The American Board of Pediatrics (ABP) was founded in 1933 to raise standards of pediatric care and help bring clarity and order to what was then a dramatically changing medical environment. It may be hard to believe in today’s world of rapidly advancing technology, scientific discoveries and the rigors of specialty and subspecialty medicine, but back in the 1920s and ‘30s, all one had to do to become a specialist was to declare himself one.

The ABP found its purpose as physicians began to recognize the need for standards of training and care. With each passing decade, the ABP has evolved to meet the changing world of pediatrics and the needs of young patients—with physician testing moving from oral exams, to written exams, and now, computer-based formats. Today, the ABP also focuses on a rigorous Maintenance of Certification program, intended to ensure that pediatricians are staying current, engaged in lifelong learning, and upholding the highest standards of medical practice for children.

The ABP Is Born

In the first few decades of the 20th century, specialization did not necessarily involve training, and there were no legal or medical requirements for it, though medical schools were beginning to organize themselves into departments and offer residency programs. The American Medical Association (AMA) would list its members as they requested, so anyone could declare himself a surgeon, internist or pediatrician.

Enough concerns were raised about this self-selection that specialty boards began to emerge, including the American Board of Ophthalmology (1916), American Board of Otolaryngology (1924), American Board of Obstetrics and Gynecology (1930), and American Board of Dermatology and Syphilology (1932).

The American Academy of Pediatrics (AAP) formed in 1931, but its founders did not consider themselves a specialty. They talked about the need for certification by a specialty board at their very first meeting. Over about a year and a half of study, a newly appointed Committee on Medical Education considered and rejected several options, including adopting the European  model of governmental control, having the National Board of Medical Examiners (NBME) take on the task or having the medical schools oversee the issue.

The committee report to the AAP Executive Committee envisioned that the board would be created by the three national pediatric organizations (AAP, American Pediatric Society, AMA Section on Pediatrics), with each group appointing members, and be autonomous, making its own rules for examination and certification.

These standards and policies remain in place today.

Examination Process Evolves

The ABP board’s inaugural meeting was in January 1934, with a charter that set forth three tasks: reviewing accreditation of training programs, developing criteria for those to be certified, and examining applicants.

Five months later, in June, the first ABP examination was administered. The exam was oral, and much less formal and structured than what it eventually evolved into. The number of candidates increased beyond the nine-member board’s capabilities, and official examiners began to be appointed.

Today, exam development follows a very rigorous process, and can take 18 months to two years to complete and ensure that the exam is valid and reliable. Fellow pediatricians and subspecialists are involved in every step of the process:

• Determining content to be covered
• Writing the questions
• Selecting and approving the exam
• Analyzing the results
• Setting the required passing standard

A rigorous process ensures that test content:

• Is related and relevant to the practice or discipline
• Covers areas where knowledge is needed to effectively perform the job
• Reliably produces consistent and stable results

Subspecialties Evolve

Subspecialties in pediatrics began emerging in the 1930s and ‘40s, starting as clinics within medical schools – probably first at Johns Hopkins School of Medicine. Subspecialty certification began through the ABP with cardiology in 1961, followed by hematology-oncology  and nephrology in 1974, and neonatal-perinatal in 1974.

The ABP awards certificates in General Pediatrics and in the following 15 subspecialty areas of Pediatrics: 

Certificates are awarded in conjunction with other specialty boards in the areas of Hospice and Palliative Medicine, Medical Toxicology, Pediatric Transplant Hepatology, Neurodevelopmental Disabilities, Sleep Medicine, and Sports Medicine.

Maintenance of Certification (MOC)

Originally, once they passed the initial exam, pediatricians were certified for life. In time, the Board recognized that a single exam at the start of a career does not serve to demonstrate ongoing competence over a lifetime of rapidly changing medical practice. In 1988, the board began requiring recertification exams every seven years. In 2000, the American Board of Medical Specialties (ABMS) partnered with the Accreditation Council for Graduate Medical Education (ACGME) to adopt six core competencies for physicians. These competencies became the foundation of improvements in initial certification and in MOC, which emerged in 2003. In 2006, MOC was redesigned to extend the secure exam cycle to 10 years, and add demonstration of self-assessment and quality improvement activities every 5 years. As medical specialties and subspecialties continue to emerge and grow, it is increasingly important to find additional ways to assess physician competence.

Other processes that have evolved include:

• Performance Improvement Modules (PIMs), part of MOC assessments, have been developed in many areas, including health literacy of patients and parents, safe prescription writing, and combatting childhood obesity. PIMs are web-based tools that enable pediatricians to implement improvements in clinical care using quality improvement methods.
• Establishing the Milestones Project, which identifies behavioral descriptors for each of the 48 competencies under the six core domains. This project was a response to the decade of struggle that resulted from attempts to teach and assess these competencies. In an effort to advance the field, ABMS member boards in 2009 partnered with ACGME in the Milestone Project. The milestones for a given competency are descriptive markers of performance levels along a developmental continuum from a novice or early medical student to a master clinician who is years into practice. The milestones help peers and supervisors assess trainees performing a specific task or competency such as “gathering essential and accurate information about a patient.” Additionally, they serve as a learning roadmap for trainees who can look at the descriptions of behaviors at each next step along the continuum and set their goals accordingly.
• Data Collection: As a service commitment to the broader pediatric medical community, ABP collects and updates workforce data, which is useful for training program planning and child health advocacy.

Looking ahead, the ABP remains true to its mission and will continue to evaluate the effectiveness of assessing pediatricians’ competence in core areas, and improving standards of certification by examining the current testing model and considering ways to encourage continuous improvement in the quality of pediatric care.

At the ABP, we know that children are some of the most vulnerable patients, and deserve the best possible care. We consider a healthier child to be the true measure of our success, treated by outstanding physicians who continue to meet standards of excellence.