MOC Alternative Showing Success

Marcia Frellick

January 09, 2019

The American Board of Anesthesiology (ABA) has demonstrated successes with a redesigned maintenance of certification (MOC) system it developed in collaboration with the Accreditation Council for Continuing Medical Education (ACCME).

Alex Macario, MD, MBA, a member of the ABA board of directors and chair of the ABA Research Committee, and colleagues described the approach, called MOCA 2.0, and early data on its successes in an article published online today in the New England Journal of Medicine.

"I think this represents the kind of innovation every specialty society should be thinking about," Lee Goldman, MD, MPH, professor, executive vice president, and dean of the faculties of health sciences and medicine, and chief executive of Columbia University Medical Center in New York City, told Medscape Medical News.

Under MOCA 2.0, an interactive Web-based assessment tool dubbed the MOCA Minute, introduced in 2016, asks physicians to answer 30 multiple-choice questions relevant to practice per quarter. As participants answer each question, the ABA gives immediate feedback and connects the physician to continuing medical education (CME) resources. Meanwhile, it tracks physicians' scores over time.

1 Minute Per Question

Because the questions concern information anesthesiologists should know without consulting a reference, only 1 minute is allowed per question.

Macario told Medscape Medical News that every 3 months he gets the questions on his smartphone and they are selected based on his practice.

"I have found that I can do a few questions every few days and that helps me retain what I was asked, especially because I can read the explanation for the correct answer that is delivered to my phone after I answer the question. If I get it wrong, I often read up a bit more about the topic," he said.

After answering each question, physicians rate their level of confidence as very confident, somewhat confident, or unsure, which indicates what they really know and what's a guess.

That scoring helps build a database that indicates where the knowledge gaps are and what the most appropriate CME would be for each physician.

When answers are wrong or are answered with low confidence, the questions are repeated to improve retention.

The ACCME allows providers of CME to target activities to MOCA 2.0, hosts a search tool so physicians can find appropriate CME, and lets the ABA know when a physician has completed CME.

"As of November 2018, 53% of MOCA Minute questions were linked to at least 1 CME activity, and more than 110 accredited CME providers had linked a combined total of 3,261 activities to the content outline," the authors write.

However, the financial separation is clear: "Neither the ACCME nor the ABA produces CME or financially benefits from physicians' participation in CME activities," the authors write.

Early Results

A 2017 ABA survey found that 82% of those who participated in the MOCA Minute pilot said it was an effective assessment tool, 91% said it identified gaps in knowledge, and 88% said the links to relevant CME were useful.

Goldman, who has been a critic of traditional MOC, said, "The concept of real-time evaluation and education embedded into your practice — that's the kind of creativity I'd expect that specialty societies would encourage, foster, and then implement. It does this without adding on an extra layer of bureaucracy and expense that may not be truly relevant."

The program "incorporates adult learning theory principles," Macario said, "which emphasize that adults prefer a self-directed approach that allows for discovery on our own as we are internally motivated to stay current, learning that is related to things we are regularly doing while taking care of patients, and education that takes into account what we already know."

Only a small number of physicians did not meet the ABA's minimum performance standards on the new assessment.

Additionally, the number of physicians who were able to finish all 120 questions over the four quarters grew in the first 2 years.

In 2016, 21,074 anesthesiologists took the assessment (18,366 had time-limited [every 10 years] board certification) and 90% of these participants completed all 120 questions.

In 2017, 24,277 physicians participated (21,334 had time-limited certification) and 93% completed all the questions.

After the success of the pilot, the American Board of Medical Specialties approved MOCA Minute as a permanent MOCA program component in April 2018, Macario said. It has replaced the previous every-10-years, high-stakes exam.

He notes that the MOCA Minute was recognized in the Continuing Board Certification Vision for the Future Commission report ( as an example of an innovative approach to physician learning and assessment.

Will Hospitals and the Public Accept New Assessment?

Goldman said he doesn't think the ABA will have to sell hospitals or the public on the merits of the change as neither group claims to have the expertise to discern which method is best and they look to the profession to do that.

"What better way to show you're up to date than to be evaluated as part of your daily practice and do well?" he said.

He added that he's not surprised that this alternative came from anesthesiologists.

"If you look over the past generation or so and ask what specialty has really led the way in standardization, reducing errors, and therefore improving outcome, no one's done it better than anesthesiology," he said.

Macario reports personal fees from the American Board of Anesthesiology outside the submitted work; and coauthors report personal fees from the Accreditation Council for C, outside the submitted work. A coauthor is a staff member of the American Board of Anesthesiology.

Goldman has disclosed no relevant financial relationships.

NEJM. Published online January 10, 2019.


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