MOC A Job for Firefighters?

Amos firemanWell, the recent debate about whether or not the Maintenance of Certification (MOC) plays a steering role in the SGR H 2 “Doc Fix Legislation” got me to thinking about what I’ve been telling medical students and residents lately about the realities they’ll face once they graduate and are out in practice, especially as it includes dealing with the regulatory structure. Dealing with MOC is a lot like being a psychiatric consultant in a general hospital–I feel like a fireman trying to put out a lot of fires.

I wonder if the recent changes in the medical student curriculum are taking this into account. I’ve called the MOC one of those “absurdities” of the health care system mentioned in the April 9, 2015 Kaiser Health Network article,  “Medical Schools Try to Reboot for the 21st Century.”

Trainees tell me that the first time they hear about controversial issues like the MOC is when they rotate through the psychiatry consultation service when I’m staffing it as faculty. I consider my informal discussion of it as part of the Systems-Based Practice competency along with the others which they learn about: Practice-Based Learning and Improvement, Interpersonal Skills and Communication, Professionalism, Medical Knowledge, and Patient Care.

In psychiatry, Practice-Based Learning and Improvement is the competency typically viewed as being most relevant to MOC. On the other hand, the debate about the controversial issue says a lot about all the other competencies as well.

For example, the American Board of Psychiatry and Neurology (ABPN) launched a newly-reorganized website which sends mixed messages about MOC. On the one hand it supports all components of the MOC including Part IV which includes the Performance in Practice modules, which thousands of physicians denounce as time-wasters. You can view the videos by ABPN President and CEO Dr. Larry Faulkner, MD and Dr. Annelle Primm, MD, Deputy Medical Director, American Psychiatric Association (APA). They both support Part IV.

However, on the same site you can also read Dr. Faulkner’s letter to the American Board of Medical Specialties (ABMS) suggesting that Part IV be made “optional” based on the recommendation from the APA and the American Academy of Neurology (AAN). Both are major organizations whose leaders make the case that Part IV is a burdensome process unsupported by convincing research evidence. It’s not lost on anyone that if Part IV were made optional, what has been called by Newsweek writer Kurt Eichenwald as “The Ugly Civil War in American Medicine” would likely dwindle to a thumb wrestling match.

There is also a great deal of acrimony over the American Board of Internal Medicine (ABIM) MOC program updates, for which the President and CEO, Dr. Richard Baron, recently publicly apologized to diplomates for getting it wrong, mainly because there was a massive protest about it from them ultimately leading to a petition opposing it which contains over 20,000 signatures and the formation of a new alternative board, the National Board of Physicians and Surgeons (NBPAS), led by Dr. Paul Teirstein, MD of the Scripps Clinic in San Diego. Not surprisingly it’s garnering a growing grass-roots support base because it doesn’t require exams or MOC.

There are probably more than a few doctors who are waiting for the NBPAS to be vetted by hospital organizations and third party payers as Dr. Teirstein himself disclosed forthrightly.

You can hardly blame them for being cautious because the ABMS and the ABIM and other specialty certification boards including the ABPN essentially control the market share of the certification business.

How does this fit into the Systems-Based Practice competency? Well, depending on where you go as a newly minted doctor, you might not be able to practice or get paid by insurance companies unless you’re board-certified by an “ABMS member board.” Not all hospital credentialing committees require participation in MOC—or even board certification per se although you could get mixed messages here too.

Take the Joint Commission’s Ongoing Professional Performance Evaluation (OPPE), another regulatory hoop for doctors. This is one way for credentialing committees to determine whether a doctor retains clinical privileges at a hospital. The OPPE is a way to continually track medical staff with respect to the core competencies necessary to maintain privileges. It may sound far-fetched but some of the metrics which could be used might be the following:

Medical Knowledge: board certification even if that’s not an institutional requirement for employment; medication reconciliation in the electronic health record

Interpersonal and Communication Skills: a report to the CEO of the organization by a disgruntled individual

Systems-Based Practice: patient length of stay

Practice-Based Learning and Improvement: the problem list in the electronic health record

Patient care: Press-Ganey evaluations

Professionalism: getting your annual TB test and flu shot

Sound good? A cursory medical literature search on Professionalism turns up articles like:

Birden, H., et al. (2014). “Defining professionalism in medical education: a systematic review.” Med Teach 36(1): 47-61.

INTRODUCTION: We undertook a systematic review and narrative synthesis of the literature to identify how professionalism is defined in the medical education literature. METHODS: Eligible studies included any articles published between 1999 and 2009 inclusive presenting viewpoints, opinions, or empirical research on defining medical professionalism. RESULTS: We identified 195 papers on the topic of definition of professionalism in medicine. Of these, we rated 26 as high quality and included these in the narrative synthesis. CONCLUSION: As yet there is no overarching conceptual context of medical professionalism that is universally agreed upon. The continually shifting nature of the organizational and social milieu in which medicine operates creates a dynamic situation where no definition has yet taken hold as definitive.

But the TB test should settle all that, right?

I think it’s useful for trainees to be aware of the state of the health care system into which they’re being graduated. It won’t hurt for the public to know about it either.

How about Interpersonal and Communication Skills? It’s a little more complicated than what the above OPPE example indicates. On the psychiatry consultation service it’s very clear that communication can be the most important skill doctors can have. Try to find anything specific about that in the PIP modules.

So if doctors get a little sensitive about the language in the SGR H 2 bill which is reminiscent of the rhetoric the ABMS uses to lobby the legislature about its unproven MOC processes, it’s probably understandable.

My firetruck

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Comments

  1. If you think we focus too much on words in our objections to the MOC, then you should read the Birden et al paper on definitions of professionalism above. It has a section about a collaboration in 2002 between the ABIM Foundation, the American College of Physicians Foundation, and the European Federation of Internal Medicine (the Professionalism Charter Project) which put together a working definition of professionalism which was criticized by some for its “poor choice of wording.”

    It used the word “inculcate” to describe the process of introducing professionalism to medical students. It denoted a “forceful, top down method.” Others have preferred the word “foster” with its “more enlightened and egalitarian connotations.”

    Funny how the term “ABIM” connotes a “forceful, top down method” regarding efforts to “inculcate” the notion in rank and file physicians that MOC is synonymous with professionalism. Apparently we’re not the only ones who sense a definite pattern of this kind of behavior in the boards.

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