2015 MOC Standards Reflect Feedback, Fail to Stem Critics

Marcia Frellick

January 07, 2015

Two articles published in the January 8 issue of the New England Journal of Medicine outline very different perspectives on maintenance of certification (MOC).

Mira Irons, MD, senior vice president for academic affairs for the American Board of Medical Specialties (ABMS), and Lois Nora, MD, JD, ABMS president and chief executive officer, say MOC is necessary self-regulation and a critical measure of physician expertise as healthcare becomes exponentially more complex.

"Board certification is a high standard. It is a rigorous process. It is intended first and foremost to demonstrate why the public can continue to put their trust in physicians," Dr Nora told Medscape Medical News.

They acknowledge the anger voiced by physicians concerning the cost and time required to complete the certification every 2 years. And after 2 years of consultation with the 24 boards that certify across 37 specialties, Dr Nora says, the 2015 MOC standards reflect changes that incorporate physicians' feedback.

"One of the biggest changes," she said, "relates to our portfolio program, where activities that physicians are engaged in — quality assurance activities, quality improvement activities that they are doing in their practices and that are institution-wide — are acknowledged and given MOC credit."

In addition, some of the member boards are also looking at changes to the closed-book portion of the test, which some physicians have said is not realistic, given the prevalence of devices with immediate information available in practices.

"Ultimately, the boards exist for the public trust.... I completely agree that physician engagement in what MOC should be is extremely important, and I am satisfied that not only are our boards doing that...but among the 2015 standards, http://www.abms.org/ is a standard related to getting diplomate feedback as part of our 24 boards' own quality improvement activities," she noted.

In their paper, Dr Irons and Dr Nora point out that there is growing evidence that MOC can improve physicians' performance and patient outcomes. Such data, they note, is documented in studies found in the ABMS Evidence Library.

Physicians Differ on Whether MOC Improves Outcomes

However, not everyone thinks the existing data adequately demonstrate that MOC leads to better outcomes.

In the second article in the same issue, Paul Teirstein, MD, chief of cardiology and director of interventional cardiology for Scripps Clinic in La Jolla, California, writes, "Almost all published studies evaluate initial board certification, not recertification or MOC, and the rigorous requirements for initial certification should not be equated with the busywork required for the MOC every 2 years."

Dr Teirstein is leading a campaign against MOC. Among his other arguments is that the process is an undue burden on physicians' time without enough benefit. He started a website to protest MOC requirements and said that so far, he has more than 19,000 signatures.

He gave an example of an MOC project he considers a time-waster from the last time he was certified: He said the practice improvement project involved asking 20 patients to call a number and register their comments on how he could improve his practice, and then drafting a plan to make changes incorporating the patient feedback. Because physicians choose which patients will comment, the information is likely to be skewed, he said. He added that physicians are already reviewed through patient satisfaction surveys, public rating sites, their peers, and the hospitals that employ them.

Substitute CME for MOC

He told Medscape Medical News that although all physicians support lifelong learning, a better alternative already exists in continuing medical education (CME).

Because physicians are currently required to take about 25 hours of CME per year, depending on the state, that should replace the MOC modules, he says. Tracking physician participation could be accomplished at nominal cost.

In addition, CME must meet standards regulated by the Accreditation Council for Continuing Medical Education, and the programs must compete for physicians' support.

"If physicians do not perceive value in a particular CME offering, they will go elsewhere — a situation in stark contrast with the [American Board of Internal Medicine] monopoly on MOC," Dr Teirstein writes.

When asked about the possibility of substituting CME for MOC, Dr Nora says, she and Dr Teirstein will have to agree to disagree.

Dr Irons and Dr Nora are employed by the American Board of Medical Specialties. Dr Nora is a coauthor on work describing the ABMS Maintenance of Certification program. Dr Teirstein reports receiving personal fees from various CME conferences, including Coronary Interventions, TCT, and institutional grand rounds outside the submitted work. In addition, he is developing an alternative board to certify physicians.

N Engl J Med. 2015;372:104-108. Irons and Nora full text  Teirstein full text

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