New Commission Report Is Tough on MOC

Alicia Ault

January 11, 2019

Many physicians — after years of complaints about the maintenance of certification (MOC) process — feel that they are finally being heard, thanks to a new report from an independent commission established by the American Board of Medical Specialties (ABMS).

The 96-page draft report from the 27-member Continuing Board Certification: Vision for the Future Commission suggests that the process was far enough off the rails that the term "maintenance of certification" should be abandoned.

"A new term that communicates the concept, intentions and expectations of future continuing certification programs should be adopted," writes the commission.

A survey of some 34,000 physicians conducted for the commission, which was included in the report, found that just 1 in 10 (12%) said they valued MOC, whereas 41% said they did not value the program, and 41% had "mixed feelings."

The report — the result of a process begun in the fall of 2017, which included 21 hours of public testimony — is open for comment until January 15, after which it will be presented to the ABMS board for review, most likely in February, said an ABMS spokesperson.

Paul Teirstein, MD, one of the fiercest critics of MOC, said that he was pleasantly surprised. "I thought they did a great job documenting the actual problems," said Teirstein, president of the National Board of Physicians and Surgeons (NBPAS), which has created an alternative certification process. "What struck me first was that they were very clear in agreeing there has been physician harm due to maintenance of certification," Teirstein, chief of cardiology at the Scripps Clinic, San Diego, California, told Medscape Medical News.

But Teirstein said the NBPAS wants action. In a four-point comment to the Vision Commission, the NBPAS said it is seeking an immediate end to requiring secure, high-stakes exams; an immediate end to requiring Quality Initiative (QI)/Practice Improvement (PI) components of MOC; retention of the continuing medical education and professionalism components; and a reduction in fees to less than $100/year, no matter how many certifications are maintained.

At press time, more than 15,000 physicians had signed on in agreement.

The Vision Commission's co-chairs said the report's recommendations would not be binding on the 24 specialty boards that make up the ABMS. But Christopher Colenda, MD, MPH, and William Scanlon, PhD, said they believed the boards would take them to heart.

"The ABMS boards have been very engaged and have expressed a sincere desire to improve the continuing certification process so that it becomes a system that demonstrates the profession's commitment to professional self-regulation, offers a consistent and clear understanding of what continuing certification means, and establishes a meaningful, relevant, and valuable program that meets the highest standard of quality patient care," said the two co-chairs in a statement to Medscape Medical News.

Warren Newton, MD, MPH, president of the American Board of Family Medicine (ABFM), said the ABFM is still working on its final response to the Vision Commission report. "We agree with many of the particulars — including the importance of a formative component, engagement of diplomates, and consistency across the boards," Newton told Medscape Medical News.

"We are pleased that they have supported the importance of consequential decisions and quality improvement — making sure that physicians get credit for what they are already doing," he said, adding, "We believe that the report encourages us to continue on our path to evolve board certification."

The American Board of Internal Medicine (ABIM), which has been the target of particularly loud complaints — and is the subject of a class action lawsuit alleging monopolistic practices, which was filed in December — said it supported some aspects of the report, but not others. Richard Baron, MD, MACP, president and CEO of ABIM and the ABIM Foundation, did not, however, specifically delineate the recommendations or findings ABIM finds either objectionable or appropriate.

"We've made dozens of changes in our program in the last 3 or 4 years, all in consultation with a pretty broad community," Baron told Medscape Medical News.

All of the specialty boards' MOC programs "are in evolution," he said, adding, "I think all of us are chasing the same goal."

Longitudinal, Not Point-in-Time Exams

The commission made 15 recommendations for improving the MOC process. It said it hoped the suggestions would all be addressed by 2024. "While some of these recommendations are aspirational, many of these recommendations can be addressed in the near term," said the commission.

Among the biggest recommendations was a call to end point-in-time exams and a preference for longitudinal, ongoing assessments that help diplomates learn and retain knowledge, identify gaps in knowledge and skills, and help them learn advances in the field. Ideally, diplomates should be engaged every year, the report's authors write.

The report noted that the commission heard substantial objection to the every-decade "high-stakes" summative exam as the only source of assessment of clinical competency. Instead, exams should be formative and should provide a way for diplomates to learn, said the commission.

The ABIM, for example, in 2018 began allowing diplomates to take shorter exams every 2 years. It called the initiative the Knowledge Check-in. Only general internists and nephrologists had that option in 2018; this year, eight more subspecialties will be able to use Knowledge Check-in, and nine others will be added in 2020.

But, the commission said, "Diplomates did not consider more frequent, shorter assessments done in a highly-secured or remote proctored environment (e.g. ABIM's Knowledge Check-in) to be formative, but rather just more frequent high-stakes assessments in a different form."

ABIM's Baron defended the Knowledge Check-in, saying that any MOC that presents the possibility of losing certification raises the stakes. "The stakes don't come from the process of assessment, they come from the value of the credential and whether it's at risk or not," he said.

The commission also recommended that exams not be siloed into a four-part format but instead be multisourced and "based on the skills and competencies required for optimal patient care in each specialty."

It also encouraged the ABMS boards to develop new, standardized ways to assess professionalism and to conduct more outreach to medical societies, diplomates, and other stakeholders, including the public, to ensure that ongoing certification was current and met multiple needs.

The ABMS boards should also consider creating status categories other than just "certified" or "not certified," said the commission. That status also needs to be made public, inasmuch as surveys, focus group data, and public testimony indicated that the public considers certification important. The boards need to have "clearly defined remediation pathways" so that diplomates have a chance to maintain certification in the face of a potential loss.

Don't Use MOC as a Bludgeon

The commission also hit on several areas that have particularly irked physicians — including the fact that certification is often used as the sole criterion for providing credentials or privileges. In recommendation 8, the commission said that although the certificate has value, meaning, and purpose in healthcare, the ABMS should tell hospitals and healthcare organizations that ongoing certification should not be the only criterion used in decisions for credentialing and privileges.

In addition, ABMS should encourage these organizations to not drop credentialing or privileges solely on the basis of certification status, said the commission.

Many MOC critics have also said that evidence is paltry on whether certification improves patient care. The commission recommended that the ABMS boards facilitate independent research to determine to what degree continuing certification helps clinicians provide safe, high-quality patient care.

Research should also aim to determine what kinds of assessment and professional development activities are most effective in helping diplomates maintain skills and knowledge.

Fees Not Addressed

The commission did not directly address the cost of MOC programs to physicians, even though, in its own survey, 58% of doctors said costs were the greatest concern. Fifty-two percent said MOC was burdensome, and 48% said it did not accurately measure their ability as a clinician.

"We clearly heard from both public testimony and the diplomate survey concerns about fee structure," said the two commission co-chairs. But they said they had addressed the issue. The commission "specifically noted that boards should have reasonable fee structures for continuing certification programs," Colenda and Scanlon told Medscape Medical News.

"However, recommending specific fee structures or pricing was not, nor should it have been, part of the scope of the commission's work," they said.

They also heard concerns of what they characterized as a "lack of value" and said that "it is believed that the changes recommended by the commission, coupled with some of the changes already being implemented by the boards, will enhance the value of the process for all of the various stakeholders."

Teirstein, however, wants more accountability. He alleges that the ABMS member boards are monopolies, and thus "they can charge whatever they want," he said. "And I lose my job if I don't have certification."

The NBPAS is recommending that an independent oversight committee be established to review fees charged to physicians — akin to how utilities are regulated.

Still, he applauds the commission. "I think they documented the problems," he said, adding that they also recommended some positive steps to improve ongoing certification.

He said he's hopeful the ABMS boards will suspend some aspects of MOC that have been found to be harmful or not useful to physicians "until new policies have been tested and have either been proven to be helpful to doctors and patients, or at least there's a general consensus from the physicians that these new policies are helpful to the physician and helpful to the patients," said Teirstein.

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