Anesthesiology Board Drops 10-Year-Exam for MOC

September 14, 2015

Tougher requirements for maintaining board certification have set off a full-scale revolt in internal medicine. Recent reforms to streamline maintenance of certification (MOC) for anesthesiologists may keep that specialty calmer, however.

On September 10, the American Board of Anesthesiology (ABA) unveiled a redesign of its MOC in Anesthesiology (MOCA) program that replaces a dreaded 10-year exam with an online learning tool called the MOCA Minute that will quiz and teach physicians on a continuous, baby-step basis at their convenience. MOCA 2.0, as it is called, also drops a requirement for assessing an anesthesiologist's simulated care of a dummy patient and makes it optional instead. The ABA has been airing these and other changes for months, so they come as no surprise to the physicians it certifies.

MOCA 2.0 has gotten good, if not rave, reviews from anesthesiologists. "The changes are all in the right direction," said John Abenstein, MD, president of the American Society of Anesthesiology, who told Medscape Medical News he was speaking for himself, rather than for his association. "They're being viewed as positive."

A prominent critic of the American Board of Internal Medicine (ABIM) and its controversial MOC program said the idea of replacing his specialty's 10-year-exam with the equivalent of the MOCA Minute holds promise.

"If it can be tailored so that it is relevant to each physician's practice, is truly educational, is not onerous, and can be accomplished at a reduced cost, I think many physicians would embrace it," Paul Teirstein, MD, chief of cardiology at the Scripps Clinic in San Diego, California, told Medscape Medical News. "This kind of program is something the ABIM should seriously explore."

"The Angst Every 10 Years Was Immense"

The ABIM and ABA are among 24 boards that make up the American Board of Medical Specialties, which has pushed to make certification more than a once-in-a-lifetime test, or even a test every 10 years. MOC programs of American Board of Medical Specialties member boards assess physicians in four areas:

  • professionalism and professional standing;

  • lifelong learning and self-assessment;

  • knowledge, judgment, and skills; and

  • improvement in medical practice.

The MOC Spring for internal medicine began in 2014, when the ABIM began requiring physicians to complete training modules, some newly introduced, throughout their 10-year certification periods. The cost of training modules and the 10-year exam also increased by nearly 16%, to $1940, for internal medicine, and by 39%, to $2580, for an additional subspecialist certification (physicians boarded before 1990 were exempted from ABIM recertification).

Droves of internists and internal medicine subspecialists complained that the new MOC requirements, although costing them more, did not make them better physicians, but instead mired them in busywork. Almost 23,000 have signed a petition demanding that the ABIM base board recertification merely on an exam every 10 years. Dr Teirstein and other MOC dissidents formed a rival to the American Board of Medical Specialties called the National Board of Physicians and Surgeons, which promises a more meaningful and less expensive path to recertification for all specialties (Disclosure: Eric Topol, MD, editor-in-chief of Medscape, is a member of the National Board of Physicians and Surgeons advisory board, an unpaid position.)

Newsweek magazine captured the drama in a piece titled "The Ugly Civil War in American Medicine." For its part, the ABIM has responded with apologies and reforms to placate critics.

American Society of Anesthesiology President Dr Abenstein, an associate professor at the Mayo Clinic, Rochester, Minnesota, said anesthesiologists also have found fault with their specialty's MOC program. "But their opposition wasn't nearly as intense as it was in internal medicine." He speculates that the ABA accelerated its MOC reforms "because of what happened with the ABIM."

Dr Abenstein said he was glad to see the demise of the 10-year certification exam. He called it a "high-wire act" because most hospitals require their anesthesiologists to be board certified. "Physicians have mortgages, kids in college, and retirements to plan for," he said. "The angst every 10 years was immense." And after cramming for the test, physicians typically forgot most of what they learned.

The MOCA Minute that will replace the test next year epitomizes continuous, as opposed to sporadic, learning. ABA diplomats must answer 30 multiple choice questions every 3 months. Regardless of the response, the MOCA Minute software will display the correct answer, the rationale for it, and links to pertinent educational material. Physicians can tackle the questions one at a time whenever they want, and wherever they are, as the ABA will release a MOCA Minute app for mobile devices.

The anesthesiology simulation on a dummy patient was another groaner for these specialists. It, too, happened every 10 years. Dr Abenstein said anesthesiologists disliked having to travel to a simulation center and perform in front of peers, much less spending $2000-plus for the exercise.

Another problem with the simulations was that anesthesiologists had to respond to faux patient emergencies in an unfamiliar and unnerving clinical setting, said Thomas Gallen, MD, MPH, an anesthesiologist in Lafayette, Indiana, who has campaigned for MOC reform in his specialty. "We should be doing simulations in our own institutions, with our colleagues," Dr Gallen told Medscape Medical News.

Dr Gallen said the ABA has listened to its diplomats and improved the MOC process, "but I don't think they've answered all the complaints." For one thing, physicians will pay just as much for participating in the MOCA Minute over the course of 10 years — $2100 — as they would for the test it replaces. However, Dr Gallen surmises that the ABA will save money by switching to the MOCA Minute, given the efficiencies of the Internet. So, he asks, why won't the price tag for physicians go down?

More important, Dr Gallen wants participation in MOC activities such as the MOCA Minute, practice improvement modules, and the like to be voluntary. He favors lifelong certification based on an initial test, just as it was done before 2000 in his specialty. Physicians undertake lifelong learning and practice improvement on their own, and "I don't think the ABA should be mandating or big-brothering us to do it," he said. If recertification by a specialty board is that critical, why were anesthesiologists who were boarded before 2000 excluded from this requirement?

Asked Dr Gallen: "If it's so great, why isn't it for everyone?"

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