Maintenance of Certification: A Reply by Dr. James Amos, MD

I’ve just received the latest print issue of Psychiatric Times, in which I was surprised to find an article supporting the controversial Maintenance of Certification (MOC). It was written by Dr. Robert Boland, MD, who is the current President of the Academy of Psychosomatic Medicine (APM) and an Associate Professor at Harvard Medical School and Vice Chair for Education at the Brigham and Women’s Hospital Department of Psychiatry in Boston[1].

I respect and admire Dr. Boland but I think he praises MOC too much, especially by tying it to the reputation of the APM annual meetings. The APM offers outstanding CME activities at their annual meetings. Dr. Boland plays a vital role in that enterprise. I don’t believe the APM educational treasure needs a MOC seal of approval. It’s one of the best stand-alone examples of the pursuit of clinical excellence available.

The digital version of his article, “Maintenance of Certification” will be out on-line in a few weeks and I’m predicting there’ll be many comments, most of them rebuttals.

His support of MOC is in sharp contrast to another Psychiatric Times article which was critical of MOC and which was published in January by Dr. James Knoll IV, MD, and Dr. Dan Cotoman, MD, entitled “Maintenance of Certification and Self-Mortification”[2].

I wonder if the editors of Psychiatric Times are trying to present what they think might be a more balanced view of MOC. In general, it’s hard to find any physicians who support MOC. I was asked to give a presentation on MOC by a colleague in our Pediatrics Department. He was interested in using a debate model—but couldn’t find anyone who was willing to present the pro-MOC side.

I suppose I could suggest he contact Dr. Boland. But I doubt exposing him to what might be a hostile audience would be a useful way to highlight what I think should be the main point, which is that we, as physicians, are already doing everything we can to implement the principle of lifelong learning in our careers. We just don’t think MOC is the best way to do that, especially in a health care system which burdens doctors in so many ways, often leading to burnout, as pointed out by Tait Shanafelt, MD and colleagues in a Viewpoint article in JAMA in March 2017[3]. The authors specifically mention MOC as a contributing stressor.

I think it’s ironic that Dr. Boland’s pro-MOC article is included in an issue of Psychiatric Times which also published very practical and neuroscience-based papers the caliber of which are far superior to any of the approved products for self-assessment and CME currently listed on the American Board of Psychiatry and Neurology (ABPN) website. Mind you, the ABPN is, strictly speaking, not responsible for the quality of the products because it doesn’t produce them.

However, in my opinion, the ABPN could expand the list of approved lifelong learning tools to include what many expert physicians use every day, which are relevant to their practices and which can be launched in a just-in-time way to meet the needs of patients and learners[4].

For example, I have followed the model of the practice-based learning and improvement competency at the University of Iowa by using what Drs. William R. Yates and Terri Gerdes called the “problem-based learning” case conference[5]. The abstract for their paper describes it:

“Problem-based learning (PBL) is a method of instruction gaining increased attention and implementation in medical education. In PBL there is increased emphasis on the development of problem-solving skills, small group dynamics, and self-directed methods of education. A weekly PBL conference was started by a university consultation psychiatry team. One active consultation service problem was identified each week for study. Multiple computerized and library resources provided access to additional information for problem solving. After 1 year of the PBL conference, an evaluation was performed to determine the effectiveness of this approach. We reviewed the content of problems identified, and conducted a survey of conference participants. The most common types of problem categories identified for the conference were pharmacology of psychiatric and medical drugs (28%), mental status effects of medical illnesses (28%), consultation psychiatry process issues (20%), and diagnostic issues (13%). Computerized literature searches provided significant assistance for some problems and less for other problems. The PBL conference was ranked the highest of all the psychiatry resident educational formats. PBL appears to be a successful method for assisting in patient management and in resident and medical student psychiatry education.”

This is now called the Clinical Problems in Consultation-Psychiatry (CPCP) and trainees from medical students to residents participate as presenters. The format is also used as a framework for the newly inaugurated Psychosomatic Medicine Interest Group at Iowa. There are lively discussions at these meetings, to which we often invite colleagues from other medical specialty departments. The model for this was adapted from that reported by Puri and colleagues[6].

Yet these and other creative practice-based learning efforts which are relevant to our practices are not on the approved product list for CME and Self-Assessment at the ABPN.

To be sure, one Performance in Practice (PIP) clinical module that I and one of our residents submitted to ABPN was approved. This was the Delirium Clinical Module, for which we received congratulations from APM leaders. This is a clinically relevant exercise which could be useful to many medical specialists, not just psychiatrists. It would also be important for enhancing patient safety—which is the whole idea of practice-based learning.

Ironically, in addition to the module being so deeply buried in the ABPN website that it’s nearly impossible to find, it’s also unlikely to be used. This is because of the recent ABPN change to the PIP requirement, which allows diplomates to substitute a Feedback module for the PIP module.

Although the Delirium Clinical Module is probably dead as an ABPN MOC product, the ABPN requirement change tends to validate what Dr. Boland says about ABPN, which is that it “…has made several changes to the requirements…” of the MOC process in response to criticisms and suggestions from diplomates.

The MOC process change of the PIP requirement might be viewed as a tacit acknowledgement by board leadership of the flawed implementation of a practice-based learning process which intends to promote the principle of lifelong learning but which fails largely because it cannot be integrated into the busy schedules of physicians who have to navigate an increasingly complex health care system seemingly intent on burying rank-and-file doctors in the quicksand of regulatory requirements.

The AMA policy is clear:

“Any changes to the MOC process should not result in significantly increased cost or burden to physician participants (such as systems that mandate continuous documentation or require annual milestones).

 

The MOC program should not be a mandated requirement for state licensure, credentialing, reimbursement, insurance panel participation, medical staff membership, or employment.”

The American Psychiatric Association (APA) Board of Trustees message to ABPN President Larry Faulkner, M.D. in 2015 was also clear:

  • APA does not agree that there should be an exam every 10 years for MOC.
  • Certification of lifelong learning should be an integrated, ongoing process relevant to actual practice.
  • APA is willing to work with the ABPN to improve the MOC process.
  • For subspecialists taking a recertification exam, the ABPN should ensure that the exam primarily consists of questions related to the diplomates’ subspecialty. Any general psychiatry questions that are included should be relevant to the diplomates’ practice.
  • No psychiatrist should be forced to maintain her/his underlying general and subspecialty certification through more than one certification process.

 

Dr. Boland is also clearly aware of the controversy surrounding MOC and he recommends “…if you are one of the many dissatisfied with the MOC process, I encourage you to become active at an organizational level, either at your state or national level.” He knows there is room for improvement.

In fact, many of us have indeed been active at many levels. I have worked with the Iowa Medical Society (IMS) to get resolutions approved as IMS Policy which support the principle of lifelong learning and which oppose both MOC and Maintenance of Licensure (MOL).

The Alaska State Medical Association adopted a resolution opposing MOC in December 2016, which brought the number of state medical societies doing likewise to 20. This list includes:

Further, Oklahoma passed a law in April 2016 asserting that nothing in its laws about medical practice shall be construed to make MOC “a condition of licensure, reimbursement, employment, or admitting privileges at a hospital in this state.” The Governor of Kentucky signed a measure that forbids making MOC a condition of state licensure.

The idea that if doctors don’t develop a “credible system for monitoring continued competence in our specialty, other groups will do it for us” according to Dr. Boland, likely comes from what are essentially cases of medical malpractice. This was probably what was meant by the ABPN response to my criticisms of the MOC process several years ago, which was that part of the reason for MOC was the public’s demand for a way to hold physicians accountable for harming patients.

One of the papers citing this problem was by Shaw and colleagues. The authors mention “damaging high-profile cases” one example of which triggered the Bristol Inquiry in the United Kingdom leading to the “development of a compulsory integrated regulatory program with oversight in all levels of medical care from hospital systems to the practice of individual physicians”[7]. This is the United Kingdom’s revalidation program, which is similar to MOC or perhaps more properly, MOL.

The irony is that the American Board of Medical Specialties (ABMS) and member specialty boards including the ABPN claim the American version of MOC is a voluntary program and that this is “self-regulation.” It’s not clear who else would “do it for us” though. Some government agency?It’s hardly necessary when, as Dr. Paul Mathews reported recently, some private insurance payers require participation in MOC. He’s a voluntary board member of the National Board of Physicians and Surgeons (NBPAS), which is a newly established alternative to the ABMS which doesn’t require MOC participation:

“WHAT DO PRIVATE PAYERS GAIN FROM REQUIRING MOC?

As a volunteer board member of NBPAS (no compensation or honorarium as opposed to the salaries of ABMS board members, which can range from $300,000 to greater than $800,000), I have often wondered why private payers require MOC when Medicare does not require board certification or MOC. The answer is quite disturbing. Private payers actually participate in certification, which is issued by the National Committee of Quality Assurance (NCQA). Margaret E. O’Kane is the founder and president of the NCQA, and she is also a member of the ABMS Board of Directors. The NCQA requires private payers to require physicians to participate in MOC in order to be NCQA certified. Thus, anyone contracting with a private payer will require MOC. In the conflicted case of Ms. O’Kane, she profits from the NCQA requiring private payers to require physicians to participate in MOC, and then she profits again from her ABMS position when said physicians must pay to comply with MOC requirements”[8].

This raises another concern about MOC, which is the ever-present cloud of suspicion the ABMS and some of the member specialty boards are under, especially the American Board of Internal Medicine (ABIM).

According to Charles Cutler, M.D., M.A.C.P., in the winter 2016-17 issue of Philadelphia Medicine, Philadelphia County Medical Society, in an issue entitled “Is The ABIM Too Broken to Fix?” article “A Message to the ABIM: Reign in Spending and Stop Turning Staff into Millionaires,” reforms should in fact include doing just what the title says and much more[9].

Board executives, especially CEOs, make what appear to be enormous six-figure incomes from the MOC programs, including Dr. Larry Faulkner, M.D., the President and CEO of the ABPN who earned over $900,000 in 2014 according to IRS Form 990.

Dr. Boland’s low opinion of the adage about “…the wise old doctor who improves with experience…” should probably be shared with those board leaders who made the arbitrary cutoff date for requiring participation in MOC, grandfathering physicians board certified prior to 1994, thereby exempting them from the program.

Participation in MOC would make more sense if there were credible research evidence that it improves patient outcomes. However, the most recent studies tend not to support this conclusion[10, 11].

And MOC is not supported by most physicians, according the results of a Mayo Clinic Proceedings survey, indicating that “Dissatisfaction with current MOC programs is pervasive and not localized to specific sectors or specialties. Unresolved negative perceptions will impede optimal physician engagement in MOC”[12].

Finally, Dr. Boland’s suggestion to sign up right away for MOC probably should be preceded by another important action, which is to first check with your institution to see if MOC participation or, indeed, board certification itself, is a condition of employment. It may not be.

What are the alternatives to the MOC approach? They depend on one’s level of attachment to keeping some sort of certification status.

There is the alternative National Board of Physicians and Surgeons (NBPAS), which was launched in 2015 and offers board re-certification without MOC or recertification examination requirements. There is a nominal fee and CME requirement. A previous ABMS certification is also required, but if that has lapsed one can still obtain certification by submitting a higher number of CME credits.

NBPAS leaders are very much aware that certain private insurance payers require MOC participation. It’s the top priority for NBPAS in 2017. See the website nbpasdotorg for full details about their re-certification process.

Physicians could simply forgo MOC or alternative certifications, which would probably raise more anxiety. For example, if one simply stops sending money to the ABPN toward MOC requirements and declines to sit for the recertification examination, then after the general board expires one would be identified as “Certified-not meeting MOC requirements.” The prudent diplomate should first check with ABPN for clarification of specific details and should check their employer’s expectations and insurance payer rules about MOC.

In my opinion, there ought to be a choice to participate in MOC or some other vehicle for fulfilling the principle of lifelong learning. Those who want MOC should keep it. Those who don’t should be allowed to continue using the method they’re most comfortable with for maintaining their knowledge and clinical skills, including CME and other creative methods for staying current with the medical literature.

Our patients deserve at least this much.

 

 

References:

 

  1. Boland, R., MD, Maintenance of Certification, in Psychiatric Times. 2017, UBM Medica.
  2. Knoll, J.L., IV, MD; Cotoman, Dan, MD, Maintenance of Certification and Self-Mortification, in Psychiatric Times. 2017, UBM Medica.
  3. Shanafelt, T.D., L.N. Dyrbye, and C.P. West, Addressing physician burnout: The way forward. JAMA, 2017. 317(9): p. 901-902.
  4. Bright, R.P. and L. Krahn, Value-added education: enhancing learning on the psychiatry inpatient consultation service. Acad Psychiatry, 2015. 39(2): p. 212-4.
  5. Yates, W.R. and T.T. Gerdes, Problem-based learning in consultation psychiatry. Gen Hosp Psychiatry, 1996. 18(3): p. 139-44.
  6. Puri, N.V., P. Azzam, and P. Gopalan, Introducing a psychosomatic medicine interest group for psychiatry residents. Psychosomatics, 2015. 56(3): p. 268-73.
  7. Shaw, K., et al., Shared medical regulation in a time of increasing calls for accountability and transparency: comparison of recertification in the United States, Canada, and the United Kingdom. JAMA, 2009. 302(18): p. 2008-14.
  8. Mathew, P., MD, MOC and Physician Burnout: Treating the Cause, Not the Symptoms, in Practical Neurology. 2016.
  9. Cutler, C., MD, MACP, A Message to the ABIM: Reign in Spending and Stop Turning Staff into Millionaires, in Philadelphia Medicine: The Official Magazine of the Philadelphia County Medical Society Philadelphia Medicine 2016, Hoffmann Publishing Group, Inc.
  10. Gray, B.M., et al., Association between imposition of a Maintenance of Certification requirement and ambulatory care-sensitive hospitalizations and health care costs. JAMA, 2014. 312(22): p. 2348-57.
  11. Hayes, J., et al., Association between physician time-unlimited vs time-limited internal medicine board certification and ambulatory patient care quality. JAMA, 2014. 312(22): p. 2358-63.
  12. Cook, D.A., et al., Physician Attitudes About Maintenance of Certification. Mayo Clinic Proceedings, 2016. 91(10): p. 1336-1345.
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Comments

  1. The irony is that, as of today, Psychiatric Times is now following me on Twitter.

    Like

  2. Paul Johnson says:

    Great summary ! Your PBL example of continuous learning reminds me of a Ted talk I saw on how one of the Scandinavian countries promotes staying current. In a a given area, an “expert leader” is identified and meets with doctors to discuss best practices and cases. In some cases, the expert leader will even come into your practice to provide mentorship and training in particular skills. The sense I got was that it was a very collaborative, hi yield learning process, not some inferior educational product participants are forced to buy. If what the ABMS had to offer was so good, we’d all be clamoring to get it.

    Liked by 1 person

    • Many thanks, Paul. Dr. Bill Yates was one of my teachers back in the day who taught me a lot about Consultation-Liaison Psychiatry. The PBL was his idea. The expert leader model you describe would never occur to MOC administrators. The so-called “approved product” list is full of expensive content often found on board websites and which is almost never relevant to my practice.

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  3. “He was interested in using a debate model—but couldn’t find anyone who was willing to present the pro-MOC side.”

    That says it all.

    The only people who are pro-MOC tend to be administrators themselves and I always wonder what the conflict of interest issues are when they are so out of touch. There is also a tendency of some to think that they need force their colleagues to make professional changes that are not based on evidence or consensus. There are clear examples from the past.

    Managed care is probably the most infamous example and yet at one point it was hyped by many people in the profession.

    The historical lesson is clear. If you don’t mind managed care, or the EHR, or any number of these set backs then by all means support MOC.

    Great update Jim.

    George Dawson, MD, DFAPA

    Liked by 1 person

    • Well said and thanks, George! You know, I’ve been squinting at the list of approved CME, etc. products on the ABPN web site and I can’t find anything worth spending hundreds of dollars for. The activities are expired, not available, or of such dismal quality I wonder why anyone bothers tinkering with this breath-taking mediocrity anymore .

      In fact, I’ve contacted ABPN and told them I’m giving up on MOC. I’ve got way too much to do in the hospital (which has critically high census levels almost every other day) in my role as a smokejumper psychiatric consultant to mess around with MOC busywork. They’ve politely informed me that I’ll be listed as “Certified–not meeting MOC requirements.”

      That doesn’t worry me now as it might have years ago.

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