Maintenance of certification under fire by endocrinologists
On Jan. 1, 2014, the American Board of Internal Medicine, along with other subspecialties within the American Board of Medical Specialties, instituted increased requirements under the maintenance of certification process and those requirements have been met with contention from endocrinologists and other physicians.
Richard J. Baron, MD, MACP, president and chief executive officer of the American Board of Internal Medicine (ABIM) told Endocrine Today that these changes are just another step in the evolution of maintenance of certification (MOC), which serves as “a professionally created framework for keeping up.”
“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,” Baron said. “An endocrinologist who is actively participating in the MOC program knows that they are acquiring skills and knowledge that makes them a better endocrinologist and that they are keeping up with the new knowledge and expectations and discipline.”
Yet experts in the field, including R. Mack Harrell, MD, FACP, FACE, ECNU, president of the American Association of Clinical Endocrinologists, believe the new requirements, which include regular completion of practice improvement modules and taking a closed-book test every 10 years, are onerous.
“Endocrinologists, and indeed all medical subspecialists, totally understand the need for lifelong learning. We’re not opposed to lifelong learning. That’s part of our DNA,” Harrell said in an interview. “What we are concerned about is the increasingly difficult, one-size-fits-all pathway that’s been created by the American Board of Internal Medicine to exclusively establish maintenance of certification as the only way of demonstrating lifelong learning.”
Richard O. Dolinar, MD, Endocrine Today columnist, agreed with Harrell and said endocrinologists are tested on a daily basis by patients and other outside forces.
Photo courtesy of Richard O. Dolinar, MD.
“Every day, in our office, every patient we see is a test. You don’t know what the next question is. ... Every day is a test of our clinical acumen, clinical abilities and medical judgment,” Dolinar said.
Purpose of MOC
Baron, who first took the ABIM recertification exam in 1998 and most recently in May, said he did so to ensure his knowledge was at its peak.
He said there is literature showing that many physicians overestimate their performance and would benefit from the practice improvement modules that MOC offers.
“In small practices, it’s not reliably being done that people are looking at their practice as a population, that they know how to do that and there are skills that it takes to do that,” he said. “It’s important to demonstrate that you have those skills because not everybody does.”
He said physicians, especially endocrinologists, should take pride in having board certification and maintaining it, proving to their patients that they are the best.
But Dolinar said the business of medicine does that on a daily basis.
“You have to bring a good product to the marketplace so the customers will buy it. You’re constantly looking at your practice. You’re constantly trying to improve it,” Dolinar said. “If my patients walk out of our office satisfied, with good results, that’s how you show them you are keeping up and you care.”
“I know where the weaknesses are in my practice and my office is working to correct them,” he said. “If we don’t, we are going to fall behind and other doctors are going to be taking your patients. It’s the discipline of the marketplace.”
The Endocrine Society hosted two sessions regarding MOC during their annual meeting and, after meeting with ABIM in July, issued a call for a suspension of the new MOC requirements until the impact and unintended consequences of the changes can be independently examined.
Graham T. McMahon, MD, MMSC, of Brigham and Women’s Hospital in Boston and chair of the Clinical Endocrine Education committee of the Endocrine Society, told Endocrine Today, “We support the ABIM’s role in maintaining a program of maintenance certification, but this particular iteration of the design of the program has been problematic for our members and those of many other professional societies.”
Harrell explained that in the early 90s, the privately-run, physician-led, non-profit ABIM, which began as a “certification board” for young physicians after medical school moved toward the “recredentialing business.”
Physicians who were certified prior to 1990 were not required to recertify, but in January, all physicians were called to engage with active maintenance of certification including regular practice assessment activities. If they choose not to do so, they were listed as not meeting MOC requirements on the ABMS website, www.certificationmatters.org, which is publicized as a resource for patients.
“We’ve all been involved in continuing medical education to maintain our licenses, but what the MOC process has done is turned that continuing medical education process into more of an ordeal,” Harrell said. “The doctor who fails the exam or doesn’t get the modules done is described as not meeting MOC requirements. This statement effectively invalidates their previous fellowship training, their initial board certification with ABIM and their ongoing attendance of continuing medical education programs required for state licensure and it can cost them hospital privileges, licensure or insurance privileges.”
Baron agreed that the current language used for reporting whether or not ABIM Board Certified physicians are meeting requirements is causing legitimate confusion.
“ABIM adopted the meeting MOC requirements language as part of the framework developed for all certifying Boards by ABMS,” Baron said in a recent announcement. “ABIM is committed to maintain common standards across the ABMS Board community and is exploring what changes to the reporting language can be made, working closely with ABMS. ABIM fully supports ABMS efforts to ensure that Web reporting of certification status is clear and consistent across the community of specialty Boards, and helps patients understand physician participation in the MOC program.”
The MOC changes pushed the Association of American Physicians and Surgeons (AAPS) to bring a suit against the ABMS.
“The reason we brought the lawsuit is because of the number of physicians who are being harmed and their patients also being harmed as a result of losing their longtime doctor. Even though ABMS and all the specialty boards keep saying this is a voluntary process, it’s really becoming necessary for a lot of physicians to keep hospital privileges or stay on insurance panels,” Jane M. Orient, MD, executive director of AAPS, told Endocrine Today.
Jane M. Orient
The lawsuit, which is still underway, challenges that the seemingly compulsory nature of MOC is restricting trade and reducing patient access to qualified medical care.
“We shouldn’t make the assumption that physicians expire every 10 years or 5 years or every 2 years or that they will be made better by the self-appointed mandarins who are going to dictate what they have to study, what they have to learn, how they spend their time and ultimately how they practice medicine,” Orient said.
One of the complaints from AAPS and other physicians is that a closed-book test does not reflect the nature of today’s medical practice.
“Years ago, when you walked in to see a patient, the only knowledge you had was in your head. But now, due to technology, the world’s literature is in your hand at your fingertips. This has helped patient care enormously,” Dolinar said. “Keeping up now means accessing the latest info when we need it.”
Harrell said the current testing method employed by MOC is “antiquated.”
“Every physician has on their belt a device that can access the internet within seconds and can come up with medication doses, side effects, recent studies on drugs, [and] diagnostic information,” he said.
McMahon agreed: “That information is ubiquitously available and it’s completely appropriate to look stuff up. And our assessment systems don’t reflect that. The assessments have moved to more general principles in management and solving complicated problems, which is also completely appropriate, and a lot of our provider colleagues don’t recognize that the ABIM has made a switch and is moving in a much more positive direction. Having said that, the process is not yet there.”
Baron said, “We have a committee looking at open-book exams, but it’s not a simple matter of you just open the book. We think what we’re testing matters. We think knowledge matters. We think endocrinologists are proud of the knowledge that they have. Not everybody has it.”
After the recertification exam, Orient said physicians who fail are not given their full results and allowed to pursue further instruction on areas in which they were weak.
“If you’re talking about learning, the one thing you normally learn from examinations is what you get wrong and what the correct answers are,” Orient said. “There’s no way of even validating that the answers they provide are correct or not. ... That’s not good education by anybody’s standards.”
Richard J. Baron
In 2009, the percentage of physicians passing the exam was 90% for the whole internal medicine group; in 2013, it was 78%. In the endocrinology, diabetes and metabolism subgroup, the pass rate in 2009 and 2013 were was 77% and 86%, respectively, according to ABIM.
On the ABIM site, there is acknowledgement of these concerns and the organization details a plan to improve communication of test results to those who do not pass, as well as research into providing access to certain online resources during the exam.
“We will be putting into place as soon as this spring a much more detailed performance report that will tell people how they did at a much more granular level,” Baron said.
Increasingly specialized care
Another complaint brought by specialists like Harrell, who focuses on thyroid care, is that the MOC process focuses on the generalist and is not applicable to those who choose to specialize.
“As doctors’ skill sets become increasingly more Balkanized and there is an increasing chasm between academic practice and what occurs in real office practice out in the world, there is an increasing schism between what academic endocrinologists who write the ABIM test are doing and what doctors in practice are doing. And we don’t feel the MOC process has taken that into account,” Harrell said. “I personally perform high resolution ultrasound examinations on thyroid and parathyroid patients for my livelihood. Because of the politics of academic practice, there are no more than a handful of academic endocrinologists nationwide who personally perform their own ultrasound examinations. Who at ABIM is going to test me?”
Thus far, Harrell has opted out of MOC without serious repercussions, though he worries they could be coming. But McMahon has taken the tests and said his fellow endocrinologists — albeit specialized — should be internists first.
“I have found the exams more relevant to practice than prior iterations of the exam,” McMahon said. “Ultimately, you have to remember we’re physicians first. Even if we’re endocrinologists, we have to be able to recognize gastrointestinal diseases or a neurosurgical problem even if we are not entirely expected to manage those issues, we are expected to recognize other system issues in our patients. We have to be good doctors first and then specialists second.”
Baron agreed: “There’s always a tension between a specialization and generalism. That characterizes medical practice for the last 100 years. Patients need a mix of both. You can’t say I’m only going to take care of this tiny little piece of you and not have any responsibility or accountability for the way it impacts the rest of you.
“That’s why our exam committees are comprised of diverse groups of physicians, many of whom are full-time practitioners outside of academic institutions. We want to ensure a relevant understanding of practice issues across the discipline.”
Evidence of efficacy
ABIM has conducted and referenced studies backing the maintenance of certification educational process, but Harrell and others said that does not justify the recent changes.
“We also are uncomfortable with the fact that in participation with this amplified process, there’s no real independent data that [shows] this improves care. We’re spending money, we’re spending time that we would otherwise devote to patients to study for tests and there’s no third party data that this really improves care,” Harrell said. He said the data put forth by ABIM does not show a difference due only to the recertification process.
“The younger doctors who are absolutely more up-to-date on current academic dogma are more likely to participate in the MOC process because they don’t have a choice and they don’t want to lose their licenses,” Harrell said. “We’d like more ongoing prospective data looking at real clinical outcomes from doctors before MOC and after they go through the testing and certification process to show that real clinical improvement occurs and that it is not just a selection artifact. My personal belief is that the MOC credential is acknowledging a group of more compliant doctors, not necessarily a group of better or smarter doctors.”
Dolinar believes that physicians know their practices best.
“I know what kind of practice I have. I know areas I need to strengthen,” Dolinar said. “Show me the evidence that recertification actually improves patient care.
“Look at all of the third parties that are looking over the doctors’ shoulders already. We don’t need another third party. There are malpractice attorneys, the state medical licensing boards, ... the federal government, Medicare, insurance companies, etc.,” he said. “We’re going to have to make my exam rooms bigger in order to accommodate all of the third parties looking over my shoulder.”
AAPS agrees with Harrell and Dolinar, even stating in their lawsuit against ABMS: “There is no evidence that Defendant’s ABMS MOC program advances any legitimate goal for patient care.”
Orient said, “There’s no evidence whatsoever that these tests have any relationship to one’s competence or clinical ability or patient outcomes.”
Baron said ABIM is not intending to micromanage the physicians.
“We’re asking them to look at their practice in a way that not everybody does and there’s plenty of data that not everybody does it,” he said. “There’s also plenty of data that doctors, without formally looking at their practice, tend to overstate how well they’re doing.”
Lastly, there is a concern among physicians that the MOC process is a way for a private group to increase its revenue stream, Orient said.
Baron explained that the organization is “fully transparent” as to its costs and requirements in financing the endeavor. As of 2014, the 10-year fee for internal medicine MOC is $1,940 and any subspecialty, such as endocrinology, costs $2,560. If you do not pass and need to re-take the exam, there is an additional $775 fee, though ABIM announced it will be lowering the first-time retake charge to $400 in 2015. Any additional attempts at the exam will cost $775.
“One hundred percent of [the money] comes from doctors. It’s professional self-regulation. 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. “Doing this truly independent of all the other entanglements that people go to, that’s an important fact.”
He said the money goes to: test creation, test administration, ABIM staff, outcomes research and customer service among other expenses.
“Doctors who operate their own practices pay rent, pay utilities, hire a staff. Those are all expenses associated with operating our program,” Baron said.
Harrell suggested that changing from a closed-book test that is highly monitored and restricted to a model more reflective of daily practice could cut some of those costs, but Orient felt a bigger stand should be taken.
“[Physicians] should just refuse to participate in it. It’s a waste of money and it enables this corrupt money-making industry to continue oppressing physicians and restricting patients’ access to the best care that may be available to them,” Orient said.
Shortage of endocrinologists
Somewhat unique to endocrinology is the concern that requiring recertification may further impact patient care and put an unwanted burden on physicians at a time when there is already a shortage in the specialty.
“To have that highly skilled, highly trained, experienced physician at his desk studying for an exam for hours and hours and hours, vs. out there seeing patients, that’s a travesty. It’s a waste of precious resources,” Dolinar said.
Harrell said, “Twenty percent of my constituents are ABIM grandfathered and these physicians could retire in the next 5 years. What we worry about is the fact that the MOC process may cause a large number, a disproportionate number, of those grandfathered physicians to retire early, thus taking the manpower shortage from a significant problem making it into a crisis.
“There’s an epidemic of endocrine disease in this country now, an epidemic of obesity, diabetes, osteoporosis, thyroid cancer. We fear that the MOC process will result in an epidemic of early physician retirement,” Harrell said. “We don’t want the MOC process to add a fifth epidemic.”
R. Mack Harrell
Baron said, “Retirement’s a complicated phenomenon and I think there are many, many factors that figure into that and I don’t think anyone wants to keep practicing if they’re not at the top of their game.”
Still, Harrell told a story of a renowned academic Chief of Endocrinology who has failed the MOC exam on three attempts, accumulating thousands of dollars in expenses and lost patient care time.
“It’s not just the isolated, hard-working and near-retirement private practice doctor who is struggling. It’s everybody,” Harrell said.
ABIM hosted a meeting with its subspecialty associations in July and plans to implement some changes based upon their grievances, Baron said.
By lowering some fees, offering to change the wording on its site and instituting a broader recognition of the continuing medical education already being completed by its physicians, ABIM hopes to make the MOC process easier.
He agreed that it is still an evolving process and there will be changes along the way, which McMahon said are already happening.
“I’m encouraged by the willingness of the ABIM to explore additional opportunities for collaboration with the societies and the provider community and recognize that we need to sort this out together as a community,” McMahon said. “We have to be deliberate about how we choose to assess our colleagues to maintain their quality of care and design systems that reflect the way doctors provide endocrine and other specialty care today.”
Harrell said he looks forward to the ABIM response to their July meeting.
“There are substantial changes that need to be made and I’m hopeful that ABIM will recognize that,” Harrell said.
Baron acknowledged that, but said, “One of the things about a program that has 150,000 people enrolled in it — which we do — is that any change has ripple effects and things that you do to respond to one set of concerns may very well raise a different set of concerns in other people. We’re going to be cautious and careful in changes that we make ... and we’re going to be in consultation with the community.” — by Katrina Altersitz, additional reporting by Shirley Pulawski
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Richard J. Baron, MD, MACP, can be reached at American Board of Internal Medicine, 510 Walnut Street, Suite 1700, Philadelphia, PA 19106; email: email@example.com.
Richard O. Dolinar, MD, can be reached the Arizona Endocrinology Center, 15640 N 28th Drive Phoenix, Arizona 85053; email: firstname.lastname@example.org.
R. Mack Harrell, MD, FACP, FACE, ECNU, can be reached at Memorial Regional Hospital, 3501 Johnson Street Hollywood, Florida 33021; email: Rmharrell1@aol.com.
Graham T. McMahon, MD, MMSC, can be reached at Brigham and Women’s Hospital, 221 Longwood Avenue, Boston, MA 02115; email: email@example.com.
Jane M. Orient, MD, can be reached at 1601 N Tucson Blvd. #9, Tucson, AZ 85716; email: firstname.lastname@example.org.
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.
Humayun J. Chaudhry
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.