The American Osteopathic Association's (AOA) board certification program began in 1939. The official AOA certifying body, the Bureau of Osteopathic Specialists (BOS), through its 18 approved specialty boards, has been the primary certification provider for osteopathic physicians and has issued more than 28,100 General, Special Qualifications, and Added Qualifications certifications (Figure 1). 

As of the end of December 2005, a total of 19,837 osteopathic physicians were actively certified by the AOA, holding a combined total of 23,016 active certificates. In 2005, a total of 1002 certificates were awarded in specialty and subspecialty areas (Table 1). Also in 2005, 35 certificates of added qualifications were awarded (Table 2). 

In February 1994, the AOA Board of Trustees directed all certifying boards to establish a mechanism for re-entry into the certification process for those physicians whose board eligibility had expired. Such a re-entry process, which may differ from board to board, may include the completion of a specific amount and type of continuing medical education (CME) credit before physicians are allowed to sit for certification examination. This process does not re-establish board eligibility status, but it does allow physicians to meet the requirements for sitting for certification examinations. 

In July 1993, the AOA Board of Trustees directed the AOA executive director, in conjunction with the BOS, to study the issue of creating a mechanism for the formation of conjoint boards in areas of overlapping specialties. This action was prompted by an application for the formation of a conjoint board of sports medicine. 

In its discussions, the BOS noted that, over time, there likely will emerge new areas of overlapping jurisdiction in osteopathic medicine in addition to sports medicine, and that the formation of a new certifying board each time would not be practical. Instead, the BOS recommended that a mechanism be formed for creating conjoint examinations that would allow all appropriate specialty boards to participate. The Board of Trustees accepted this recommendation in February 1994 and approved the mechanism for creating conjoint examinations. 

The conjoint mechanism allows diplomates (those holding general certification) from participating boards to establish eligibility to sit for examinations. Currently, three conjoint examinations are offered (sports medicine, addiction medicine, and dermatopathology). 

Effective January 1, 1995, the AOA certifying boards were directed to offer a recertification mechanism to its diplomates. In conjunction with implementation of the recertification process, numerous boards have instituted time-limited certificates (that is, new certificates are issued with an expiration date.) By January 1, 2004, those AOA certifying boards that had not yet implemented a certificate time-dating policy were required to make all newly issued certificates time-limited to 10 years or less. Fifteen of the 18 AOA certifying boards had already time-limited their certificates before January 1, 2004. Certificates issued before the time-limit requirement are valid for life. All diplomates are eligible to sit for recertification examinations, even if they hold a lifetime certificate. Figure 2 summarizes the current status of time limits on the certificates issued by AOA certifying boards. 

American Osteopathic Association recertification rates continue to rise as many of the initial time-dated certifications expire (Table 3). In 2005, there was a 72% increase in the recertification rate compared with 2004. This increase was driven primarily by family practitioners recertifying through the American Osteopathic Board of Family Physicians, as well as by internal medicine specialists and subspecialists taking the various recertification examinations provided by the American Osteopathic Board of Internal Medicine. Certain other specialties, including orthopedic surgery, are also beginning to see rising recertification rates. It is expected that recertification activity through the certifying boards of the AOA will continue to increase as more of the time-dated certificates expire and as recertification becomes a more widespread requirement for managed care participation/credentialing and obtaining hospital privileges. 

Because certification is so consequential, the certification process must be legally justifiable and valid for credentialers to accept it. In January 1994, the AOA began providing psychometric services to assist osteopathic medical certifying boards in the validation of their certification examinations. The AOA provides consultation and data analysis services to certifying boards and assists them in creating, scoring, and analyzing their examinations. These services provide psychometric guidance to a board in all steps of the examination process, including written, oral, and practical examinations. 

From the beginnings of the AOA's certification program, the AOA has been concerned with the quality and standardization of its certifications. In 1992, the AOA Board of Trustees established a policy on uniform standards for all AOA certifying boards for test construction, evaluation, and use. In 1995, the Board of Trustees resolved that the BOS provide for rigorous statistical validation of the examinations of all AOA certifying boards. In 1997, formal approval was granted to the Guidelines for AOA Certification Examination Standards, which describe the psychometric standards that all AOA examinations must meet. From this document, a plan for a formal evaluation process to assess the validity and reliability of each AOA certification examination was devised and, in June 2000, the first official reviews of three AOA certifying boards were conducted. This review process brings value to osteopathic certification and to those holding it. The process is in essence a continuous improvement mechanism that benefits not only the certifying board but the current and future diplomates as well. 

The format of the certifying board review is a self-study with completion of a report. These reports are then reviewed by the Standards Review Committee, which includes six elected members plus the BOS public member, two alternate members, and the AOA psychometrician (nonvoting). After the first cycle review, each board is reviewed again in 3 ½ years. After the second review, the time interval between reviews is 5 years. At each BOS meeting, three certifying boards are reviewed. Conjoint examinations are reviewed at the last meeting of the evaluation cycle. 

After review of the certifying board's self-study report, the Standards Review Committee may make recommendation of compliance to the BOS, or the committee may defer making any recommendation at that time. Within 30 days of the Standards Review Committee's evaluation, the certifying board will receive a written evaluation, and examination activities found not in compliance with the standards will be clearly described to the board. In the first evaluation cycle, if the certifying board was not approved by the BOS as compliant, the board has 120 days from the date of the written evaluation to respond in writing with its action plan, specifying how the activities not in compliance will be addressed. For the second and later review cycles, the submission of an action plan is not required. 

For the first review cycle, at the next meeting of the Standards Review Committee, the certifying board's action plan is studied, and any comments are forwarded to the board. In most cases, the board's action plan is formally accepted at this time, but in some cases, further information from the board may be requested. Within 1 year of the Standards Review Committee's appraisal of the action plan, the certifying board must submit an updated report to the committee with evidence that the board is in compliance with the standards. 

For the second and later review cycles, if any examination activities are found not in compliance with the standards, the certifying board must submit an updated report within 1 year of the review date, along with acceptable evidence showing that all the examination activities are in compliance with the standards. The board must submit its updated report at least 45 days in advance of the meeting in which the Standards Review Committee will study it. 

The Standards Review Committee will review the updated report and make a recommendation to the BOS for action. If the BOS finds the certifying board not in compliance, the BOS may impose a 1-year probation period and the practice affiliate will be notified of the board's probationary status. The failure of the certifying board to comply with the standards results in a BOS recommendation to the Board of Trustees that the certifying board's directors and/or members may be replaced and that certification activities may be suspended until the board demonstrates compliance with the standards. At the end of the probation period, the board must demonstrate compliance with the standards. 

The Standards Review Committee began meeting in conjunction with the BOS meetings (held in January and June) in June 2000. The second review cycle began in January 2004. Subsequent review cycles start in January 2009 and will occur every 5 years after that. The schedule for the first and second review cycles is shown in Figure 3. 

Ensuring the validity of the BOS board examinations through its standards review process is only one initiative that the BOS has taken to better assess the competence of board-certified physicians. In January 2005, the BOS adopted a resolution mandating that each specialty include the seven core competencies (interpersonal and communication skills; medical knowledge; osteopathic philosophy and osteopathic manipulative medicine; patient care; practice-based learning and improvement; professionalism; and system-based practice) in its board examination process. These are the same competencies that have previously been adopted at the training level in osteopathic residency programs. The process to test core competencies, under the guidance and support of the BOS, will vary according to the specific needs of each specialty board. 

In addition to testing core competencies, the BOS continues to evaluate the concept of continuous assessment of physician competence. The BOS has reviewed the allopathic model of maintenance of certification (MOC) and considers it to be one of several possible models to maintain the high competency levels of osteopathic physicians. The BOS is also considering its own continuous assessment model as a way to better fit the needs of the osteopathic medical profession and as a response to public and government calls for improved patient care. It should be noted that many of the elements of MOC, including professional standing, required CME, and cognitive examination, are part of the osteopathic recertification process currently in place. The method by which continuous assessments will be made will be decided in the near future. 

The commitment of the BOS to assess continued competence of board-certified physicians is clear. It is this commitment that is guiding the BOS to create an assessment process that fulfills its function to protect the public and promote the continued competence of board-certified osteopathic physicians to deliver quality care. 

In October 2002, the AOA Board of Trustees created a Task Force on Certification to review the overall operational structure of the AOA's certification program and to study future trends that may impact or change the certification process and demand. The Task Force on Certification worked closely with the BOS on determining future steps to safeguard and promote AOA certification. The task force transferred its functions to the newly created BOS Committee on Financial and Administrative Board Matters, which will monitor existing and upcoming certification trends in the osteopathic medical profession. 

In July 2004, the AOA Board of Trustees approved a new certification pathway that provides a more streamlined and facilitative process for osteopathic physicians trained by the Accreditation Council for Graduate Medical Education (ACGME) and certified by the American Board of Medical Specialties (ABMS) to enter into the AOA certification process. To be eligible, candidates must have completed an ACGME-accredited residency program at least 5 years before application and hold ABMS certification in a primary specialty. The pathway is for AOA certification only and does not confer approval of the first year of training as equivalent to an osteopathic internship (provided through Resolution 42 [A/2000]). For complete requirements and eligibility information, and to determine whether a particular specialty participates in this new pathway, inquiries can be referred to the AOA Division of Certification at (800) 621-1773, extension 8266 or 8105. 

As the needs of the healthcare environment continue to change rapidly, the AOA and its specialty boards will keep adapting to meet the needs of osteopathic physicians and protect the interests of the public. Board certification no doubt will continue to play a key role in the professional lives of osteopathic physicians well into the future.