Reimagining Initial Certification as a Process That Begins During Residency to Support Continuous Development Across Training and Practice

Abstract

In the United States, initial board certification remains focused on a high-stakes knowledge examination after completion of training. A more contemporary view supports a program of assessment that includes multiple types and sources of data with an emphasis on direct workplace observation to get the best picture of an individual’s performance. In this article, the authors reimagine initial certification as a continuous assessment for learning that begins in residency, focuses on both knowledge acquisition and its application, and interdigitates intentionally with the first cycle of maintenance of certification to advance learning and smooth the transition from training to practice. A more expanded view of competence, as a 3-layered construct (canonical, contextual, and personalized), supports this proposal. Canonical competence (context-independent knowledge)—best assessed through examinations of knowledge—is most heavily weighted and assessed during medical school but remains critical throughout one’s career. Contextual competence (context-dependent knowledge) is best assessed in the workplace and is key during residency and fellowship as trainees navigate a myriad of clinical work environments. Personalized competence, representing the totality of one’s unique areas of expertise, is best demonstrated during the practice years when deliberate practice experience supports the growth of personalized expertise and discoveries that advance the field. Shifting initial board certification from relying on an anxiety-provoking, high-stakes, often single moment in time standardized examination to a nuanced approach that is part of an individual trainee’s program of assessment offers a more just and robust decision about readiness for unsupervised practice. Such a model would also sow the seeds of meaningful individualization of learning needs that begins in training, continues through practice, and lays the foundation for improving the quality of care for patients within a given practice as well as shifting the current contiguous phases of training and practice into a true continuum.