I read an interesting article about letting patients tell their stories. Doctors are under many pressures to bypass this empathic practice. Maintenance of Certification (MOC) is only one of them. The latest news in the struggle between the boards and rank-and-file physicians is the new American Medical Association (AMA) policy just adopted opposing MOC recertification exams.
Unfortunately, the American Board of Medical Specialties (ABMS) doesn’t agree, which was not unexpected. Most trainees I tell about this ongoing conflict see the ABMS and member boards as wrong. I’m sure some of them don’t share that opinion–probably because they’re simply not aware of the issue. The Pennsylvania Medical Society (PAMED) sponsored the panel discussion about MOC at the AMA meeting in Chicago June 13, 2016. PAMED has even issued a vote of no confidence in the American Board of Internal Medicine (ABIM). Newsweek’s Kurt Eichenwald has written articles critical of the ABIM MOC process.
Most of us who have been opposed to MOC have been skeptical of the effectiveness of the program at influencing patient outcomes. There is controversy about whether or not there is good evidence in the literature supporting it (see references).
I think the struggle between working doctors and the boards is indicative of trouble with the whole MOC process and suspect the main reason it isn’t dropped is because the boards make a lot of money out of it. And I also believe one of the major criticisms against it is that it takes an inordinate amount of time to deal with all of the modules and it takes time away from patient care. We don’t have time to listen to our patients’ stories partly because we’re doing MOC busywork.
We graduated several combined specialty residents last week, in the Internal Medicine/Psychiatry and Family Medicine/Psychiatry programs. We’re all extremely proud of them. I’m not worried about their competence. I’m worried they’ll become cynical about our regulatory system. It takes a great deal of work and dedication to succeed in these and the traditional psychiatric residencies. In my opinion, it’s scandalous to subject them to the MOC for the rest of their careers, which will be difficult enough.
I know the new alternative board, the National Board of Physicians and Surgeons (NBPAS) is making progress in being recognized as another certifying board. I also hope that the leaders of the ABMS and member boards realize what bad press they’re accumulating and finally understand what it will take to persuade the next generation of doctors to be proud of their legacy. It won’t be the MOC.
It’s time for the boards to listen to the doctors’ stories now.
Lee, T. H. (2014). “Certifying the good physician: a work in progress.” JAMA 312(22): 2340-2342.
Hayes, J., et al. (2014). “Association between physician time-unlimited vs time-limited internal medicine board certification and ambulatory patient care quality.” JAMA 312(22): 2358-2363.
IMPORTANCE: American Board of Internal Medicine (ABIM) initiatives encourage internists with time-unlimited certificates to recertify. However, there are limited data evaluating differences in performance between internists with time-limited or time-unlimited board certification. OBJECTIVE: To determine whether there are differences in primary care quality between physicians holding time-limited or time-unlimited certification. DESIGN, SETTING, AND PARTICIPANTS: Retrospective analysis of performance data from 1 year (2012-2013) at 4 Veterans Affairs (VA) medical centers. Participants were internists with time-limited (n = 71) or time-unlimited (n = 34) ABIM certification providing primary care to 68,213 patients. Median physician panel size was 610 patients (range, 19-1316), with no differences between groups (P = .90). MAIN OUTCOMES AND MEASURES: Ten primary care performance measures: colorectal screening rates; diabetes with glycated hemoglobin (HbA1c level) less than 9.0%; diabetes with blood pressure less than 140/90 mm Hg; diabetes with low-density lipoprotein cholesterol (LDL-C) level less than 100 mg/dL; hypertension with blood pressure less than 140/90 mm Hg; thiazide diuretics used in multidrug hypertensive regimen; atherosclerotic coronary artery disease and LDL-C level less than 100 mg/dL; post-myocardial infarction use of aspirin; post-myocardial infarction use of beta-blockers; congestive heart failure (CHF) with use of angiotensin-converting enzyme (ACE) inhibitor. RESULTS: After adjustment for practice site, panel size, years since certification, and clustering by physician, there were no differences in outcomes for patients cared for by internists with time-limited or time-unlimited certification for any performance measure: colorectal screening (odds ratio [OR], 0.95 [95% CI, 0.89-1.01]); diabetes with HbA1c level less than 9.0% (OR, 0.96 [95% CI, 0.74-1.2]); blood pressure control (OR, 0.99 [95% CI, 0.69-1.4]); LDL-C level less than 100 mg/dL (OR, 1.1 [95% CI, 0.79-1.5]); hypertension with blood pressure less than 140/90 mm Hg (OR, 1.0 [95% CI, 0.92-1.2]); thiazide use (OR, 1.0 [95% CI, 0.8-1.3]); atherosclerotic coronary artery disease with LDL-C level less than 100 mg/dL (OR, 1.1 [95% CI, 0.75-1.7]); post-myocardial infarction use of aspirin (OR, 0.98 [95% CI, 0.58-1.68]) or beta-blockers (OR, 1.0 [95% CI, 0.57-1.9]); CHF with use of ACE inhibitor (OR, 0.98 [95% CI, 0.61-1.6]). CONCLUSIONS AND RELEVANCE: Among internists providing primary care at 4 VA medical centers, there were no significant differences between those with time-limited ABIM certification and those with time-unlimited ABIM certification on 10 primary care performance measures. Additional research to examine the difference in patient outcomes among holders of time-limited and time-unlimited certificates in non-VA and nonacademic settings and the association with other ABIM goals may help clarify the potential benefit of Maintenance of Certification participation.
Gray, B. M., et al. (2014). “Association between imposition of a Maintenance of Certification requirement and ambulatory care-sensitive hospitalizations and health care costs.” JAMA 312(22): 2348-2357.
IMPORTANCE: In 1990, the American Board of Internal Medicine (ABIM) ended lifelong certification by initiating a 10-year Maintenance of Certification (MOC) program that first took effect in 2000. Despite the importance of this change, there has been limited research examining associations between the MOC requirement and patient outcomes. OBJECTIVE: To measure associations between the original ABIM MOC requirement and outcomes of care. DESIGN, SETTING, AND PARTICIPANTS: Quasi-experimental comparison between outcomes for Medicare beneficiaries treated in 2001 by 2 groups of ABIM-certified internal medicine physicians (general internists). One group (n = 956), initially certified in 1991, was required to fulfill the MOC program in 2001 (MOC-required) and treated 84 215 beneficiaries in the sample; the other group (n = 974), initially certified in 1989, was grandfathered out of the MOC requirement (MOC-grandfathered) and treated 69 830 similar beneficiaries in the sample. We compared differences in outcomes for the beneficiary cohort treated by the MOC-required general internists before (1999-2000) and after (2002-2005) they were required to complete MOC, using the beneficiary cohort treated by the MOC-grandfathered general internists as the control. MAIN OUTCOMES AND MEASURES: Quality measures were ambulatory care-sensitive hospitalizations (ACSHs), measured using prevention quality indicators. Ambulatory care-sensitive hospitalizations are hospitalizations triggered by conditions thought to be potentially preventable through better access to and quality of outpatient care. Other outcomes included health care cost measures (adjusted to 2013 dollars). RESULTS: Annual incidence of ACSHs (per 1000 beneficiaries) increased from the pre-MOC period (37.9 for MOC-required beneficiaries vs 37.0 for MOC-grandfathered beneficiaries) to the post-MOC period (61.8 for MOC-required beneficiaries vs 61.4 for MOC-grandfathered beneficiaries) for both cohorts, as did annual per-beneficiary health care costs (pre-MOC period, $5157 for MOC-required beneficiaries vs $5133 for MOC-grandfathered beneficiaries; post-MOC period, $7633 for MOC-required beneficiaries vs $7793 for MOC-grandfathered beneficiaries). The MOC requirement was not statistically associated with cohort differences in the growth of the annual ACSH rate (per 1000 beneficiaries, 0.1 [95% CI, -1.7 to 1.9]; P = .92), but was associated with a cohort difference in the annual, per-beneficiary cost growth of -$167 (95% CI, -$270.5 to -$63.5; P = .002; 2.5% of overall mean cost). CONCLUSION AND RELEVANCE: Imposition of the MOC requirement was not associated with a difference in the increase in ACSHs but was associated with a small reduction in the growth differences of costs for a cohort of Medicare beneficiaries.