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Maintenance of certification and licensure remains inevitable, but controversial
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The recertification pathway for orthopedic surgeons has recently undergone a transition and changes to medical state license renewal processes may be on the horizon. While supporters of these renewal and recertification processes say that these systems ensure physician competency, others claim they produce unnecessary burdens.
According to the American Board of Orthopaedic Surgery (ABOS) website, development of their maintenance of certification (MOC) process was a result of pressure from public demand and “external regulatory forces.” This involved the definition of general competencies by American Board of Medical Specialties (ABMS), which include patient care, interpersonal and communication skills and practice-based learning and improvement.
The ABOS MOC program, according to its website, addresses these competencies through the use of four components the ABMS has specifically urged: evidence of professional standing, evidence of life-long learning and self-assessment, evidence of cognitive expertise and evidence of performance in practice.
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Image: Indiana University School of Medicine Office of Visual Media |
“At this point, MOC is a program mandated by the ABMS for all 24 member boards, of which our board — the ABOS — is just one,” Jeffrey O. Anglen, MD, said. Anglen is a volunteer senior director on the ABOS.
“ABOS has attempted to structure the orthopedic MOC program so that it meets the requirements of the four parts of MOC in a way that adds value for orthopedic surgeons in practice — making the most of the components of recertification that are already in place and adding components that can meet other needs of surgeons, such as hospital credentialing or state licensing, while giving surgeons a selection of meaningful ways to improve their own practice,” he said.
The current iteration of the MOC process for ABOS was instituted in 2010, replacing the recertification pathway originally set in place in 1993. According to Judith F. Baumhauer, MD, who is in the active operative practice of orthopedic surgery and a volunteer director on the ABOS, the 10-year cycle inherent to the process includes 3 years of continuing medical education (CME), a further 3 years of CME and then credentialing, case list submission and a test within years 8, 9 or 10 if all the reporting cycles are on time. The test can consist of a written exam with the option of a specialty profile test in adult reconstruction and spine. There is separate hand and sports subspecialty examination for certificate holders in those specialties. Lastly, there is an oral examination that examines the applicants “case-based” practice.
“In an effort to promote lifelong learning, all of the ABMS boards began the MOC initiative,” Baumhauer said. “Our patients and the public embrace this concept, as do other credentialing arms of medicine, including hospitals, state licensing boards and payers.”
Evidence for efficacy
Though the ABOS supports MOC as a way to ensure that practicing orthopedic surgeons are up-to-date and competent, some feel the program is unnecessary and may, in fact, be counterproductive. Lee D. Hieb, MD, an orthopedic surgeon and immediate past president of the Association of American Physicians and Surgeons, said the evidence-based support for such a program is limited or even non-existent.
“Before discussing the mechanics and problems of recertification, we should be asking ourselves, ‘Why?’ I can tell you that most non-medical people are totally unaware of the process,” Hieb told Orthopedics Today. “I have no patients who ask me, ‘Doctor, have you complied with [MOC]?’ There is no public hue and cry for this.”
She added, “The question is, what is the value — if any — of this process? In real medicine, we assess risk and benefit and we above all do no harm. In this case, I have not heard one compelling case for benefit. I am aware of no studies showing any improvement in the quality of orthopedics from recertification … where is the evidence? The website at ABMS, possibly the unifying force behind MOC, reads like an ad for hair tonic or weight loss plans — lots of testimonials, no facts.”
Hieb noted that none of the testimonials at the ABMS website are from orthopedists.
This sentiment is echoed by allergist/immunologist Martin Dubravec, MD, who published an editorial in the Journal of American Physicians and Surgeons.
“There is no consistent scientific evidence showing that recertification or MOC improves the quality of health care or the quality of physicians,” Dubravec told Orthopedics Today. “Recertification is costly, time consuming and, for many physicians, clinically irrelevant. Furthermore, the specific sources for the content of the exams is not disclosed — making some of the test material potentially outdated or clinically irrelevant.”
Hieb noted that one has to look at “the reality of test taking and preparation,” pointing out that surgeons would likely study for a test by looking at the areas of medicine that they do not practice on a daily basis. Hieb studied total joint theory for her first recertification exam, even though her focus area of practice is spine and she had not performed a total joint procedure since residency. She wrote about her recertification experience and challenges with the process in the Journal of American Physicians and Surgeons.
“Such preparation takes time that could be more productively used to study and improve performance in those areas that target one’s specific practice,” Hieb told Orthopedics Today. “Is this process effective in anything but attempted public relations? Do we really weed out bad doctors? What would it mean to be in successful practice for 30 years only to fail a computer test of 300 questions?”
“From the point of view of the health care system, the examinations do improve patient care by identifying practitioners who are incompetent and either removing them or making it more difficult for them to practice,” Anglen said. “From the point of view of an individual surgeon, I do not know that we can say whether taking an examination improves the care of his or her patients. Certainly the goal of MOC — particularly part four — is to add activities, not examinations per se, to the whole process, which help the surgeon evaluate his or her own practice … and thereby improve it.”
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Anglen explained that the ABOS MOC program takes the complexities of the orthopedic profession into account, and added that if surgeons feel that a computer test does not best assess their technical proficiency, there is the option of an oral examination.
“Many of our issues are similar to other surgical specialists, and of course they are very different from medical specialists in that we deal with a large component of technical proficiency as well as cognitive expertise,” he said. “It is hard to assess, particularly in a computer exam, and so we believe that the oral examination is actually the best way to do it — although few select it.”
Anglen noted that the credentialing procedures in the orthopedic recertification process is relatively unique, as this involves the input of numerous board-certified orthopedic surgeons and other medical professionals.
Costs and potential barriers
He described the monetary barriers to MOC as being low, noting that the monetary cost is “probably lower than state license renewal fees.” Other barriers, Anglen said, include the collection and submission of CME credits in two 3-year cycles. This includes 20 hours of credit from an approved self-assessment examination in each cycle and the collection of a case list for submission.
“In the future, in order to comply with ABMS requirements, we will need to add some activities in part four of MOC — performance improvement in practice,” he added. “We will offer a variety of options for this activity, including the submission of a focused case list, participation in a standardized database or completion of practice improvement modules, which we are developing in conjunction with the American Academy of Orthopaedic Surgeons and the Orthopaedic Specialty Societies.”
The ABOS website cites a $50 fee with every CME cycle, as well as a $975 fee for the secure exam and an examination fee varying from $1,040 to $1,350, with a late fee of $350.
“Potentially, you could spend $1,800 for one whole cycle of 10 years, so about $180 per year — which seems to be a pretty reasonable amount for the benefits of being board certified, which may be required by some hospitals or institutions to practice, and is a valuable credential in many ways,” Anglen said.
Baumhauer noted that barriers to recertification can include suspension of license, substance abuse and missed deadlines — “all the same issues that would have barred a diplomat from being certified from the beginning.” She added a timeline can be found on ABOS website, which allows for surgeons to enter their certification expiration date and see a guideline for the process.
According to Hieb, these additional demands, while perhaps small in a vacuum, should be taken into account with the full spectrum of worries an orthopedist deals with on a daily basis.
“The major stress to orthopedic surgery is no longer worry over treatment method or litigious patients, but compliance with the rules of government — and now our own board,” Hieb said. “Add to this yet another requirement, MOC, a complicated and time-consuming process which costs $1,000 just for the privilege, as well as many more dollars in staff time and loss of revenue, while surgeons peck away at the computer inputting information their staffs cannot add.”
However, Baumhauer noted, “The MOC process is simply not complicated, and when the continuing medical education is averaged over the 10-year period, it amounts to just 24 category 1 CME credits per year. The case list requirement involves review of 3 months or 75 cases in years 6 through 10 – 4 years is a long time and entering each case involves answering only four questions.”
In terms of the time lost, Anglen said the most likely drain is case list collection. During this process, surgeons are required to review their own practices for 3 months or 75 cases and verify factors such as surgical site marking, informed consent and antibiotic prophylaxis.
“These activities take a variable amount of time, but this should be time well spent in terms of self-assessment and improvement of each person’s improvement in practice,” Anglen added. “It is something we should be doing anyway: an investment in quality. These sorts of activities will likely be required by hospitals or state licensing boards in the future, and we are hopeful that by structuring our MOC program in this way, participation in MOC will satisfy those bodies.”
Changes for the future
In addition to the MOC transition, surgeons may soon have to deal with state-by-state changes to the licensing program. The Federation of State Medical Boards has started to discuss maintenance of licensure program that would require work similar to that needed for the MOC, Anglen said.
“This would be a good thing for patients, and we are all patients or will be soon enough,” he said. “We are hoping that if such requirements arise, participation in an ABMS-sanctioned MOC program will satisfy this requirement.”
Baumhauer elaborated on these potential changes to license renewal processes.
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“Currently, several states ask if the licensee has taken a secure knowledge exam within the past 10 years, and if not, the choice is to take a state medical exam or take a specialty recertification exam,” she said. “Additionally, surgeons who move to a new state may be asked if they are currently recertified and participating in their board’s MOC process. If not, these surgeons may need to take a state medical licensure exam.”
However, the reaction from some physicians has not been supportive.
“States are now looking to initiate maintenance of licensure, not just CME requirements,” Dubravec said. “This would add layers of time and money, which many are trying to meld in with the ABMS. Some feel this would unduly ensure their long-term program, which has not shown to improve the quality of physicians.”
Baumhauer noted that the field of orthopedics is changing — citing the advancement of techniques, technology and an emphasis on evidence-based outcomes. The MOC, she added, encourages continuous learning and the development of licensing and MOC requirements is a reflection of changes in the orthopedic field. Still, Baumhauer said, there are no changes planned for MOC process requirements for the 10-year cycle to 2017.
“The goal is to provide additional options for the orthopedist to obtain meaningful CME for practice assessment and improvement initiatives,” she said, noting this could involve activities — such as patient safety modules and improvement initiatives — that surgeons are already undergo through hospital or state involvement.
The controversy continues
Anglen said it is too early to determine any meaningful impact the MOC transition has had on surgeon quality and health care, as participation has only been required for those whose certificates expired beginning in 2010.
“I was a member of that first class, and the only thing different for me so far was the submission of a 3-month case list to qualify for the exam,” he said. “I will need to submit my first round of CME by the end of 2013, including 20 credits of self-assessment examination credit.”
According to Dubravec, the lack of results for MOC and similar programs goes back further.
“Board certification, recertification and MOC have, according to many physicians, become burdensome programs that take doctors away from patient care, cost thousands of dollars and have not been shown to improve the quality or competency of physicians,” he said. “The data presented by the ABMS showing that board-certified doctors are better is just not the case, according to many of us who have reviewed this data.”
Hieb ultimately sees the MOC program as counter-productive, noting that orthopedists are under considerable strain from factors such as malpractice and Medicare payment cuts.
“At last count, nearly 20% of orthopedic practices in California were verging on bankruptcy,” she said. “But the leaders of our specialty have chosen to add more cost and burden by demanding we take a test every 10 years, which may or may not bear any relationship to our actual practice.”
Hieb referred to MOC as a “showstopper,” noting that it is likely to force her and other surgeons older than 55 years of age into retirement.
Baumhauer noted that the ABOS has seen no evidence that the MOC process is forcing surgeons into retirement.
“To the contrary, those surgeons are participating at the same levels as their younger counterparts. In addition, it should be noted that board certification and participation in MOC are voluntary processes,” she said.
Baumhauer added, “The majority of certificate holders for 2010 and 2011 have completed the MOC requirements and taken the recertifying examination. Approximately 10% of orthopedists did not complete the CME or self-assessment examination (SAE) credits, or did not finalize an application. This 10% is equivalent to the numbers of orthopedists not recertifying in the past. There are no other results at this early timeframe.”
According to Anglen, it is simply a matter of understanding that the transition into use of the MOC program is not optional for ABOS.
“I guess one foreseen result thus far has been the anxiety of some orthopedic surgeons in practice, many of whom feel like this is just another administrative burden on their already stressed-out lives — and do not understand the necessity of it,” Anglen said. “Unfortunately, it is not optional if we want to continue to be part of ABMS. However, for each person, being board certified is totally voluntary, and some surgeons choose not to have that credential. If doing a few hours of practice improvement activity, over several years, is enough to push someone into retirement, then that is probably the best choice for everyone – including the patients. Hopefully, most surgeons will embrace it as a way to demonstrate continued competency and continual improvement in their care of patients.” – by Robert Press
References:
- Dubravec M. Board certification/recertification/maintenance of certification: A malignant growth. Journal of American Physicians and Surgeons. 16(2):52-53. 2011.
- Hieb LD. Down the rabbit hole of recertification. Journal of American Physicians and Surgeons. 16 (2):36-37. 2011.
- www.abos.org
- www.abms.org
- www.jpands.org
- Jeffrey O. Anglen, MD, is in the active operative practice of orthopedic surgery and a volunteer senior director on the American Board of Orthopaedic Surgery. He can be reached at the Clinical Building, 541 Clinical Dr., Suite 600, Indianapolis, IN 46202; 317-274-7372; email: janglen@iupui.edu.
- Judith F. Baumhauer, MD, is in the active operative practice of orthopedic surgery and a volunteer director on the American Board of Orthopaedic Surgery. She can be reached at 601 Elmwood Ave # 655, Rochester, NY 14642-0002; 585-275-2100; email: judy_baumhauer@urmc.rochester.edu.
- Lee D. Hieb, MD, can be reached at 1351 W. Main Street, Lake City, Iowa 51449; 928-344-8220; email: loganpod@gmail.com.
- Martin Dubravec, MD, can be reached at 200 East Mason Street Cadillac, Michigan 49601; 231-779-4444; email: biosp3@aol.com.
- Disclosures: Anglen, Baumhauer, Dubravec and Hieb have no relevant financial disclosures.
What impact, if any, would an increase in requirements for the maintenance of medical certification have on health care quality?
No evidence of improved quality with testing
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Those who tout maintenance of certification (MOC) like to talk about “evidence-based medicine,” but there is no evidence showing that MOC improves patient care. It does take physicians away from their patients, and from the study of material they might find to be more worthwhile to cram for expensive exams that may be mostly irrelevant to what they actually do.
The main purpose of MOC appears to be to make money for the self-appointed recertification experts. Many physicians who have endured the onerous and expensive process say they will retire before they do it again. It is telling how many proponents exempt themselves from the process.
A random survey of members of the Association of American Physicians and Surgeons (AAPS) showed that of those who had been recertified, only 30% felt the process had improved their performance as physicians and only 22% would voluntarily do it again.
One recent article in the Journal of American Physicians and Surgeons called MOC “a malignant growth.” Another called it MOB for “maintenance of bureaucracy.” Lee D. Hieb, MD, an orthopedic surgeon, the immediate past president of AAPS, wrote about her experience of going “down the rabbit hole of recertification.”
Physicians with decades of education and experience are better able than monopolistic, self-interested agencies to determine for themselves the best way to maintain and enhance their knowledge and skills.
Jane M. Orient, MD, FACP, is the
executive director, Association of American Physicians and Surgeons.
Disclosure:Orient has no relevant financial disclosures.
References:
Better care through education from meetings
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Maintenance of certification may not necessarily contribute to quality of care. It is my belief that regular attendance at subspecialty-oriented meetings and venues, such as the American Academy of Orthopaedic Surgeons Annual Meeting and Orthopaedic Learning Center courses, to improve surgical skills is invaluable to the practicing orthopedic surgeon. It is critical for orthopedists to remain educated in cutting-edge technology and to continuously educate himself or herself on the most appropriate care and treatment for the conditions that he or she is treating on a regular basis. In my opinion, that is the only way to treat patients properly in our rapidly advancing technology-oriented subspecialty.
Jack M. Bert, MD, is the Business of
Orthopedics section editor for Orthopedics Today.
Disclosure:
Bert has no relevant financial disclosures.