Faraze Niazi
Jack Riggs
Morgantown, West Virginia, United States

“The devil is always in the details.”
“Be careful what you wish for, you just might get it.”
—Two Old Wise Sayings

Certifying clinical competence has virtually universal support. After all, who does not want their doctor to be competent? Moreover, how many physicians feel that they are incompetent? Despite support for the concept, recertification and maintenance of certification have become controversial and contentious issues.^1-3 Physicians are dissatisfied and claim that the process is too time-consuming, too expensive, and largely irrelevant to the purpose of validating clinical competence. In response, physicians have formed alternative board certifying bodies and advocated for laws minimizing any adverse professional impact of maintenance of certification programs.^4-5

Although rarely a source of solutions to current problems, history often provides insight into present day dilemmas.

The “first” examination certifying clinical competence

As commonly told, the Caliph al-Muqtadir in 931 CE became aware that one of his subjects was the victim of medical malpractice.^6-12 In an effort to avoid the likelihood of this occurring again, al-Muqtadir issued an edict that all physicians practicing in Baghdad be examined by his court physician, Sinan ibn Thabit, and certified as clinically competent to practice medicine.

This story does not likely, accurately or entirely, reflect reality. Al-Muqtadir ascended to the throne of the Abbasid Empire at the age of thirteen, and his rule was disastrous.¹² During his twenty-five-year reign, al-Muqtadir displayed little interest in ruling and rarely ventured outside his palace. Courtiers dictated the affairs of state and squandered the caliphate’s money. As revenues plummeted, the treasury surplus that al-Muqtadir inherited was depleted. The Caliph’s area of control shrank to the borders of Baghdad. This leadership record does not suggest that al-Muqtadir was the type of ruler who would have taken a direct interest in physician clinical competence.

A more likely explanation behind the mandated clinical competence examination of Baghdad physicians is Sinan ibn Thabit. Better known as a mathematician and astronomer, Sinan ibn Thabit, the courtier physician, depended on al-Muqtadir’s patronage. As might be expected with any examination controlled by a single individual, inconsistencies and irregularities in its application were noted.^{6-7, 9} We suggest that Sinan ibn Thabit saw an opportunity to enhance his standing with al-Muqtadir when one of his subjects died because of medical incompetence. Notably, al-Muqtadir died in 932 CE, one year after issuing his edict. Sinan ibn Thabit quickly lost favor with al-Muqtadir’s successor and had to flee Baghdad. The requirement for clinical competence examinations for Baghdad physicians immediately ceased.

Connections—certification in ancient and current times

What does this historical vignette have to do with current concerns about recertification and maintenance of certification? There are two applicable principles emerging from this story and a third principle revealed by the current recertification issue.

Principle 1: Autocratically imposed requirements may be short-lived and cause less long-term burden than regulations entrenched and rooted in bureaucracy.

Comparing al-Muqtadir’s autocratic edict and the current bureaucratic requirements for specialty recertification reveals the contrasting nature of this principle. Al-Muqtadir’s edict requiring demonstration of clinical competence quickly died with him. However, this principle does not imply that either autocratic or bureaucratic regulation is superior over the other.

Principle 2: Commonly expressed stories or complaints rarely reveal the complete truth. 

As with the al-Muqtadir story about the origin of examinations to certify clinical competence, the complaints of physicians about recertification and maintenance of certification warrant deeper exploration.^1-3

In 1973, the American Board of Medical Specialties agreed to the principle of recertification for diplomates of the member specialty boards.¹⁴

When the American Board of Family Medicine was established in 1969, lifetime certification gave way to the concept of a time-limited certification process, which required periodic recertification. 

Since then, all of the ABMS member Boards have adopted time-limited certification.¹⁵

The issues encountered with the processes of recertification and maintenance of certification did not suddenly emerge. Physicians had decades of warning.

Principle 3: It is unwise to agree to a goal without understanding and accepting the costs and methods associated with attaining that goal. 

Physicians had long ago agreed to continuing certification of clinical competence but surrendered the mechanism of realizing and validating that goal. This is akin to warring parties agreeing to make peace but leaving the details to be worked out later.

Unlike the ancient certification of clinical competence, the ultimate resolution of the current controversy will not be as simple as an al-Muqtadir dying or running a Sinan ibn Thabit out of town.

References

1. Welcher CM, Kirk LM, Hawkins RE. Alternative pathways to board recertification, to what end?  JAMA 2017;317:2279-80.
2. Schwartz AB, Schwartz JS. Physician certification and recertification, the role of empirical evidence.  JAMA 2017;317:2288-9.
3. Goldman L. Maintenance of certification: glass not entirely empty?  Ann Intern Med 2018;169:124-5.
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5. Johnson DH. Maintenance of certification and Texas SB 1148, a threat to professional self-regulation.  JAMA 2017;318:697-8.
6. Browne EG. Arabian Medicine. Cambridge: University Press, 1921:pg 40.
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8. Syed IB. Islamic medicine: 1000 years ahead of its times.  JISHIM 2002;2:2-9.
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12. Zunic L, Karcic E, Masic I. Medical ethics in the medieval Islamic sciences. J Res Pharm Pract
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14. van Berkel M, el Cheikh NM, Kennedy H, Osti L. Crisis and Continuity at the Abbasid Court, Formal and Informal Politics in the Caliphate of al-Muqtadir (295-320/908-32).  Boston: Brill, 2013.
15. Manning PR, Petit DW. The past, present, and future of continuing medical education. Achievement and opportunities, computers and recertification. JAMA 1987;258:3542-6.
16. Weiss KB. Future of board certification in a new era of public accountability. J AM Board Fam Med 2010;23:S32-9.