Ten years have passed since sleep became a subspecialty recognized by the American Board of Medical Specialties. The anniversary also comes during a time of change for maintenance of credential requirements.

In 2007, the administration of physician sleep medicine certification passed from the American Board of Sleep Medicine (ABSM) to the American Board of Medical Specialties (ABMS), an institution that oversees 24 specialties and dozens more subspecialties. The anniversary serves as a milestone for the relatively young field of sleep medicine, but also has practical implications for many sleep specialists. Unlike the ABSM, which issued lifetime certifications, ABMS generally requires physicians to re-sit these exams every 10 years. That means that the first class of ABMS-certified sleep physicians—about 1,300— is due to re-certify this November if they haven’t already done so.

The anniversary comes during a time of controversy over the recertification process, also known as the maintenance of credential, or MOC. MOC requirements have become the subject of intense debate within the medical community, with many physicians deriding the 10-year exam and continuing education requirements as unnecessary, irrelevant, and costly. The controversy boiled over in 2014 when the American Board of Internal Medicine (ABIM), an ABMS member, added new MOC requirements and began publicly reporting whether physicians met those requirements.

“It is almost impossible to exaggerate the intensity of the pent-up rage that poured forth from US doctors,” wrote Elizabeth Loder, an internist and editor at the BMJ.

The American Academy of Sleep Medicine (AASM) was one of several physician groups to petition for relief. In 2014, the AASM sent a letter of concern to ABIM, which oversees the sleep exam and certifies the majority of sleep specialists. Chief among the concerns cited by then-president Timothy Morgenthaler, MD, were high MOC costs, the overlap of MOC and state CME requirements, and the “arbitrary requirement” that sleep specialists also maintain the internal medicine certification.

ABIM dropped the dual-certification requirement in 2015, but concerns about the cost of MOC activities and educational redundancy remain, says current AASM president-elect Douglas Kirsch, MD.

“It’s a lot of money for something that is primarily at this point administratively managed,” he says. “Now one could say that includes the test, that that’s part of the cost of this piece, but as tests evolve and as pieces change, who knows exactly what that money is going for other than making sure that you can continue to practice medicine.”

Above all, AASM is seeking clarity and communication from the ABIM and other boards that certify sleep specialists, Kirsch says. Besides internal medicine, sleep specialists can become certified through psychiatry and neurology, pediatrics, otolaryngology, family medicine, and anesthesiology. While all initially take the ABIM-administered exam, MOC requirements vary from board to board.

“[A]s you keep changing things, it’s hard to plan and for members to understand what it is that they have to do in order to maintain their board,” he says.

To that end, AASM is awaiting news of the sleep medicine governing board set to be established by the ABIM. Such a board would help organize and communicate the requirements for sleep specialists across overarching specialties, Kirsch says.

“The hope is that the AASM and sleep doctors in general have a voice in how that process begins to occur and evolve in the next few years not just through ABIM but through some of the other boards that sleep doctors have as well.”

ABIM has begun toying with “knowledge check-ins:” shorter, open-book tests taken outside of testing centers that are delivered more frequently, which physicians can choose to take in lieu of the once-a-decade exam. This option will be offered to sleep specialists starting in 2020, according to an ABIM spokesperson.

Other boards have implemented changes as well. The American Board of Anesthesiology has already replaced its 10-year test with something similar to knowledge check-ins, and the American Board of Psychiatry and Neurology now offers some combined MOC testing for multiple specialty holders. A competing organization, the National Board of Physicians and Surgeons (NBPS), offers recertification based on CME hours with no additional testing required. According to NBPS spokespeople, about 6,000 doctors have chosen to re-certify this way, including 250 sleep specialists.

The Value of a Test

Even the most vocal MOC opponents agree that the initial test, which is administered at the beginning of a specialist’s career, is a good idea. But many question the value of prodding doctors to regurgitate memorized information 10 years down the line.

“When there is a complex patient in clinical practice, no doctor relies just on memory; we look up the information, check a journal or consult a colleague. To rely solely on memory, especially for rarer illnesses or complicated patients, would be malpractice,” wrote one physician in an op-ed for the New York Times.

But the sleep specialty test is meant to assess vital, basic knowledge, says Vishesh K. Kapur, MD, director of sleep medicine for the Division of Pulmonary, Critical Care and Sleep Medicine at the University of Washington and the chair of ABIM’s sleep test writing committee this year. “Passing the test shows that you have a certain level of knowledge in something, and the cut-off for passing is not there to distinguish someone who’s great versus someone who’s less great,” he says. “It’s really to distinguish someone who is minimally competent from someone who may not have the knowledge that’s needed.”

Kapur says that the test evolves every year it’s administered with new questions tried out and old questions revised or thrown away. The committee is made up a variety of specialists who write questions that are then critiqued by the whole committee; once on the test, statisticians evaluate candidates’ answers to make sure the questions are neither too hard nor too easy, he says. In the trial period, these questions typically don’t count towards an individual’s score.

“I’d like to emphasize that there’s a great amount of care that’s taken in preparing the exam from folks on the exam committee and what gets onto the exam gets there after a lot of effort and debate about its validity, plus preliminary testing on the exam to show that the question works,” he says. “We’re always trying to make the exam more relevant to the clinical work that sleep specialists are doing.”

For the next few years at least, the 10-year follow-up exam remains a requirement for sleep specialists who want to maintain their board certification with ABMS. To prepare, Kapur recommends checking out the exam’s blueprint and reviewing weak areas.

Test-takers can also take a mock MOC test online, and AASM offers MOC modules online will host in-person review courses this fall.

Rose Rimler is associate editor of Sleep Review.