A guest column by the American College of Physicians, exclusive to KevinMD.com.
Some think that it should be repealed and replaced. Others support it but feel that it needs to be improved. A few believe that it’s OK as is. I’m not writing about Obamacare — I’m describing maintenance of certification (MOC).
I will not use up my word count summarizing the MOC debate — you can read about that elsewhere and will probably see it rehashed in the comments section. I will focus on a change that the American Board of Internal Medicine (ABIM) made to its governance, one that is referred to frequently in the debate. ABIM’s specialty boards, the entities responsible for certification and MOC, must include “a minimum of one practitioner whose primary practice is in a non-university, community setting.”
I am one of those community-based physicians. Since July 2014, I have been a member of ABIM’s internal medicine specialty board. How did I end up on an ABIM specialty board? I nominated myself. The selection process involved my submitting my CV, providing two references, and participating in an interview with a consultant retained by ABIM for this process. The interview focused more on my experience working on boards and committees than it did on my views on MOC, which I do not recall even discussing. Had there been a “litmus test” on MOC, I undoubtedly would have flunked it based on discussions over the years with ABIM leadership as well as public comments as far back as 2001.
Some will complain that having at least one community-based physician on the specialty boards is not enough. I have seen calls for a majority of board members to be practicing physicians. But this is not the United States Senate, where majorities matter. If optics is the main concern, then stack the boards with practicing docs. However, if the goal is to make sure that the perspective of the practicing physician is heard, the numbers don’t matter as much.
Fixating on the composition of the specialty boards misses a bigger point. Many, if not most of the criticisms of MOC are germane to all internists, regardless of who signs their paycheck. For example, an academic general internist who spends hours preparing resident conferences has no easy way to get MOC credit for the self-education involved. Similarly, a hospitalist who is involved in multiple quality improvement activities can’t easily report them to ABIM, unless his institution reports data to ABIM on his behalf (an option that exists but is out of reach for most organizations). In addition, time spent preparing for and taking the secure exam takes away from other pursuits, no matter what your “day job” is.
So far, the internal medicine specialty board has met once in person as well as by webinar. Its members come from a variety of practice settings, inpatient and outpatient, community-based and academic. There are board members other than myself who currently are or have been in community practice. All of us on the specialty board are touched directly by MOC because all members (as well as other physicians in the ABIM’s governance structure) must participate in MOC. That is particularly significant for me since I was initially certified in 1988, meaning that I have lifetime certification, and MOC would otherwise have been voluntary.
From the conversation at our first face-to-face meeting, it would have been difficult for anyone to tell who was in private practice, who was in academic practice, and who was in administrative practice. Members acknowledged and shared most, if not all, of the concerns that critics have been raising for the last several years. What we had in common was the desire to make the MOC less redundant and more concordant with each participant’s learning styles and preferences.
I will share one of the issues that I raised. My private practice is a patient-centered medical home and accountable care organization. Quality improvement activities, patient safety initiatives, and patient experience assessments are part of my day-to-day existence. These are activities that fulfill the goals of MOC’s practice assessment requirement (part 4), but right now I can’t get MOC credit for these as easily as I can for finishing a MKSAP chapter, where all I have to do is click a button for credit in medical knowledge (part 2). Existing pathways for getting credit for practice improvement work that was already completed require data entry, forms, and time that most MOC participants don’t have.
Many internists have made similar comments on blogs, at meetings, and in letters to journals and trade press. What was different was that I discussed them face-to-face with ABIM leaders and staff who are responsible for administering and fixing the MOC program.
I hope that the work of the specialty board will add to and accelerate the improvements to the MOC program that have already occurred in response to feedback from individuals and professional societies such as ACP. These changes include expanding options for self-education credit, including many ACCME-approved CME activities, and redesigning the MOC secure exam to better reflect real-life practice.
As I noted at the beginning, for some, ABIM and MOC are broken beyond repair, so everything that I have written here is irrelevant. However, for those in the physician community who believe in the concept of recertification but feel that the current process is too burdensome, redundant, and lacks value, I think that we have an opportunity to improve things.
Yul Ejnes is an internal medicine physician and a past chair, board of regents, American College of Physicians. His statements do not necessarily reflect official policies of ACP.