ABIM Embraces 'Self-Paced' Longitudinal Assessment for MOC

Ken Terry

August 26, 2019

The American Board of Internal Medicine (ABIM) has announced that it plans to move away from its nearly 30-year-old maintenance of certification (MOC) program to a longitudinal assessment approach that will allow internists to complete ABIM-designed knowledge assessments at their own pace instead of having to sit for a comprehensive examination every 10 years.

The ABIM, which has taken the brunt of doctor resistance to MOC programs that involve make-or-break exams, chose to go this route because it decided that "one test every 10 years is probably not the best way to ensure that a doctor is staying current," Richard Baron, MD, president and CEO of the ABIM, told Medscape Medical News.

ABIM leaders, he said, wanted to build more educational value into the assessment and give doctors the opportunity to learn continuously. In addition, Baron said, the ABIM was impressed by the positive experiences that a number of other medical boards have had with longitudinal assessment.

The ABIM has not yet announced when the new program will begin because it's still working out the details. Until it does, the group said, internists will have to continue taking the decennial exams or, alternatively, perform a certain number of "knowledge check-ins," which are self-service assessments in certain areas of medical knowledge.

The latter option is currently available for 10 internal-medicine subspecialties, and 10 more are expected to have the option in 2020. Baron said the ABIM hopes to roll out the new MOC program to all of its subspecialties at once. Along with this new "self-paced pathway," ABIM plans to keep the 10-year exam available as an option, according to a blog post.

Baron said that about 20% of ABIM diplomates prefer to take periodic exams rather than cope with ongoing assessments of their knowledge. Most internists, however, favor the longitudinal assessment approach, he added.

The new assessments, Baron noted, will evolve from the knowledge check-ins. But there will be a key difference between the two, he said: With knowledge check-ins, ABIM doesn't supply the correct answer after a diplomate answers the question. It also doesn't send the physician a score on the assessment for a couple of weeks.

When the ABIM rolls out its new longitudinal assessment, he said, doctors will receive immediate feedback on their answer, an explanation of why the correct answer is right, and educational resources related to that question. They will have to take a certain number of these assessments each quarter and each year, and they'll probably be graded every 5 years, Baron said.

In addition, the questions can be answered whenever the physician has time, rather than at a certain point in time, as is the case with a traditional exam, noted Yul Ejnes, MD, chair-elect of the ABIM board of directors and chair emeritus, board of regents of the American College of Physicians.

Asked whether he believes the new MOC program will enable its diplomates to keep up with medical knowledge, Baron replied, "Yes, I do. It will help doctors stay current with medical knowledge and will give them a vehicle to demonstrate to their patients and colleagues and healthcare institutions that they are staying current."

ABIM has set up a website for physicians to offer feedback on the new idea.

A History of Revolt

Many internists have complained about the high stakes and the high pressure of the comprehensive exam, as well as its cost and the amount of time they have to spend preparing for it.

After the ABIM introduced the knowledge check-ins in 2018, four internists launched a class-action suit against the boards on behalf of more than 100,000 internal-medicine physicians. The suit alleged that the ABIM illegally ties its initial board certification to MOC exams that internists and internal-medicine subspecialists must take to keep their certification.

Physicians feel they must maintain their certification because hospitals and health plans require it, so MOC requirements are a burning issue for them.

In 2017, the American Medical Association's (AMA's) house of delegates failed to adopt a resolution that would have required the AMA to weigh in on state legislation that would have protected physicians against the loss of hospital privileges and decredentialing by health plans if they didn't maintain board certification. The subtext of this battle was that some doctors felt they had to be protected if they didn't participate in MOC or if they failed MOC exams.

Meg Edison, MD, a Grand Rapids, Michigan, pediatrician who participated in that debate, said that ABIM still doesn't meet doctors' needs with its new MOC approach. Although she's not an internist, she maintained that the American Board of Pediatrics has the same problem. In her view, what ABIM is offering is just another CME program, but with one crucial difference: "You can lose your job and your career can be ended if you don't buy these products," Edison told Medscape Medical News.

"ABIM can change all they want, but the problem is that we can't buy another program. The issue is that doctors don't have a choice. If they think this CME is valuable, they can buy it. If they don't, they should be able to buy it somewhere else," she said.

Better Educational Approach?

Ejnes, who is a practicing physician in Cranston, Rhode Island, is aware that some physicians would rather just take CME courses and keep up with medical knowledge on their own. "CME is often mentioned as a way of staying current that doesn't require external validation," he told Medscape Medical News. "But studies show that CME doesn't always achieve that. People tend to pick the things they're comfortable with. And CME is often sitting in the back of a room for an hour rather than doing something interactive that shows you're learning."

Edison retorted that MOC longitudinal assessments have not been shown to promote learning, whereas regular CME programs have. "CME is the only thing that's ever been proven to be beneficial in keeping physicians up to date. This is why state boards of medicine require CME. None of them require you to take MOC CME," she said.

In fact, she added, last year, Michigan passed a law prohibiting health plans from expelling primary care physicians for failing to maintain their board certification.

That law was prompted by some doctors' fears that they might not pass the high-stakes MOC tests. Ejnes said he understands this concern, having taken the comprehensive exam in 2016.

As a 1988 diplomate, he wasn't subject to the MOC requirements, which ABIM issued in 1990. But when he became involved in ABIM governance, he was committed to participating in MOC, so he took the comprehensive, all-day test. "The questions were reasonable, and I learned something and was happy to pass, but this new option [of longitudinal assessment] is much more humane," he said.

The old system, Ejnes noted, "didn't harmonize with how docs learn in a continuous way. I like this longitudinal assessment because it's more in line with how I learn and how a lot of people learn."

Positive Responses

Some internal-medicine subspecialties like the board's new "self-paced" direction.

"The American College of Gastroenterology (ACG) supports ABIM's plan to move toward longitudinal assessment," the association said in a statement. "ACG has a longstanding and deep commitment to education that values lifelong learning over high-stakes testing."

In a statement, William Oetgen, MD, executive vice president of science, quality, and education for the American College of Cardiology, said, "The American College of Cardiology is glad to see ABIM responding to physicians seeking alternative pathways for maintaining certification by offering a variety of options, including the new ACCSAP-based Collaborative Maintenance Pathway (CMP) options for certified cardiologists. The ACC will continue to work with ABIM to ensure options like the CMP and others meet the learning needs of physicians."

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