Last year, in response to a continued groundswell of criticism focused on requirements for maintenance of certification (MOC), the American Board of Medical Specialties (ABMS) formed an independent “Vision Commission” on MOC, designed to “reimagine a system of continuing certification.”
Although led by ABMS board members, many of the 27 commission members are not directly associated with ABMS. After several meetings and 21 hours of testimony, on Dec. 11, the Commission released its draft report and has requested public comment by Jan. 15 — i.e., this coming Tuesday. Through testimony from numerous stakeholders, including alternative certification organizations and representatives of the public, the draft report contains a fairly comprehensive and accurate summary of many controversial MOC issues. The report’s findings validate many of the concerns raised by physicians over the past four years.
Before I read all 96 pages of the report (don’t worry, after page 35 it’s all appendices), I assumed the Commission would gloss over most of the problems created by MOC. I was wrong. The report clearly, honestly, and with specificity documents the reasons for recent physician anger over MOC. The report is divided into “Findings” (i.e., the evidence) and “Recommendations.”
The “Findings” describe most of the MOC deficiencies. Here are highlights from the report:
- In the Commission’s own survey of 34,616 physicians who were asked if they valued MOC, only “12% said they valued the program.”
- Robust evidence does not exist correlating physician grades on secure, pass/fail MOC exams with patient outcomes, stating: “There are gaps in the research evidence that conclusively demonstrate that diplomate participation in continuing certification leads to better patient outcomes.”
- The American Board of Internal Medicine (ABIM) was criticized for its newly devised “knowledge check-in,” stating: “Diplomates did not consider more frequent, shorter assessments done in a highly-secured or remote proctoring environment (e.g., ABIM’s Knowledge Check-in) to be formative, but rather just more frequent high-stakes assessments in a different form.”
- MOC exam questions are difficult to tailor to the individualized content of established physician practices, stating: “Diplomates cited that the content of the examination was not relevant, was not a reflection of the application of knowledge in the clinical environment and was not current with advances in medicine.”
- Exam questions do not reflect real-world physician access to colleagues and the internet. The report stated: “Diplomates routinely access medical knowledge on their computers and smartphones while providing patient care. Assessments that rely exclusively on knowledge recall are not aligned with how diplomates practice.”
- Many of the recently revised “Practice Improvement” initiatives are problematic. The Commission found them onerous and duplicative of other physician mandates, stating, “Diplomates did not find value in checkbox activities or activities not relevant to practice. Diplomates complained that requiring multiple PDSA (Plan-Do-Study-Act) cycles in a quality improvement activity or requiring improvement in an activity in order for the activity to count in the certification program was onerous and artificial.”
- Physicians were critical of Board’s financial disclosures and leadership compensation.
- Most importantly, the report documented significant harmful consequences of MOC, stating: “The Commission heard compelling testimony from all stakeholders that loss of certification can lead to loss of employment or certain employment opportunities for diplomates or loss or reimbursement from insurance carriers.”
Among the “Recommendations”:
- Develop new approaches
- Create common standards
- Clearly define pathways
- Collaborate with other organizations
- Improve effectiveness of programs
- Expect diplomate participation
- Regularly communicate with diplomates
While the “Findings” are accurate, the “Recommendations” are far too weak, with few specific, immediately actionable calls for change. As physicians, we must “first, do no harm.” Leadership of an alternative certification board, the National Board of Physicians and Surgeons (NBPAS), of which I am president, believes that until generally acceptable and/or truly evidence-based practices are developed, the Commission must recommend an immediate moratorium on the most onerous and harmful components of MOC. This means an immediate end to secure pass/fail examinations and an immediate end to the Quality Improvement/Practice Improvement components of MOC.
In response to the Commission’s request for public comment, the NBPAS has created a “petition-like” comment that, in just two weeks, has been signed by more than 16,000 physicians as of Thursday afternoon. It calls on the Commission to recommend such a moratorium. The NBPAS prepared comment also requests a reduction in fees charged for MOC and initial certification along with financial transparency. To maintain the ABMS’s credibility, independent financial oversight is required to ensure expenses, including employee compensation/travel, are reasonable.
The Vision Commission report and the prepared NBPAS on-line comment being circulated via social media have created a buzz in the physician community. The report provides clear evidence validating the recent physician uprising against MOC.
However, many of us believe the Commission must take it one step further. Since real physician harm from MOC has been documented by the Commission, it is incumbent on the Commission to recommend a suspension of harmful MOC activities until a better process is created.
Paul Teirstein is chief of cardiology and director of interventional cardiology, Scripps Clinic, La Jolla, CA. He is also president, National Board of Physicians and Surgeons. This article originally appeared in MedPage Today.
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