ABIM Maintenance of Certification (MOC) has been controversial, but most physicians agree that it is important to participate in continuous learning as evidence-based medicine, drugs, and technologies are innovating rapidly. Feedback from physicians in practice is driving adjustments to MOC programs in the American Board of Internal Medicine (ABIM) and other specialties, but change is slow despite the creation of a small new certifying body, laws passed in a few states limiting the use of MOC as a physician credential, and ongoing announcements from ABIM and other boards of tweaks to the MOC process and exam. Most insurance companies will only reimburse physicians who are board certified, so MOC remains necessary for the majority of practicing doctors. What has changed in MOC already, what are the leaders of MOC innovation doing to stay ahead of the curve, and what developments are on the horizon?
ABIM Announced Changes to MOC in 2015
In February 2015, ABIM released a response to strong opposition by their physician diplomate community. In it, ABIM said, “We got it wrong and we’re sorry.” Effective immediately, ABIM suspended the Practice Assessment, Patient Voice, and Patient Safety requirements for at least 2 years. ABIM stated, “This means that no internist will have his or her certification status changed for not having completed activities in these areas for at least the next two years.”
ABIM sought feedback from physicians and then took steps to revise the MOC exam blueprint — in an effort to make the exam more relevant to their practice. The new blueprint was extremely detailed, showing what was likely to be on the exam by not only listing specific topics but also the topic-related tasks, such as diagnosis, testing, and treatment. At the same time, ABIM released a new performance report, which made finding out how you did on the exam easier to parse.
In August 2015, ABIM and the Accreditation Council for Continuing Medical Education (ACCME) announced that they would collaborate to simplify and integrate MOC and CME. As a result of this collaboration, physicians are now able to earn both CME and MOC points for certain educational activities — and are also able to use a single system to submit both their CME points to the ACCME and their MOC points to the ABIM.
Finally, in September 2015, ABIM released a report [PDF] from its Assessment 2020 Task Force (now called “Transforming ABIM”) that recommended replacing the 10-year MOC exam with “meaningful, less burdensome” assessments that physicians could take at home or at the workplace. In addition, the panel recommended new assessments on cognitive and technical skills, as well as recognizing specialization in practice.
Backing up ABIM, the American Medical Association (AMA) then voted in Resolution 309 [PDF] in 2016 calling for an “immediate end of any mandatory, recertifying examination by the American Board of Medical Specialties (ABMS) or other certifying organizations as part of the recertification process.”
Most recently, ABIM announced in May 2016 that it would test a new open-book MOC exam option with a pilot group participating in shorter, more frequent quizzes — according to ABIM, passing those would allow those diplomates to skip the 10-year exam.
ABMS Weighs In
The American Board of Medical Specialties (ABMS) has been supportive of formative assessments in theory and agrees with the idea of reviewing the MOC process but is not sure that ending the exam is the best next step for assessing American clinicians. ABMS, in directly responding to the ABIM’s February 2015 announcement, wrote:
ABMS supports ABIM in its efforts to make its MOC Program more meaningful for its physicians …ABIM’s acknowledgement that its MOC Program could improve clearly demonstrates that ABIM is listening to the internal medicine community and is serious about making changes as part of its own continuous quality improvement process.
However, ABMS made clear that it opposes AMA’s call for immediately ending the 10-year high-stakes Maintenance of Certification exam:
The American Board of Medical Specialties (ABMS) is opposed to the American Medical Association’s (AMA) call for the immediate end to any mandatory, secure recertifying examination by ABMS or other certifying organizations as part of the recertification process for those specialties that still require a secure, high-stakes recertification examination.
Innovation Leaders in Maintenance of Certification
ABMS, along with some of its member boards, is not standing by simply defending MOC, however. In the same statement I quoted above, ABMS wrote:
ABMS Member Boards and the AMA Council on Medical Education have been working together to modernize the Boards’ recertifying examination processes and more than half of the ABMS Member Boards are in the process of developing and piloting alternative assessment models. ABMS Member Boards are working to make MOC more relevant and customized to individual practices, and are adopting changes to their assessments to make them less burdensome, more formative and more relevant to practice.
Pediatrics
The American Board of Pediatrics (ABP) has been receiving similar feedback as ABIM from their diplomates and began talking about changing MOC in 2015. ABP may go to an open-book exam sooner rather than later. ABP already offers MOC through a weekly Question available on the web and through an email signup, and it is building an MOC platform that will, in collaboration with the American Academy of Pediatrics (AAP) and interested specialty societies, consolidate the top articles necessary for pediatricians to keep up with the latest medical knowledge. ABP says of this platform, “You will be able to rank and comment on the submissions—or offer suggestions of your own. Not only will this dialogue help you to know what literature pediatric experts consider to be important but it will also allow us to link life-long learning (MOC Part 2) with knowledge assessment (MOC Part 3) more effectively.”
ABP said that changes will come to MOC — and soon. There will be pilot groups using an electronic version of the MOC assessment that would quiz pediatricians every quarter beginning in January 2017. As quoted by the AAP blog, the ABP Vice President of Psychometrics and Assessment Linda Althouse, PhD, said:
“We can capitalize on the fact that there have been advances in technology that will allow us to assess differently …And we feel that we can now use that to also allow learning to happen so we’re just not assessing.”
Pediatricians who volunteer for the pilot will answer 20 multiple-choice questions every 3 months. They can decide when to take the questions and how many to answer at a time.
Anesthesiology
Perhaps ABP was inspired by the American Board of Anesthesiology (ABA), which, in 2014, began piloting its “MOCA Minute,” an interactive learning and assessment tool that allows diplomates to earn MOC by taking multiple-choice questions on an adaptive platform delivered via email, mobile app, and website. ABA has now rolled out MOCA Minute in place of their MOC exam (MOCA Part 3) for diplomates whose certificate expires in 2016. Diplomates need to answer 30 questions per calendar quarter (120 per year).
ABA encourages participants to answer questions over time, rather than all of them in a single day, “to promote continuous learning and knowledge retention.” The system delivers similar questions over time to assess whether users have retained the material. ABA gathers data “to determine whether diplomates are continuing to meet the standard for certification.”
MOCA Minute is an example of one of the earliest and boldest innovations in the world of Maintenance of Certification — its format is very similar to NEJM Knowledge+ with case-based questions, key learning points and detailed feedback with every question, and an opportunity to communicate with content creators “to report how RELEVANT the question is to your practice.”
Other Boards Reviewing But Not Changing MOC Yet
The American Board of Dermatology (ABD), among the majority of specialty boards, is not yet ready to make sweeping changes to its Maintenance of Certification program. However, ABD has stated on its website that it is gathering feedback and “re-evaluating many aspects of the MOC Exam.” It also created a 2-year pilot that started in January 2016 to develop focused activities targeting practice improvement.
The American Board of Family Medicine (ABFM) has also begun to rethink its MOC process. A study aims to test a new approach to simplifying MOC for family physicians. The study, known as TRADEMaRQ (TRial of Aggregate Data Exchange for Maintenance of certification and Raising Quality), will assess a method for physicians to automatically record data from all of their patients for the quality-improvement portion of MOC.
Dr. Robert L. Phillips, TRADEMaRQ’s principal investigator and Vice President of Research and Policy at ABFM, told us in a Q&A that ABFM sees the MOC exam going away eventually:
The ABFM no longer believes that it is sufficient for MOC to be simply summative. Certifying boards must move toward helping physicians critically assess and improve patient care and, when possible, also help solve other burdens in their lives. We have already gone on record as saying that, in the future, family physicians participating in a process like TRADEMaRQ may not have to take a recertification examination. If we can effectively assess the scope and quality of their practice, and if they are demonstrating self-assessment and improvement, we won’t have to test their knowledge as a proxy for quality.
It is unclear whether or not these deliberative boards’ reviews and re-evaluations of MOC will eventually lead to a removal of the MOC exam, but it is clear that many physicians are affected by these programs and are watching and waiting for decisions on what will come next in their specialties.
Will Technology Have a Role in MOC Innovation?
As the Maintenance of Certification landscape continues to shift, the primary driver of change will likely also remain physicians in practice — most of the boards state that they welcome feedback from their diplomates and are actively seeking to reform their MOC process. It would be short sighted, though, to ignore the other big innovation operator: technology.
In the medical world, no one should be surprised that adjustments in practice often result from new and improved software, devices, communication channels, and other technologies. It should also be no surprise that the methods of determining a physician’s fitness to practice would begin to change as the platforms and channels available to impart and assess knowledge transform.
What are your thoughts about the changing landscape of Maintenance of Certification? Have you given your specialty board feedback on the MOC process or the recertification board exam? Have you participated in a MOC pilot program? Please share your stories and opinions in the comments below.
Show us the money. Money is what MOC has and continues to be about. This is not an exercise in “showing the public” we are keeping up. It’s about the collusion between the AMA, ABMS, ACP, CMSS, and the entire ACGME to profit off working physicians. There has never been proof that MOC improves pt care quality or outcomes. Instead, we see the corruption, the cronyism, the luxury condos, and use of strongmen felon with access to our personal information. MOC is irreparably broken, and until the Medical Establishment (including the NEJM – who also profits, by the way) understands that the entire program was built on deceit and propaganda, not data, the sooner we will end this very bad chapter in the history of medicine that’s a disgrace to our profession.
Notwithstanding his use of emotionally charged nouns and adjectives, Dr. Fisher has lucidly characterized a sad truth about the continuing erosion of the autonomy and integrity of our profession as it devolves from a vaunted healing art into an increasingly senseless labor force being exploited to assure the growth and financial success of ever larger – and ultimately unsustainable – “healthcare” businesses. MOC etc. and the governance that generates this corrosive, hugely wasteful, and depressing nonsense without any plausible evidence base is, however, just one symptom of the larger and more profound problem.
the costs of maintaining one’s license in a state should not be hitched to continuing board certification for senior physicians practicing as volunteers in organizations where much good can be accomplished without the qualifications for advanced prescribing of medication or other complex treatment. what good is served by school physicians to understand the fine points of leukemia management or septic shock. an experienced physician sitting in on an individualized education plan for a boy with autism doesn’t require ability to fully manage diebetic ketoacidosis. screening fainting spells at school doesn’t require cardiologic expertise to decide which children need to see a cardiologist, when their regular pediatrician can evaluate their needs the next day if there are no suspicious findings or history and the child seems able to return to class. what supports should be available to keep senior physicians who wish to remain modestly active in less critical clinical settings than a hospital emergency room? should they be prevented from using their skills when participating in situations of less risk in relatively healthy populations? these are not decisions to be made by a multiple choice test advanced by academicians who must regularly perform in situations with severely acute events more likely to occur in their workplaces. advising a teen about managing his acne with over the counter treatments will not likely lead to tragic consequences. our medical organizations need not acquiesce to the dire warnings of legal advisors who do not know what an individual physician is capable of in a given medical setting.
It’s about the money….
For an organization that requires the physicians to abide by “evidence-based” care rules, to not be able to show any evidence that MOC or certification actually improves patient outcomes or improve patient care quality is a bit ironic.