Have a Beautiful Day Gaming the MOC System

So if you haven’t seen my tweet about doctors being sorely and understandably tempted to game the Maintenance of Certification (MOC) Performance in Practice (PIP) component of the misguided component of this bewildering system, see below:

Be sure to read Dr. Weiss’s article, but also don’t miss Dr. Moreland’s comment following the essay, although I’ve copied the relevant part of it below.

All of us who are board-certified in urology should contact Dr. Jordan and let him know what a joke the MOC process is. I have now ‘gamed the system’. When I do the PAP for the first time (due by July 1), in the particular topic I have chosen, I purposely get one “patient’ answer wrong. Then I review the AUA guidelines for that topic, as I am told to do. When I am contacted by the Board again, to do the PAP again (by October 1), I get all the answers right. Then I am told by the BOARD: “Congratulations, this proves that with further studying and education you have improved your abilities as a urologist, and are now a better urologist for the public!” Really??? All I did was play a game!

This is especially important as I continue to work on the Delirium PIP. The reality of Part IV of the ABPN or any other board’s version of the MOC is that doctors can, in fact, game this system. I suspect that’s exactly why the Feedback Module was made optional. Who is going to submit negative feedback? Every doctor is going to cherry pick to complete that farce and that’s gaming the system as well. I’ve been saying that for years.

I was tempted to game the PIP regarding a suicide risk assessment activity. I do suicide risk assessment every day and I teach it to trainees. The components of the PIP are initial assessment, an action plan for improvement, then reassessment. Although it may sound boastful, I think almost any doctor who has decades of experience doing a clinically essential activity every day might find it difficult to improve (except by compulsively searching PubMed or PLoS ONE, a genuine and practical way to improve) and therefore would find it impossible to honestly complete all three steps of the PIP activity and obtain full credit. I could not honestly complete all three for suicide risk assessment…and so did not get full credit.

What do you think might happen if I tried to participate in my own Delirium PIP activity?

Ironically, though Dr. Moreland was technically not honest in his documentation of his own specialty’s version of practice improvement, if he had not been dishonest, he might have risked losing his hospital and clinical privileges or not been eligible for 3rd party payor reimbursement.

Is this what patients want their doctors to do on their behalf?

My wife compared this to the File and Suspend strategy for Social Security Benefits, which some people, including President Obama, regard as a species of gaming the system. I don’t pretend to understand it but, apparently, you can get thousands more dollars from our government by the File and Suspend strategy than if you used any other strategy. Is there anything wrong with that? It’s not illegal, is it? Then why do some think it’s almost like cheating the government? In fact the author of the article I highlighted begins by asking “Are high-income Americans gaming Social Security?” Hey, I guess it’s completely legal.

But is it completely right?

You could say the same sort of thing about the MOC PIP activity. Sure, there’s nothing illegal about boards picking my pocket for MOC activities like the PIP. On the other hand, how reliable is the activity as a method for ensuring doctors are sincerely engaged in honest self-reflection about improving their medical practice? The boards can’t ask for protected and confidential patient data. So how do they effectively “audit” those who are gaming the system? How can anyone tell how many physicians are engaging in lying about their deficiencies in order to get MOC credit just so they can comply with this crazy system in order to keep caring for their patients? You can’t be identified by answering the following poll:

Does the ABPN really even want to know? Does the ABPN truly believe that this is the right way to measure physician progress in lifelong learning? I don’t see how they can and I surely don’t think it’s right.

None of us are that naive.

That’s why I think Part IV of the MOC, including the PIP, is flawed and should probably be removed as a MOC requirement, not just made optional.

But hang on; is there a reason to look the other way? Some physicians and some board leaders might defend this so-called system by saying that if we don’t show policy makers and the public that the medical profession is policing itself–then the government or some other regulatory agency will take over and then, boy, will things get evil.

Sound familiar? It’s the same tired song the boards have been singing since the MOC travesty got started.

The Presidents and CEOs of the ABPN and the American Board of Medical Specialties (ABMS) are not my enemies, though I doubt I could honestly make them my friends. Colleagues are predicting that my Delirium PIP activity will likely be approved by the ABPN. Why wouldn’t it be approved? Go ahead…answer the question.

I’m getting a little too self-important. Now if you’ll excuse me, I have to set an example for getting small to my trainees.

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