Clinicians seek MOC modifications to maximize benefits, ease burdens

American Board of Internal Medicine certification has long stood as the culmination of a physician’s training.

“ABIM certification is very important to all physicians in that it assures the public they’ve had the proper training and keep up with their education,” Julie M. Vose, MD, MBA, FASCO, chief of the oncology/hematology division in the department of internal medicine at the University of Nebraska Medical Center and president-elect of ASCO, told HemOnc Today. “In general, the premise is very important.”

Due to changes implemented in January 2014, hematologists and oncologists now face more rigorous maintenance of certification (MOC) requirements. Many have lamented the additional time and money necessary to meet the requirements, and they also have questioned whether the exam is a useful and accurate assessment of their knowledge.

In May, the American College of Physicians sent a letter to ABIM on behalf of 14 medical societies — including ASCO and ASH — to express physicians’ concerns. ABIM subsequently met with representatives of those societies and agreed to amend its requirements based on the feedback.

“With some modification, it’s a very important program that we want to continue,” Vose said. “We just hope that ABIM will listen to the subspecialty societies and allow us to assist them in making the exam and modules practical.”

Value of certification

There are more than 200,000 ABIM board certified physicians in the United States, according to data on the group’s website. This figure includes nearly 8,000 hematologists and 13,000 medical oncologists who hold valid certificates.

“ABIM certification is tangible evidence that physicians have met a rigorous, peer-developed standard that reflects both a summative and formative assessment of that individual’s knowledge, skills and attitudes essential for excellent patient care,” David H. Johnson, MD, MACP, FASCO, chair of the department of internal medicine at UT Southwestern Medical Center, past president of ASCO and chairman of the ABIM board of directors, said in an interview. “It was purposely established to develop a non-membership organization that would set standards. That’s precisely what ABIM does and has done for its entire history.”

Samuel M. Silver, MD, PhD, MACP, FASCO, professor of internal medicine at the University of Michigan and HemOnc Today’s Health Policy and Value of Care section editor, originally underwent board certification for internal medicine, hematology and medical oncology.

“I thought it was very important for me to be able to sit down, study and pass those examinations and show competency as I was beginning my career for these disciplines,” Silver said. “It’s a capstone of one’s training and education — very anxiety provoking — and good to pass.”

Recertification, meanwhile, serves as “a professionally created framework for keeping up,” Richard J. Baron, MD, MACP, president and chief executive officer of ABIM, said in an interview.

“Things change pretty rapidly in medicine, and knowing that you’re maintaining your knowledge base in a way that is professionally appropriate can be challenging for physicians in practice,” Baron said.

Data indicate physicians may overestimate their day-to-day performance, Baron said.

For example, a study by Ludikhuize and colleagues — published in 2012 in Critical Care Medicine — found 198 nurses, doctors-in-training and specialists rated themselves highly with regard to their skill (mean, 7.9 out of 10) and knowledge (mean, 7.7) to recognize signs of deterioration in a patient prior to a serious complication. However, researchers determined these providers failed to immediately recognize deterioration in 28 of their 47 patients (60%). When the providers were asked to retrospectively review the cases, they identified delays in only fewer than one-third of those cases (range, 15% to 31%).

Further, a physician’s performance may deteriorate over time.

“There is an association of time out of practice being inversely associated with quality of care,” Scott D. Gitlin, MD, FACP, associate professor of hematology/oncology at the University of Michigan Health System, told HemOnc Today. “People who have left training most recently seem to be more up-to-date with what’s new, and that affects the quality of care that they provide.”

The MOC practice modules and 10-year exam are designed to prevent that deterioration. Due to the program’s changes, physicians are required to complete 100 points worth of modules, practice assessments and “patient voice” activities every 5 years.

Physicians who have protested the increased MOC requirements contend there are inadequate data to draw associations between these assessments and quality of care.

“I have seen little information that certification statistically improved practice over physicians who were grandfathered in or who don’t maintain their maintenance of certification,” J. Philip Kuebler, MD, an oncologist with Columbus Oncology and Hematology Associates and HemOnc Today’s section editor for independent/private community practice, said in an interview. “Who appointed them as our guardians? They certify physicians [and] come up with the tests, but where are the data?”

Johnson — who said this is a common complaint ABIM receives — referred to studies listed on their website.

One example — a study by Holmboe and colleagues published in 2008 in Archives of Internal Medicine — found physicians who scored in the top quartile on the MOC examination were more likely to perform processes of care for diabetes (OR=1.17; 95% CI, 1.07-1.27) and mammography screening (OR=1.14; 95% CI, 1.08-1.21).

In another study, published in 2010 in Archives of Internal Medicine, Reid and colleagues found higher quality of care was associated with board certification, female sex and having attended a domestic medical school (P˂.001 for all).

But these data may not be enough.

“There is not enough evidence to demonstrate MOC improves patient care,” Vose said. “There has not been enough evidence-based research conducted in a way appropriate to judge that.”

Onus of MOC

Although physicians agree on the importance of lifelong learning, many say MOC is overly burdensome.

“The practice modules are quite onerous. They take a lot of extra time and effort — and, in some cases, money — to do,” Vose said. “I do not think that they’re very useful as far as the information that a physician gets back.”

ABIM states physicians should expect to spend 5 to 20 hours fulfilling MOC requirements in non-exam years.

“There are many little projects you have to do. It reminds me of being a Boy Scout,” Silver said. “The very fact that the ABIM has these ‘busy work’ projects as part of their grand scheme of MOC in a way degrades the certification proper.”

Time to maintain knowledge already should be built into physicians’ schedules, Johnson said.

“If you’re telling me that physicians don’t have time to stay current or maintain their skills … that’s an argument that’s hard to engage in,” he said. “All learning activities require ‘time.’ Time commitment is not unique to MOC.”

ABIM continually adds opportunities physicians are already doing that will count toward recertification, including broader recognition of different forms of continuing medical education, Johnson said. ASH and ASCO also have increased the number of modules they have that count toward MOC.

Yet, commitment during exam years — for both initial certification and recertification every 10 years — is substantial.

Philip Schweitzer, MD, of Gastroenterology and Liver Associates of Riverdale in the Bronx, N.Y., published an article in July on The New England Journal of Medicine Knowledge+ website stating he spent 6 to 8 hours a week for 16 weeks in preparation.

Taking the exam will count for 20 MOC points in order to account for that extra time. Some say this is not enough, as physicians may have to take time off to attend a board review course, which tends to run at least a week.

“They’re missing out on helping patients, they’re missing out on income and they’re paying a large amount [of money] for a board review course,” Vose said. “If you don’t have a general practice where you see all of these types of patients, you almost have to do these reviews in order to pass.”

The ABIM 10-year MOC program and initial secure exam costs $2,560 for a subspecialty such as hematology or oncology. Physicians can also opt to pay an annual fee of $256.

Based on the number of physicians enrolled in the program, if each paid the 10-year exam fee, this would equate to more than $300 million, Kuebler said.

“There is a lot of money involved in this, and the ABIM understandably would want to maintain their hegemony over certification,” he said. “That is why they’re very aggressive — you have to sign a statement saying you won’t discuss any of the test questions. It’s like a big corporation controlling physicians.”

In 2013 — the year before the updated requirements were enacted — ABIM accumulated $55.5 million in revenue, according to a chart on its website. Most of this revenue was derived from initial certification (62%), and 35% came from MOC fees. Of the $53.3 million in expenses that year, 24% went to exam delivery and scoring and 15% went to administration costs.

“One hundred percent of the money comes from doctors ... It’s not industry money. It’s not drug company money. It’s not drug-and-device money. It’s not government money. It’s physician self-regulation,” Baron said. “Doctors who operate their own practices pay rent, pay utilities [and] hire a staff. Those are all expenses associated with operating our program.”

In order to assuage some of the dissatisfaction, ABIM reduced the exam retake fee from $775 to $400 beginning in 2015. This reduction may be particularly important to hematologists. From 2009 to 2012, the first attempt exam pass rate for hematologists ranged from 84% to 91%. Last year, however, the pass rate for hematologists trailed the average for all specialties (80% vs. 86%).

Those who run ABIM are physicians, and they understand the pressures created by increasing regulatory burdens, Johnson said.

“We’re in an environment when physicians are under increasing pressures to document and to prove the worth of what they do,” Johnson said. “We often hear that the burden of recertification takes away from other clinical activities. But, candidly, it’s a responsibility of physicians to be up to date and maintain their competence. That’s going to have to be done in some fashion, and MOC is one means of doing so.”

Current practice

Critics of the updated MOC process have reasoned that the generalized content and closed-book nature of the exam are not reflective of current practice.

Vose, who originally received her certification in hematology and oncology, now only sees patients with lymphoma or multiple myeloma.

“A lot of the questions that I get under the oncology or even hematology modules are totally unrelated to any patients I’ve seen for the last 25 years,” Vose said. “I think it needs to be more flexible and geared toward a specific physician population. It doesn’t mirror what actually happens in practice for many physicians.”

The generalized exam poses particular problems for those who do not practice in standard settings, Silver said.

“Especially as people have alternative careers in administration but who still see patients, there should be some understanding and flexibility in order to encompass those individuals,” Silver said. “[Otherwise], you are going to lose very bright clinicians who just don’t want to go down the standard pathway, even though they are excellent educators and clinicians.”

ABIM has emphasized that the general exam is another component that helps physicians stay current.

“We believe there is a core of knowledge that any medical oncologist or hematologist should know,” Johnson said. “That core knowledge is imbedded within the examination that allows the individual to call him or herself board certified.”

ABIM is looking into ways to make the test more modular, although this may change the definition of “board certified.”

“If lung cancer is someone’s area of expertise and they are able to take a specialized care exam, does their board certification mean something different than someone who is a generalist who has some expertise and knowledge across the board in different aspects of oncology?” said Gitlin, who serves on ABIM’s hematology board and conveys feedback from the clinical community to ABIM. “If they are called exactly the same thing, then how does that differentiate what their experience is and what they’re being certified for?”

Physicians also have said the secure exam requires intensive preparation and is not reflective of contemporary practice.

“The closed-book exam is quite old fashioned, and not how practice is today,” Vose said. “Everyone uses online resources or books and journals to get the most up-to-date information, in addition to talking with colleagues, and these practices aren’t reflected in the exam.”

ABIM contends the core knowledge should be readily known by any hematologist or oncologist; however, they are exploring possible new ways to deliver the secure exam.

“These exams consist exclusively of content that experts in the field have deemed necessary for a diplomate to know without the use of external resources,” Johnson said. “An individual taking the exam is presented with a given clinical situation and asked what he or she would do next. That’s not something you look up in a book. That’s knowledge you should carry with you.”

Although ABIM is looking into allowing outside resources, this presents challenges.

“Let’s say that ABIM chose to use UpToDate as an electronic database,” Johnson said. “I have access to UpToDate because I’m in an academic center and I don’t have to pay a fee to access it. But someone in the community in Marble Falls, Texas, may not have that privilege. Does that advantage me and disadvantage that other person?”

Regardless of any changes that are made, a time restraint should still be placed on the exam, Silver said.

“Just as one does when one sees a patient, you can’t take all day to do a literature review. You have to be able to use what is out there in order to get the information one needs to answer the questions,” Silver said. “The ABIM are experts in these exams, and they should be able to meld in the information that one needs.”

Grandfathers, exemptions

Many of the vocal critics of MOC are those who were certified prior to 1990 who had been “grandfathered in” and previously exempt from all MOC activities. Under the new regulations, grandfathers will remain certified for life; however, they must participate in MOC and take a secure exam in their specialty by 2023 in order to be listed as “meeting MOC requirements.”

“This is a big modification from what these physicians were told many years ago, and it’s unfair to them to change the rules at this point,” Vose said. “They were not expecting to have to participate in MOC and they haven’t been having to do it all along. That is probably a huge issue for them.”

Some have worried that these increased requirements may propel physicians into early retirement.

“There is a cumulative effect of regulatory burden,” Silver said. “The burden of the boards, the burden of the electronic health records — there is no question that, at a time when certain specialists and subspecialists are at a premium, physicians are retiring early because of these burdens.”

Similar predictions were made in 2003 with the Medicare Modernization Act, yet huge waves of early retirement did not occur, Johnson said.

“Given the projections of impending physician shortage, I think it’s irresponsible for us to not at least think about the impact on the physician force, but it’s also a conflict of interest,” Johnson said. “To single out MOC as a major cause of early retirement seems hyperbolic.”

The other option is to simply not participate.

“There are grandfathered physicians who are refusing to participate and spend the $2,500 plus costs for classwork and travel to take a test on somewhat esoteric diseases in order to get a certificate,” Kuebler said, who was board certified in oncology but who is opting out of the program.

However, an increasing number of hospitals and third-party payers are requiring certification of their physicians, which has prompted the Association of American Physicians & Surgeons to file a lawsuit against the American Board of Medical Specialties, which oversees ABIM, on the contention that MOC is a restraint of trade. The hearing for the lawsuit began in October and is ongoing.

“There is not a lot physicians can do, especially if hospitals and insurance companies are beginning to demand that you maintain certification in order to practice,” Kuebler said. “All of a sudden your hospital or insurance plan could demand that you participate in MOC, and that — in effect — takes your practice away. ABIM basically has a monopoly on certification for physicians.”

Only 2% of all grandfathered physicians had voluntarily participated in MOC prior to the new requirements. Now, data from ABIM indicate 38% of grandfathered oncologists have enrolled in MOC. However, these data do not necessarily suggest that the other 62% are opting out, because some may have been board certified in multiple subspecialties that they are not maintaining, Gitlin said.

Due to his decision to opt out, Kuebler is listed on ABIM’s website as certified in medical oncology but not meeting MOC requirements.

“They are misrepresenting my skills,” Kuebler said. “ABIM is pushing people to look at their website, but to date no patient has mentioned the website or certification to me.”

Johnson, who had been grandfathered in, said he had a positive experience with the exam.

“Like most grandfathers, I, too, had doubts about the ‘value’ of MOC — that is, until I participated,” he said. “Once I did so, I realized how valuable it was to me and the renewed sense of professional pride it imparted.”

Ongoing changes mediated by the subspecialty representative boards may allow more physicians to share this outlook.

“There’s no question that these are challenging times,” Johnson said. “MOC is caught up in that maelstrom of angst that physicians are coping with. Believe me, I get why this is frustrating, but to back away from decades of peer-developed standards and the privilege of self-regulation granted to us by the public would be a mistake.” — by Alexandra Todak, additional reporting by Katrina Altersitz

References:

ABIM. Maintenance of certification guide. Available at: www.abim.org/maintenance-of-certification. Accessed Nov. 20, 2014.

Holmboe ES. Arch Intern Med. 2008;168:1396-1403.

Ludikhuize J. Crit Care Med. 2012;40:2982-2986.

Reid RO. Arch Intern Med. 2010;170:1442-1449.

Schweitzer P. Preparing for the internal medicine exam as a “grandfathered” physician. Available at: knowledgeplus.nejm.org/preparing-internal-medicine-exam-grandfathered-physician. Accessed Nov. 20, 2014.

For more information:

Richard Baron, MD, MACP, can be reached at American Board of Internal Medicine, 510 Walnut St., Suite 1700, Philadelphia, PA 19106; email: press@abim.org.

Scott D. Gitlin, MD, FACP, can be reached at University of Michigan Health System, 1500 E. Medical Center Drive, Ann Arbor, MI 48109; email: sgitlin@med.umich.edu.

David H. Johnson, MD, MACP, FASCO, can be reached at UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, Texas 75390; email: david.johnson@UTSouthwestern.edu.

J. Philip Kuebler, MD, can be reached at Columbus Oncology and Hematology Associates, 810 Jasonway Ave., Suite A, Columbus, OH, 43219; email: pkueb@colombus.rr.com.

Samuel M. Silver, MD, PhD, MACP, FASCO, can be reached at University of Michigan Health System, 1500 E. Medical Center Drive, Ann Arbor, MI 48109; email: msilver@umich.edu.

Julie M. Vose, MD, MBA, FASCO, can be reached at 987680 Nebraska Medical Center, Omaha, NE 68198-7680; email: jmvose@unmc.edu.

Disclosure: Baron and Johnson receive salaries from ABIM. Gitlin receives an honorarium from ABIM for attending ABIM council meetings. Kuebler, Silver and Vose report no relevant financial disclosures.

 

 

Should Maintenance of Licensure be implemented, and if so, what should be its relationship with MOC?

The purpose of MOL is to ensure that physicians engage in practice-relevant lifelong learning.

Maintenance of Certification (MOC) and Maintenance of Licensure (MOL) are two separate concepts, and it is important to understand what they are intended to achieve. Maintenance of Certification (MOC) is a specific continuous professional development (CPD) program intended to ensure competence among physician specialists, while MOL is a physician-directed system that would eventually ensure that all physicians are pursuing some form of CPD as part of their license renewal processes.

The overarching purpose of MOL is to ensure that physicians engage in an evidence-based process of practice-relevant lifelong learning while giving them the flexibility to pursue whatever path of CPD makes the most sense for their needs. Thus, under the proposed system of MOL, MOC would be just one pathway a physician could use to demonstrate that he or she is engaged in satisfactory CPD. Other systems, ranging from hospital credentialing or privileging requirements to practice-specific continuing medical education (CME), would also be available to physicians.

Under the envisioned MOL system, MOC — with its robust requirements for CPD — would satisfy MOL requirements for the hundreds of thousands of physicians who are currently engaged in MOC programs. But MOC would continue to be voluntary; it would not be a condition of licensing.

One of our highest priorities in helping develop MOL is that an eventual system must be user-friendly and non-burdensome for physicians. To implement MOL and facilitate physicians’ compliance with MOL’s three major components (reflective self-assessment, assessment of knowledge and skills, and performance in practice), it is likely that state medical boards will use a model similar to that currently being utilized by a majority of medical boards to facilitate compliance with CME requirements for license renewal. That is, boards will set standards for the fulfillment of CPD and require licensees to attest to participation in CPD programming as part of the license renewal process. Again, it is anticipated that the vast majority of physicians will have no trouble demonstrating compliance, as they are already engaged in relevant CPD activities.

Under these circumstances, in its simplest forms, compliance with MOL may involve little more than checking a box on a license renewal application.

MOL has evolved in response to a growing interest in the United States and internationally in the enhancement of patient safety, the measurement of quality outcomes, and improvements to systems and processes. As medicine continues to rapidly evolve and grows more complex, the need for lifelong learning and skills maintenance has also increased. As the sole entities that regulate all physicians and that operate with a direct mandate to protect the public’s safety, state medical boards are uniquely positioned to ensure physicians are actively engaged in these important, ongoing continuous professional development activities.

Humayun J. Chaudhry, DO, MS, MACP, FACOI, is the president and CEO of the Federation of State Medical Boards. Disclosure: Chaudhry receives a salary from the Federation of State Medical Boards.

I would consider lifelong learning to be “lifelong larceny.”

Is there a link between specialty medical board certification and clinical outcomes? According to a review of 56 papers attempting to link outcomes with specialty medical board certification and partially funded by the American Board of Medical Specialties, the answer is a resounding “No.” (Sharp LK. Acad Med. 2002 Jun;77(6):534-42.)

If ABMS has shattered the myth of quality care being linked with specialty board certification, let alone mandatory board re-certification during a physician’s career, why does it, along with the Federation of State Medical Boards, thrust MOC and MOL on hapless physicians under the guise of ensuring “competence among physician specialists?”

For thousands of highly skilled US physicians, the answers to this question are greed and control. Others argue for humiliation of fellow physicians. John L. Marshall, MD, in his video “Taking the Boards: A Frisking, Then a Mugging,” describes being “basically naked” upon entering the examination room.

An expert in his field, he was a previous test writer. Not only did he posit that the questions were completely irrelevant to his area of expertise, but he maintained that there were no right answers to some of the questions. But, why should this concern the specialty medical boards? After all, if they set the pass rates low, they can keep the cash registers ringing, keep recycling their fellow physicians through the turnstiles, and maintain the generous annual compensation packages for MOL/MOC executives, which have ranged as high as $1.2 million.

In order to justify these salaries, some doctors have invented their own lingo. Continuous professional development (CPD) is now the preferred term. What happened to Continuing Medical Education (CME), in which all doctors already participate? CME allows physicians to choose that which will be most relevant to them and their patients. Recertification activities have been branded as “voluntary,” while hospitals, insurers, and medical boards are being urged to discriminate against physicians who avoid recertification, and in some cases, being forced to close their medical practices for failure to “comply.”

Lifelong learning (LLL) has been used to imply that physicians will not keep up with current medical practices. I would consider, however, LLL to be “lifelong larceny.” The notion that “compliance with MOL may involve little more than checking a box on a license renewal,” simply links MOC with MOL. The correct interpretation of this phrase is: if physicians don’t comply with “voluntary” MOC, they will not be able to obtain state medical license renewal.

While this is terrifying to physicians, even more frightening is what Choosing Wisely can do to harm our patients. Choosing Wisely was started by the American Board of Internal Medicine, and has since metastasized to other specialty medical boards. Its goal, quite simply, is to limit care. With specialty medical boards increasingly invading physician practices, will Choosing Wisely be linked to MOC? Will honest, ethical physicians who are violating Choosing Wisely guidelines be denied MOC status, and thus denied hospital privileges and even state medical licenses?

 

Kenneth D. Christman, MD, is the past president of the American Association of Physicians and Surgeons. Disclosure: Christman has no relevant financial disclosures.