Today I had no secretarial support but soldiered on and finally mailed a letter in protest of Maintenance of Certification (MOC) to Dr. Lois Nora, MD, JD, MBA, President and CEO of the American Board of Medical Specialties (ABMS). It’s a long enough read by itself so I don’t have much preamble except to say that I’m trying to set an example for trainees on what, in my opinion, is one way to conduct civil, constructive activism in medicine.
Dr. Lois Margaret Nora, MD JD MBA
President and Chief Executive Officer
The American Board of Medical Specialties
Re: Maintenance of Certification
Dear Dr. Nora:
I’m Clinical Professor of Psychiatry at UIHC and I have just found a letter posted on line dated November 20, 2013 to you from Melissa Waters, then President of National Association Medical Staff Services (NAMSS), https://www.namss.org/Portals/0/Regulatory/ABMS%20MOC%20-%20NAMSS%20Comments%202013.pdf
The letter lists several shortcomings (with which I and probably many other physicians agree) of the American Board of Medical Specialties (ABMS) Maintenance of Certification (MOC) standards. I think the criticisms are still valid today. The NAMSS made several recommendations which I will annotate based on my status as a rank-and-file psychiatrist working every day as a consultant in our 800 bed academic medical center.
“Recommendation One: Implement More Uniform Measures among Member Boards:”
Waters thought the overall policy was vague and invited “ambiguity for physicians and medical staffs.” While she cautioned against granting member boards some independence in individualizing their implementation of the standards, she was concerned about inconsistencies which could arise, making “MOC an overly complex and arbitrary process.”
The example Waters gave was the issue of not limiting time-certificate exemptions. My understanding of this is that some older physicians are still exempt from time-limited certification. There is no “uniform timeline” for the American Board of Psychiatry and Neurology (ABPN) certification that I know of. Three years later, this still creates an air of frustration and resentment for many diplomates who must cope with the MOC, which remains a cause of “unnecessary work and confusion” for doctors.
Flexibility is also occurring in terms of how each member board interprets the standards. For example, the ABPN has recently changed the requirement for both Performance in Practice (PIP) clinical module and a PIP Feedback module. A diplomate may now choose to do either and is not required to complete both. This effectively makes the PIP clinical module optional, which was an important feature of Part IV of the MOC standards. Many psychiatrists, including me, welcomed this change. In fact, the American Psychiatric Association (APA) has recommended that Part IV be removed from the standards.
“Recommendation Two: Implement More Objective Competency Measures:”
Waters recommended that the standards “should clearly explain how competency data is compiled, assessed, and weighted for each module of MOC’s four-part competency framework: 1) Professional Standing and Professionalism; 2) Lifelong Learning and Self-Assessment; 3) Assessment of Knowledge, Skills, and Judgment; and 4) Improvement in Medical Practice.”
Although I frequently remind my medical students and residents of the 6 competency version of this framework, I’m aware of the subjective nature of the data used to evaluate the competencies. According to Waters:
“Depending so heavily on intangible data presents validity and reliability issues and may not appropriately assess a diplomate’s competency. For example, one of these six competencies, Interpersonal & Communication Skills, evaluates a diplomate’s “…skills that result in effective information exchange and partnering with patients, their families, and professional associates….” There is no objective mechanism to assess this data.”
On the other hand, I always teach my trainees that the Interpersonal & Communication Skills competency underlies and supports the rest of them. Frankly, I’m unsure of the best way to teach them other than by role-modeling, to say nothing of how to measure a trainee’s performance in this domain. Self-report and patient and peer surveys are vulnerable to error. There can be a lack of insight into one’s own flaws, yet patient and peer surveys are almost certainly cherry-picked, making their reliability suspect.
Practice improvement modules (PIPs) offered on the ABPN web site are often not relevant to my practice and substituting the Feedback module, while superficially preferable because it’s relatively easier to obtain, is flawed because I control to whom I give the feedback form.
According to Waters, these kinds of data “should not serve as major competency measures.” And if they are not used, I’m at a loss as to suggest a more objective alternative. Waters adds, “The final Standards should also address cases in which diplomates have not been tested because they are life-time certified. Because much of the certification assessment is not evidence-based, there is no objective criterion to determine these diplomates’ qualifications and competencies.”
“Recommendation Three: Accurately Define MOC’s Participation Policy:”
Waters’ statement about the so-called voluntary nature of MOC strikes a chord in me and I suspect in many other psychiatrists:
“ABMS’ MOC process is not mandatory, but it is not truly voluntary. Diplomates who do not participate in the MOC process lose their certification. This gives those who intend to continue to practice their specialties little choice but to participate. If MOC is truly voluntary, the final Standards should include a “Not Participating” category to classify non-participants. The current process only offers, “Yes,” “No,” or “Not Required.” There is no option that accurately categorizes those who choose not to participate. ABMS should better accommodate physicians’ participation decisions and provide facilities a certification end-date for those who do not choose to participate in MOC.
That MOC is technically voluntary creates many inconsistencies throughout the industry – especially for physicians and facilities. Many facilities, departments, and specialties mandate MOC, which compels participation. The resulting inconsistency is unfair to physicians and does nothing to simplify healthcare and only muddles the concept of MOC for the healthcare community, patients, and the public. NAMSS does not assert that everyone must participate, (e.g., life time certificants), but recommends that ABMS add a category that would represent the non-participatory provider, which is not punitive in nature to the healthcare community.”
While it’s probably true that the letter of the law has been followed regarding Waters’ recommendation about how the MOC non-participant is labeled, it is also true that some hospitals and third-party payers base privileging and reimbursement on participation. One example of this has happened in Michigan, prompting physicians to form the Right2Care initiative which seeks legislative assistance in preventing Blue Cross Blue Shield from basing reimbursement on MOC participation.
I believe that, while the ABMS may not be directly responsible for this behavior by hospitals and insurers, their response was probably foreseeable.
“Recommendation Four: Define and Clarify Board-Certification Status:”
Waters’ recommendation to apply a uniform procedure for identifying diplomates who are or are not meeting requirements of MOC are unlikely to materialize because of the many differences amongst the 24 different specialties. While it’s possible to define “Board Certified” it is not generally agreed that board certification reliably identifies a physician as being superior to one who is “Board Eligible.” For example, The University of Iowa Hospitals and Clinics (UIHC) does not require board certification for appointment or hospital privileging regarding physician faculty, much less participation in MOC.
One could probably argue whether regular listing as one of the top hospitals in the country by U.S. News and World Report is a solid indicator of world class care and physician excellence. But UIHC is consistently identified as such.
“Recommendation Five: Make the Recertification Examination Optional:”
According to Waters, “If MOC adequately measures “…knowledge of core content, judgment, and skills,” the 10-year examination, which claims to do the same, is unnecessary for diplomates who successfully complete continuous certification. NAMSS recommends that these diplomates be exempt from this exam.”
Changes or proposals to change the recertification examination have been made by the American Board of Anesthesiology and the American Board of Internal Medicine. The APA has also recommended changes to the ABPN recertification examination. Dr. Jeffrey Lyness, MD, psychiatry director for the ABPN, was recently quoted indicating that the anesthesiology board briefed him on its recertification exam model and he said it is “clearly allowed by the ABMS.”
I think it’s unclear yet whether more frequent tests at the same cost is better or worse overall. What is clear is that some specialty certification boards are making changes to the standards in an effort to reduce the time and cost burdens to diplomates.
Waters’ last point about collaborating with the Federation of State Medical Boards (FSMB) to “ensure that MOC satisfies each state medical board’s maintenance of licensure criteria” alludes to the Maintenance of Licensure (MOL) initiative and which you have pointed out is “distinct and separate” from MOC. However, I and many other physicians believe that MOC would inevitably be coupled to obtaining and renewing one’s medical license. Let me say that I’ve discussed this with my state medical board’s executive director. Iowa was one of several states which initially partnered with the FSMB to implement pilot projects to determine our state’s readiness to implement MOL. The short story is that Iowa will not be doing that in the foreseeable future.
In my opinion, the state of the MOC now is not substantially different from what it was in 2013 when Waters made her recommendations.
I know you and others believe that Part IV of MOC are demonstrably helpful in improving patient care although I also notice that this is one item for which you did not provide supporting references in your blog post in 2014, http://thehealthcareblog.com/blog/2014/01/20/why-the-maintenance-of-certification-exam-will-make-you-a-better-doctor/
I think it’s important to reiterate that the American Psychiatric Association (APA) does not believe Part IV is essential and have recommended that it be removed from the MOC requirements. The pertinent excerpt from the APA letter to Dr. Larry Faulkner, President and CEO of ABPN on March 16, 2016:
“APA members have found Part IV to be onerous, cumbersome and not meaningful. While we very much appreciate ABPN leadership’s efforts to create alternative pathways for meeting this requirement, neither our members nor the APA Board of Trustees support the continuation of Part IV of MOC.”
In a follow up letter to ABPN diplomates on March 24, 2015, the ABPN recommended that “Based upon the feedback we have received from the AAN and the APA, the ABPN has respectfully asked the ABMS to consider modifying its 2015 MOC Standards so that Part IV is an optional component of MOC.”
Because the ABMS did not allow that, indicating that it supported all parts of the standards (which the NAMSSS clearly did not support in 2013 as noted above), Part IV remained…until just recently almost exactly a year following the decision to uphold Part IV. Now the diplomate has the option of choosing either to complete a Performance in Practice (PIP) clinical module or a Feedback Module. It’s obviously a compromise.
Dr. Faulkner went out of his way to follow the ABMS requirements. Did the ABMS change its position or did the ABPN independently modify the requirement as other boards are now doing?
In either case, the MOC is evolving just as you said it would, although maybe not exactly in the way you might have envisioned.
In view of the foregoing, I think it’s incredible for Dr. Lyness to have also been quoted in a Medscape article as saying that psychiatrists are “more satisfied” with the MOC process than other medical specialists. I did not receive a copy of the survey which allowed him to draw that conclusion.
Further, the recent changes are only a step in the right direction. I think MOC has had its chance to prove whether or not its valuable to patient care and my opinion is that it has failed to do so. I’m not the only one who holds this opinion. The APA is only cautiously supportive of what they call the initial changes in the ABPN MOC.
I think the ABMS should drop the MOC. Even as I write this, I know I’ll probably be ignored. But I’m doing this for another reason. I’m trying to role model the core competencies for my medical students and residents. The MOC controversy is a challenge to be met by all doctors acting as individuals, including those who believe in civil, constructive activism.
Systems-based practice competency implies our responsibility to be accountable for our mistakes as well as our successes in a complex health care system with many moving parts influenced by money, self-interest, and political alignments. As far as I know I’m the only faculty member at my hospital who tries to teach this to trainees.
Practice-based learning and improvement competency implies our commitment to personally designed individual programs to ensure our ability to provide safe and effective care to patients keeping pace with the latest research. This must be relevant to our practice, flexible, and not create more burdens in an already overly complicated health care system over which physicians have little to no control and which is an identified cause of burnout.
Medical knowledge and patient care competencies implies our acknowledgement of the continuously evolving knowledge base and the need to individualize the care we provide based on the particular needs of our patients in view of the inadequacy of the one-size-fits-all approach and always looking outside of our own spheres for help and new knowledge.
Professionalism competency implies our recognition of the difficulty of even arriving at an agreed upon definition of what professionalism is, much less how to measure it, but despite that challenge continuing to engage in daily self-reflective improvement for our patients, ourselves, colleagues, families, and communities. Like art, we may not know what integrity is precisely—but we know it when we feel it as our leaders practice the art and science of medicine.
Communication and interpersonal skills competency implies our acknowledgement that this competency is foundational to all the rest and encourages the pursuit of diplomacy, respect, empathy, tolerance, justice, and civility in our relationships and this supports professionalism…and must come from the inside out and cannot be measured or imposed from without.
Since my first year of residency I’ve struggled to reconcile my practice of medicine with the principles Stephen Covey outlined in his earliest works including The 7 Habits of Highly Effective People. Covey pointed out that one is more effective if one tries to be a change agent within one’s circle of influence rather than one’s circle of concern. I have always been conflicted about that.
Some of the world’s greatest leaders are remembered precisely because they chose to work against all odds and risk even their lives over burdens and oppression that were often clearly outside their circle of influence.
Help me remove at least one of the obstacles to success facing the next generation of doctors.
James J. Amos