The AGA, ACG, ASGE, and AASLD were unified in their opposition to the recently proposed pathway changes to the American Board of Internal Medicine’s Maintenance of Certification program, according to Art DeCross, MD, chair of the MOC Subcommittee of the AGA Education and Training Committee.
ABIM has proposed to replace the traditional 6-hour closed-book exam every 10 years with either a 2- or 5-hour open-book exam taken every 2 or 5 years in one’s office. Though the AGA advocated for moving away from the high-stakes 10-year exam, it said the proposed alternatives “fall short of our principles of individualization, lifelong education and low-stakes testing.”
ABIM’s announcement in May discussed forthcoming assessment formats, which were outlined in more detail in a communication to the societies earlier this month, DeCross told Healio Gastroenterology. The four GI societies and most of the internal medicine societies present at the Liaison Committee on Certification and Recertification meeting agreed these proposals are unacceptable in their current format, he added.
“We felt that the ABIM could play a critical role in remaining vital to vetting the accountability of [an MOC] process,” that prioritizes lifelong learning over lifelong testing, DeCross said. “The AGA is very disappointed that the ABIM instead appears to remain committed to a program of lifelong testing.”
ABIM promoted these new assessments as “low-stakes,” because failing would not cause immediate loss of certification. The test would provide “granular feedback” on learning objectives that need improvement and, as long as the diplomate passes the next exam, he or she can continue on the pathway, according to the AGA’s announcement. Failing two consecutive exams, however, would require the diplomate to pass the traditional 10-year exam to continue on the MOC pathway.
Timing and tailoring
The main objections to these proposals were that the open book concept is not meaningful in a timed examination, and that assessment could not be individualized to practice patterns, according to DeCross.
While diplomates would have internet access during testing, “that’s not helpful when they’re answering questions every 2 to 4 minutes,” he said. “The standard exam module is 60 questions to be completed in 120 minutes, so making that open book is not very helpful.”
In addition, the AGA membership would lack the ability to direct their assessments to fit individualized practice patterns within these alternative pathways, DeCross said. “Really what they are offering is, instead of studying the entire breadth of the field every 10 years for a single 6-hour exam, you have to study the entire breadth of the field every 2 years for a 2-hour exam. And that makes no sense.”
Thus, these proposals fail to adequately address the main criticism of the original assessment, which was that taking a closed-book exam that “encompasses the entire field of gastroenterology and hepatology does not reflect current practice; it actually doesn’t reflect any type of lifelong learning curriculum,” DeCross said. “Physicians today don’t approach every patient and every problem simply with the knowledge they have memorized in their head. When a physician has a problem, and the answer is not immediately apparent, they consult with colleagues, and they look up information, [which] is much more rapidly accessible in the digital age.”
While new physicians should be responsible for having a competent grasp of their entire field, as their practice matures, most “start to tailor their practice to areas of specific interest or expertise,” DeCross added. “Sometimes that depends on the availability of different community resources to support that practice, so maturing clinicians really should be able to tailor their lifelong learning and assessments more individually.”
The societies also objected to the fact that the ABIM has not yet committed to a plan for the practice improvement components of the MOC pathway, DeCross said.
“In a true process of lifelong learning and accountability, an MOC program would engage physicians in assessments for learning — with the emphasis on the for — and the assessments [would be] essentially formative,” DeCross said. “The assessments would be tied to current, state-of-the-art, continuous medical education offerings, such as tying assessments into journal articles that we’re reading, tying assessments into the end or the middle of live meetings, and also providing assessment with more traditional enduring materials. If the physician did not pass that assessment, they would be directed to remediation that would be required for failed assessments.”
DeCross said he hopes the ABIM understands that the dissenting societies “would like to move forward with them in co-creation of the MOC pathway that we all find acceptable, and we’d like to move forward briskly. I believe that ABIM has received the message that the majority of societies don’t find any of the alternative pathways that have been offered in their current format to be acceptable.”
“While we are pleased the ABIM is taking steps toward addressing issues within the current exam model, and we think they are getting closer to an alternative, AASLD believes there is still work to be done to fully address the current issues facing maintenance of certification,” AASLD President, Keith Lindor, MD, FAASLD, told Healio Gastroenterology. “We are working closely with other GI societies — and ABIM — to ensure collaboration that represents our respective and combined memberships on this important issue.”
“The 2-year and 5-year pathways are still proposals and have not been finalized,” Erin Frantz, communications specialist at ABIM, told Healio Gastroenterology. “We are currently surveying physicians and having discussions with the community about these proposed pathways and expect to share some additional details later this year.” – by Adam Leitenberger
DeCross reports no relevant financial disclosures. Lindor serves on the advisory boards of Intercept (not paid and does not meet) and Shire (not paid).