the public trust in the regulation that we do. Board certification is an integrative, summative decision based on information related to professionalism, on-going learning assessment, both self-assessment by the physician and by others and continuous quality improvement. There is an initial grant of certification, which usually comes within the years following residency and fellowship, and then a continuing certification process that we've talked about in past years has really generated a fair amount of discussion within the profession, particularly focused on is it as relevant as it needs to be? Is it too burdensome for clinicians, particularly in a time when we're very concerned about clinician well-being? So the opportunities I'm going to talk about today are particularly focused on the ethics community and they are based in some substantial changes that many of the ABMS member boards, there are 24 independent member boards, are doing to their continuing certification programs to both enhance relevance and meaning and reduce burden. And my sense is that some of this may have particular relevance for the ethics community. Based on these substantive new changes, I wanted to mention that there are new sub-specialties. Addiction medicine is the most recent sub-specialty that has been recognized under the American Board of Preventive Medicine. I mention that because in years past, on occasion, people from the ethics community have asked about sub-specialty certification. I believe for a variety of reasons that is not the interest in the ethics community right now, but to point out that new sub-specialties are evaluated and approved. There is something that may be of particular interest, which is a focused practice designation that I'll talk about in a moment, and alternatives that are developing to high stakes examination and movement within the board's community to longitudinal assessment. I think that may be a particular opportunity to enhance ethics learning across the profession of medicine in a way that you could be very important to. So what is the focus practice designation? Focus practice is distinct from specialty or sub-specialty certification. It recognizes, as the boards are recognizing, that physicians over years of practice oftentimes focus their work in a particular area. It's why many of the boards are moving towards focused examinations within their continuing certification programs or the like. But this designation recognizes an area that is directly related to the work that the clinician does and the continuing certification activities that would then be most relevant to that clinician. These are some of the rules around it. I just want to focus on the last one in particular, that focus practice has developed in some ways because within a number of the specialties they are saying, our continuing certification activities should be focused on this work that we do. And so it is intended to really impact what the continuing certification or maintenance of certification requirements are. And so a question, is ethics practice something that would be worthy of focus practice designation within one or more specialties of medicine? I should point out the boards do not develop focus practice designations. These are things that come from the specialty societies and elsewhere when they say we are interested in this. So this is something that I know I'm speaking to people who are leaders in their specialties within the ethics components within their specialties and the ethics organizations nationally, perhaps something to consider. So there are many, the next thing I want to talk about are the alternatives to high stakes periodic exams. For most, if not all of the boards, the ongoing assessment has been a periodic every six to ten years high stakes examination for which physicians went to a testing center, were palm printed, and reported substantial stress around the experience of the examination but also around the experience of preparing for the exam. Related to that but also consistent with new knowledge about adult learning and assessment, many of the boards are moving towards longitudinal assessment. This slide identifies the various boards that have pilots either planned or on the way in longitudinal assessment, which is a system in which their physicians or other diplomates receive a set number of questions quarterly on their home computer or on their cell phone, answer those questions, get immediate feedback and also get critiques that help direct the physician in terms of their ongoing learning. So something that is very much based in assessment for learning while at the same time allowing the boards to look at the overall performance over a period of years and use that as part of their summative conclusion about continuing certification. These are cert link is a platform that ABMS has developed to allow some of our smaller boards to actually do longitudinal assessment when it would be too costly for them to do it on their own. These are some of the hallmarks that we talk about in terms of flexible delivery, immediate feedback on performance. Let me share a little bit more about what that looks like. This would be an example of a question that might be given. People would answer it, have a period of time to answer it, and each of the boards are developing these somewhat differently. Many of the boards allow the use of external materials, for example. Then the diplomat is asked a number of questions. I think these are two of the important ones. First of all, how confident are you in your answer? And the physician has the opportunity to answer, and it does not impact their score whether or not they're confident or not. Because the needs of learners who are correct but not confident are very different than the needs of learners, the ones that scare us the most who are confidently incorrect. As part of our own continuous quality improvement, people are also asked how relevant this is to their practice. And then they get back immediately and answer why it was correct, why their answer was correct or not, and references and other learning materials that they can go to. So this is something that I think is very much going to be something that is popular with diplomats. Pediatrics in anesthesia are the furthest along in this, and in fact they have had very positive reactions from their diplomats. What are some of the opportunities for the ethics community? When the ongoing assessment of physicians was 200 or 250 questions every 10 years, it is very limited opportunity for the inclusion of ethics information. When boards are going to be giving lower stakes assessment for learning 80 questions a year to diplomats, there is a much greater opportunity for a broader construct of what those questions might be. I would suggest to you that within your boards, within your specialty societies, identifying the key areas for blueprints and potentially joining the over 5,000 volunteer physicians who work in the board's community right now may be worth thinking about. Emerging issues and knowledge. When Zika came out within a month, anesthesia had sent out a formative question that linked to the emerging evidence-based guidelines on Zika. What are the emerging issues that demand ethical comment? I would suggest to you, I've spent the last day and a half hearing a lot of them. I think it's an extraordinary opportunity to emphasize ethics education and practice. For this to happen, I encourage you to speak not only within your specialty societies but to the specific boards that are developing the questions and your board in particular. I wanted to mention the American Geriatric Society, which is some work that ABMS did to create a project of virtual patient cases. It's not longitudinal assessment, but it may be a mechanism where cases could be constructed that apply across many boards, something to think about. And finally, I want to make you aware of an initiative because I think as a community that truly understands continuing professional self-regulation and the importance of protecting that within our country, while at the same time understanding some of the challenges that there have been, I want to tell you about the vision initiative that has just been announced. We believe that certification is an important part of professional self-regulation. We recognize within the profession there is substantial agreement with the requirement of continuing certification, while there has also been anger about how it's been implemented. The boards have been criticized for limited involvement of the public and the broader profession when MOC was developed 20 years ago, and this is an attempt to identify that issue as well. And so the work of the commission assumes that participants are committed to professional self-regulation and recognize the role of a continuing process of board certification, not once and done. But otherwise, this vision initiative will totally reconsider what should continuing board certification look like and make recommendations to the board's community. It is intended to be inclusive, open, collaborative and candid. We are in phase one right now where a planning committee is developing what a commission, a group of 21 to 25 people working over a year period of time will do. I want to point out that none of the improvements are being delayed until the commission is finished. And then phase three is implementation. This is what the planning committee will do. I show you this slide only to point out that the boards have a minimum, a minority of individuals on the planning committee, and the planning committee otherwise has come from associate members of ABMS and particularly those who rely upon the credential. These are the members of the planning committee you will note that Graham McMahon who leads ACCME, Tom Naska who leads ACGME, and many others including three public members are here. Norm Kahn who is retiring from the Council on Medical Specialty Societies and I who am leaving the ABMS at the end of the year are co-chairing this and so as we leave the new commission will take over. As I said, the exact construct is still being determined but it is expected to engage the profession, the public and other stakeholders to receive information, answer questions, and make recommendations. My recommendations for the people here is a time for the ethics community to consider focus practice designation. Would this be appropriate within your board? Many boards across multiple boards you can have a focus practice designation. I encourage you within your specialty societies to leverage the opportunities inherent in longitudinal assessment and related learning opportunities because the specialty societies do the learning and within your boards to be talking to them about longitudinal assessment and whether you can join the cadre of people who are helping to write these assessments that will help drive learning. And I also encourage you to engage in the vision initiative as a community. There is an email address there if you want to volunteer yourself, your organization, at least in hearings if not actually suggesting that you might sit on the commission. Thank you very much. Lois, thank you so much. I want to go back to this focus practice designation. It's been surprising to me over the past 30 years how uninterested the ethics community has been in certification. And I think that that probably derives from the heterogeneity of the community. That is to say, I still, to the present, the majority of the community are not physicians and therefore they don't have any particular place where they can get certified. But that's not the case for clinical medical ethics. We've trained 400, 450 fellows about three-quarters of whom are physicians representing most of the specialties. And so this idea of focused practice designation of getting physicians, if I understood you correctly, recognized by their own subspecialty societies, is that it? Boards, not societies. By their boards, yes, by their boards. And working with their boards, both in terms of longitudinal assessment and the questions that would be prepared and written, that's a great opportunity. Can we talk with you further about that? Absolutely, you can talk with me further, but I would suggest the boards don't grow these. We have requirements. It should mostly come out of the subspecialty, the societies, if you will, but I'm happy to talk to anyone. I'm presenting it to you because I do think it's an opportunity, particularly because I believe a lot of the continuing certification work that is done by people in this room actually is focused in ethics. I do want to correct one misapprehension, however, which is two ABMS boards actually certifying non-physicians, and the absence, the lack of someone being a physician is not an absolute issue with subspecialty certification, but without question, what I have heard over the years is that the diversity of our community is something that lends itself to people not wanting to take this trick. Thank you.