By: Leigh Page
The Situation Had to Change
Anger and near-revolt were the obvious emotions of physicians a few years ago when the American Board of Internal Medicine (ABIM) made it tougher and more expensive to attain maintenance of certification (MOC).
The resulting physician action and activism paid off. This year, certification boards, led by the American Board of Medical Specialties (ABMS), that direct the MOC are now implementing a wide range of reforms designed to make the MOC process easier and more relevant for physicians.
These reforms are at a pivotal point in 2018. Several boards—including the largest one, the ABIM—are launching short online tests that physicians can take instead of the traditional 10-year exam, which many physicians dislike.
In addition, some boards have softened the MOC's Performance in Practice (PIP) modules. In this controversial activity, physicians collect data on the treatment of their patients for certain conditions, compare their work to national standards, and then implement a performance improvement plan.
The boards' other proposed MOC changes include:
Protecting low scorers from automatically losing their board certification;
Helping doctors find content that better reflects their practices;
Keeping MOC fees in check and, in some cases, even reducing them;
Expanding continuing medical education (CME) options under MOC;
Providing seamless reporting of CME credits;
Allowing simpler attestation of work done;
Upgrading physician portals; and
Improving boards' customer service.
However, none of the reforms span all 24 boards, and some of them involve only a few boards. The ABMS must approve the boards' changes, but it allows them to move quite significantly from the standard MOC plan. Also, many boards appear to be holding back from some reforms, perhaps waiting to see if they are feasible, statistically valid, or appeal to physicians.
The new changes cover three of the four parts of MOC: the Part III exam and Parts II and IV, where physicians engage in activities to earn points. (Part I, which involves having valid state licensure, has never been in dispute.)
Leadership Becomes More Conciliatory to Doctors
In addition to the policy changes, ABMS leadership seems to be adopting a more conciliatory approach to physicians.
Lois Nora, MD, a neurologist, served as ABMS president and CEO from 2012 through 2017—a crucial time when the ABMS and its boards were trying to phase in their MOC agenda, and many physicians were reacting with great anger.
Physicians signed petitions against the changes, set up an alternative recertification system, demanded that ABIM leaders step down, and lobbied state legislatures to pass laws controlling use of the MOC designation.
Nora was a staunch promoter of the new process. Her message to physicians was often that the changes were on behalf of patients, and doctors needed to get used to them or watch their public standing plummet.
"Why MOC?" Nora wrote in a January 2014 column. "Because it is simply untenable in today's world that a quality credential—and particularly one as meaningful as ABMS Board Certification—would be granted or used without associated expectations of continued professional development."
Richard E. Hawkins, MD, who succeeded Nora in January 2018, has taken a more conciliatory tone, even as he seems to strongly support the MOC.
"When it comes to physicians, we need to listen more and understand what their concerns are," Hawkins wrote in March. "Although our primary stakeholder is the public, unless we get the profession's buy-in to, and engagement in, the process, continuing certification will never live up to its full potential."
His background makes him a different kind of CEO. Previously, Hawkins was on the medical education staff at the American Medical Association (AMA). There he worked for the AMA Council on Medical Education and helped write a somewhat critical assessment of the MOC at the AMA's June 2016 meeting.
At that same meeting, the AMA House of Delegates passed a resolution calling for an "immediate end" to the MOC exam and asking the boards to find "alternative ways to assess medical knowledge."
In a letter to the AMA after the vote, the ABMS defended the exam but was chastened. The boards were working to make MOC "more relevant and customized to individual practices," and to make assessment process, "less burdensome, more formative, and more relevant to practice," they said.
Is This Too Little Too Late?
Even if all of the boards enact all of the reforms they're planning—and there are many technical and logistical challenges to doing so—it is not clear yet whether they could satisfy physicians who have become highly skeptical of the MOC.
The process, which has been gearing up for more than a decade, is based on the assumption that physicians would keep current only when participating in a required set of exams, CME, and other learning activities.
Many physicians disagree with that assumption, including Karen S. Sibert, MD, an associate clinical professor at UCLA Health and president of the California Society of Anesthesiologists. "It's insulting for the ABMS to imply that people who have devoted so much time and effort to their profession need policing to read and learn," she says. "That's what we've done our whole lives."
Sibert is a trustee of the National Board of Physicians and Surgeons (NBPAS), a new anti-MOC organization that offers a simpler alternative to ABMS recertification. The NBPAS certificate is based on initial ABMS certification plus regularly earning CME credits.
NBPAS officials have convinced some hospitals and insurers to accept its certificates, but it's an uphill climb. Though ABMS boards insist that their certification is voluntary, many hospitals and insurance networks require it.
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