'That criticism was justified': ABIM MOC program adapts, faces new challenges and success

Key takeaways:

• ABIM’s maintenance of certification program has faced scrutiny for barriers like time and clinical relevance.
• Healio spoke with several experts to provide an overview of the situation and a look at alternatives.

The benefits and drawbacks of maintenance of certification programs are nuanced, so reform must rely on feedback from the medical community, according to experts.

There are 71 state medical and osteopathic boards for the 50 United States, meaning there is significant variation for the requirements to maintain medical licensure, Furman S. McDonald, MD, MPH, president and CEO of the American Board of Internal Medicine (ABIM), told Healio. Most states require some CME, and some states recognize participation in an American Board of Medical Specialties (ABMS) maintenance of certification (MOC) program to fulfill that requirement. (The ABMS is a self-governed umbrella organization including specialty members like ABIM.)

“Dr. Ebbinghaus, over 100 years ago, began to study and document the forgetting curves,” McDonald said. “That’s a characteristic of humans. We are not able to remember everything. That can be mitigated, though, by continued learning and assessment.”

Even if physicians could remember every fact they have ever learned, that would still be insufficient because medical knowledge is also advancing exponentially, he said. With MOC programs, patients can rest assured that their physician is staying current with their practice.

In fact, a retrospective cohort analysis recently published in JAMA, including 6,898 hospitalists and 455,120 hospitalizations, revealed a link between newly trained hospitalists’ certification examination scores and patient outcomes. Compared with the bottom examination score quartile, the top quartile was associated with a 9.3% reduction in 7-day readmission rates (95% CI, 13% to 5.7%) and an 8% reduction in 7-day mortality rates (95% CI, 13% to 3.1%).

“In medicine, we want to self-regulate, and we have not done a good job of ensuring that we stay up to date, historically,” Alan Dow, MD, MSHA, FACP, the Ruth and Seymour Perlin Professor of Medicine and Health Administration at Virginia Commonwealth University, told Healio. “When there is a new advance, it takes about 18 years to get into practice, on average. The idea behind MOC was that we need to be able to decrease that gap and get the advances out into practice much more quickly than 18 years.”

Dow, who is also a Healio Primary Care Peer Perspective Board Member, said that careers lasting significantly longer than previous generations of physicians and the rapid pace of scientific advancements have made MOC programs increasingly important, but “I’m not sure that the boards have done a great job in rolling out these processes.”

“Doctors are busy people,” Dow said. “It feels like a lot of this was maybe overly ambitious.”

Controversy

In recent years, the ABIM MOC program has been the subject of controversy.

There is currently an online petition, created in July 2023, calling for ABIM to eliminate its MOC requirement that has garnered more than 22,000 signatures In January, the Infectious Diseases Society of America (IDSA) requested that ABIM change the MOC program to make it more relevant to the scope of practice, clinically meaningful, inclusive of infectious disease physicians and supportive of their continuous learning. Other specialty societies, whose members participate in the ABIM MOC program, including the American Society of Hematology, expressed similar concerns.

Additionally, in 2015, ABIM announced immediate and significant program changes after the internist community raised concerns that the program failed to keep them updated within their field. The following year, the organization’s board of directors voted to not require MOC practice assessments for 2 years, again based on feedback from the internal medicine and subspecialty community.

Steven K. Schmitt, MD, FIDSA, president of the IDSA said that, although he thinks every infectious disease physician believes in lifelong learning as a principle and most support continuous learning assessments in some form, “many of our members feel that the current program structures have significant flaws.”

“Most of the problems identified by IDSA members relate to clinical and practice relevance, and the burden of time and money to complete the programs,” Schmitt said. “ We estimate that our members spend 25 to 62 hours per year for recertification and licensure in both internal medicine and infectious diseases. This represents a significant opportunity cost for busy physicians.”

Over the typical 10-year cycle, IDSA members spend around $3,400 to $4,100 to recertify in internal medicine and infectious diseases.

“For doctors who are among the lowest paid of any specialty, these represent significant burdens,” he said. “With burnout challenging an already thin workforce, the burden is unacceptable, especially [for] those at early career stages or working in communities with limited resources.

However, the biggest issue is that most of the members surveyed believe the current process “lacks value for clinical care and practice,” Schmitt said.

“Our field, like many other[s] ... is becoming increasingly specialized,” Schmitt said. “As a result, the recertification process asks them to spend a large amount of time preparing for assessment in areas that do not affect their practice or patients. There should be a process that allows a more focused assessment.”

Infectious disease physicians “are committed to lifelong learning and to dialogue with ABIM to improve the process of certification and recertification,” Schmitt emphasized.

The programs can be difficult to understand, “and just led to a lot of doctors being frustrated and confused and uncertain about how things are going forward,” Dow said.

“This is the right thing to do to help the profession stay current and for all of us to be better able to take care of patients,” he added. “I think it was a noble effort but probably a little bit misguided in terms of the approach.”

Dow also noted that ABIM has simplified the process in response to physician feedback but said there is still room for improvement.

“I had a brief period where my certification lapsed for a couple days because I didn't have something filled out correctly, and I had to go get myself declared as recertified, so it is hard to keep track of these kinds of things,” Dow said. “The customer service was great. They were very helpful and we got things fixed, but it was the kind of thing that, as someone who cares about these kinds of things, [even] I was caught flat-footed by some of the requirements.”

Karen Schatten, MLS, associate director of The National Board of Physicians and Surgeons (NBPAS), said that the organization “believes that choice and competition play critical roles in driving innovation and improving value.”

“Unfortunately, the dominant American certification board holds a monopoly over the industry,” she said. “NBPAS disagrees that recertification exams in any format — 10 year, 5 year, 2 year, or newest all-year — make better doctors or improve patient outcomes. Despite years of trying to prove the latter, the data [are] just not solid. When we talk about data, it’s important to distinguish between educational theory, which says, for example, that people retain knowledge better if they are tested, and high-quality scientific research, which would require a randomized control trial to determine causation.”

Although NBPAS agrees with initial board certification exams, as the medical community at large agrees that this offers career-long benefits for patient care and physician quality, Schatten said mandatory MOC creates serious, real-world consequences.

“NBPAS hears every day from expert, board-certified physicians who lose or are denied employment opportunities, which further delays patient access to much-needed care,” she said. “Rigorous, random controlled trials are prerequisite to offering new medical treatments to patients; the same standards should apply to programs required of our nations’ physicians.”

Response

McDonald acknowledged the public’s critiques.

“ABIM has been criticized in the past, and a lot of that criticism was justified,” McDonald said. “In fact, part of the great learning journey for ABIM is to recognize how important it is — when someone cares enough to give you feedback, even if it's critical, the ability to listen to that and try to modify where you can to make things better is really important.”

In response to the feedback, ABIM has made changes, like altering its governance model to have dedicated specialty boards for each discipline. For example, the cardiology board has more than 750 cardiologists offering input for ABIM’s system and practices, McDonald said.

“The standards, the blueprint, the content, is developed by people who are practicing in the discipline,” he said. “When ABIM was founded, ... if you weren't a professor at a large academic medical center, [which] meant you weren't helping to make the decisions. Now, we are pretty confident that we have probably the most diverse governance across a lot of the organizations in internal medicine, and we benefit from that.”

Perhaps the most notable change is that ABIM added a new assessment method in 2022: the Longitudinal Knowledge Assessment (LKA).

“It used to be that the only way to be assessed was to take a large point-in-time assessment,” McDonald said. “You go into a testing a secure testing center, and you dedicate an entire day to 8 hours of testing. I actually did that when I was initially certified.”

He said that, although some people prefer that method, about 80% of those who take an assessment choose the LKA.

LKA program

The LKA has many benefits, McDonald said.

“The LKA has been one of the great evolutions in assessment across the ABMS member boards,” he added.

McDonald said the assessment, which can be taken anywhere, includes 30 questions per quarter with a time allocation of 4 minutes per question, and is done in a 5-year cycle.

“With each question, you get immediate feedback, so you know right away whether you got the question right or wrong,” he said. “The long-form exam, you get a score report back in 6 to 8 weeks, and you don't get the question back; you only know categories. But for the LKA, you see the question, you see whether your answer was correct or not. You get the rationales for why the correct answer was correct, and then there are references which allow you to look them up.”

The LKA also gives a question history so participants can go back and study what they have gotten wrong and a progress report, so they can track how they are doing over time.

“It’s undeniably the most popular assessment ABIM has ever fielded, and we also have some people who are giving us good feedback on how to make it better,” McDonald said. “We’re continuing to work on how to make it better.”

Dow said that there are some questions about areas of practice he does not regularly encounter, but that means the assessments offer a good opportunity to learn more about other areas of medicine.

“I find that many of the questions are relevant to clinical practice, and they’re all relevant to general internal medicine practice overall,” Dow said. “You can almost always find the answers in the 4 minutes you have to answer a question. It’s maybe not something you can know right away for sure, so you may have to go and do some research, but it's not like the questions are asking things that the answers are not out there for you to find and then learn.”

Dow also said he found the open-book method of testing to be appropriate, as it parallels everyday practice.

“You really, in practice, always have the internet available, so you can always go on to the various electronic resources and read through this, but you don't always have colleagues available,” he said.

It takes Dow, at most, 4 hours to complete the exam, which he said is very helpful.

“I learn things when I do the questions. I think the quality of questions have gotten better over time. They're a little bit less esoteric, a little bit more current. So, I think it's a useful task,” he said. “Now is it another task? Yes. So it does take away from other things that I could be doing, either at work or in my personal life. But I think it's important to stay current. The alternative is to not stay current and not be as good of a physician.”

Schatten countered that it is inaccurate and unfair to suggest that 80% of physicians choose to participate in the LKA “when physicians are stripped of their board certification status and listed in public-facing credentialing databases as ‘Not Certified’ for failure to comply with an unproven program.”

“There is no real ‘choosing’ involved in that scenario,” she said.

Breaking away

Some have questioned if alternatives are enough to keep physicians up to date on medical advancements — like CME activities, for example.

CME “certainly helps you stay up to date,” Dow said, but there are challenges, like the fact that it is reliant on the person planning an activity “to bring the right content to you.”

“With MOC, you have the ABIM guiding what the content should be, and they’re at least an expert,” he said.

Ultimately, he said he believes the MOC program is more useful than most CME activities.

“I still enjoy going to large conferences,” Dow said. “I still learn things from them, but it's not always as good a use of time to me.”

Schmitt said CME activities are one alternative that can offer more flexibility, but other certification options have begun to appear.

For example, NBPAS offers another option.

Schatten said the organization is a physician-led nonprofit working to “modernize the onerous, unproven MOC programs that are driving physicians out of medicine, reducing patient access to physician care, and elevating U.S. health care costs.”

“Fundamentally, NBPAS believes that a continuous certification program must align with the highly specialized nature of medical care and designed the NBPAS certification process with this in principle in mind — to ensure that physicians seek continuous training and education in areas specifically relevant to the needs of their patients,” Schatten said.

The concept of professional self-regulation, which suggests that physicians are intensively trained and naturally driven to continually learn and improve throughout their careers, is the backbone of NBPAS’ requirements, she said.

“NBPAS believes that a commitment to lifelong learning is integral to being a physician, and represents an ongoing promise to patients and the public,” Schatten said. “NBPAS diplomates choose to demonstrate this commitment through an NBPAS certification.”

Schatten said the organization’s model ensures quality because it is specialty-focused and aligns with many other learning requirements for physicians, “making NBPAS more streamlined and without an unjustified drain on physicians’ limited time and energy.”

“NBPAS believes that specialty-specific CME credits are a superior learning opportunity as compared to open-book multiple choice questions that now can be answered by AI,” Schatten said. “A significant majority of physicians prefer the NBPAS pathway for lifelong learning since our requirements are streamlined, rigorous, and clinically relevant.”

Currently, the NBPAS program certifies more than 14,000 physicians and is accepted at more than 200 hospitals, telemedicine companies, payors and health systems, she added. Additionally, it costs an average of 72% less than other MOC programs.

“At the end of the day, NBPAS believes that no single entity should be able to wield an expensive, arduous, and unproven process that taxes the medical industry, adds to physician burnout, and further exacerbates the known and growing physician shortage,” Schatten said. “With each physician lost, patient wait times increase, critically needed care is delayed and patient access to care worsens.”

Additionally, some specialties have started to break away from ABIM’s program.

For example, in cardiology, a consortium of societies have come together to submit a request to ABMS for the creation of a new, independent Board of Cardiovascular Medicine.

The application was submitted in January, and there was a public comment period from April to July, where more than 1,300 comments were put forth, Jeffrey Kuvin, MD, board president and chair of the proposed American Board of Cardiovascular Medicine, said.

“There’s a lot of interest, not only from the cardiovascular community, but the broader community for this to move forward,” he said.

Kuvin said that, recently, the proposed board presented in front of ABMS for the first time.

“We expect the ABMS to make a decision within the next couple of months as to what the next steps are, remembering that the ABMS has not developed a new board in over 30 years, so this is somewhat of a novel process, " he said. “This is, I think, an important step, not just for cardiovascular medicine. This is a really important step for the ABMS to define what they want to see for the future of assessment of competency.”

Kuvin said the proposed board has ideas and strategy “to really move forward with a new way of thinking about assessment of certification.”

“There's been a lot out there in terms of what people are saying and their mistrust or dislike for the ABIM. Our application for a new board is not focused on the ABIM,” Kuvin stressed. “Our board is focused on how cardiology has evolved outside of internal medicine and has become its own specialty deserving of its own board.”

Kuvin said the board wants to “think out of the box, more holistically” about patients and physicians’ interactions with them. Notably, this process would focus not only on medical knowledge, like the current system, but much more on evaluation of the ABMS’ other five core competencies: patient care, systems-based practice, problem-based assessment, professionalism and communication.

“We have a blank slate — let's figure it out,” he said. “I think that's what's so unique about this: we're being creative. We're being innovative. We're not thinking about older ways of assessing medical knowledge. There are so many new tools we can use; give people credit for what they're already doing. It is not meant to be easier. It's meant to be more meaningful, more appropriate, and I think at the end of the day, the patients will benefit from this. That's the goal.”

References:

• A whirlwind tour of the evidence. Available at: https://www.abim.org/about/research/journal-articles-by-topic/medical-knowledge-and-patient-outcomes/. Accessed Sept. 16, 2024.
• Board of cardiovascular medicine. Available at: https://cvboard.org/. Accessed Sept. 16, 2024.
• Eliminate ABIM’s MOC requirement. Available at: https://www.change.org/p/eliminate-abims-moc-requirement. Accessed Sept. 16, 2024.
• Gray BM, et al. JAMA. 2024;doi:10.1001/jama.2024.5268.
• The value of assessment. Available at: https://www.abim.org/about/research/. Accessed Sept. 16, 2024.