By: ALICIA AULT, Internal Medicine News Digital Network
August 7, 2014
The American Board of Internal Medicine is making several changes to its maintenance of certification requirements, but, so far, it is not enough to quell the still-growing tide of anger and resentment against the process.
The ABIM announced the changes just ahead of a July 15 "summit" with 26 specialty societies that receive certification through the organization, and outlined them in a detailed letter that was sent to internal medicine diplomates on July 28. That correspondence also responded in detail to a May 7 letter sent by the American College of Physicians (ACP) on behalf of 14 medical societies, enumerating their concerns about the process.
Dr. Patrick T. O’Gara
The Endocrine Society, which attended the July 15 meeting, said that it left with many of the concerns it came in with. In a statement issued shortly thereafter, the Society called on the ABIM to suspend the maintenance of certification (MOC) requirements until it conducted "a formal analysis of all possible unintended consequences of the new MOC requirements."
Among the unintended consequences it says might result: If endocrinologists have to spend more time on MOC, they might spend less time with patients or on research, or they may even leave the field all together. That will put a dent in access to care when there is an increasing need, according to a letter from the Society to the ABIM in early June.
The American Association of Clinical Endocrinologists (AACE) also warned ABIM that by "monopolizing physician time," MOC could end up harming patient care. The group also said that many endocrinologists who previously did not have to recertify (so-called "grandfathers") might leave practice rather than go through the current process. In a letter to ABIM in late June, AACE also called on the Board to suspend the new requirements until there was a better understanding of how it might affect the endocrinology workforce. The ABIM should also "refrain from publicly reporting that a physician does not meet the MOC requirements," said Dr. R. Mack Harrell, AACE’s president, in that letter.
Meanwhile, 3,000 or so physicians have signed on to a "Pledge of Non-Compliance" with the ABIM’s requirements. The pledge was organized by Dr. Paul Teirstein, chief of cardiology and director of interventional cardiology at the Scripps Clinic, La Jolla, Calif., and his colleagues who have formed Physicians for Certification Change, an anti-MOC organization. Dr. Teirstein also launched a petition drive in March to overhaul the MOC process. That petition had about 18,000 signees at press time.
There are several other organizations hoping to derail or significantly change the ABIM’s requirements, including the Association of American Physicians and Surgeons, Change Board Recertification, and Docs4PatientCare.
In addition, many of the 26 professional societies whose members are certified by the ABIM have also been very organized in presenting their discontent.
Dr. Richard Baron
The ABIM understands the frustration, said Dr. Richard Baron, ABIM president and CEO, in an interview. "One of the things that people have said is that we’re not listening," he said. That is one reason why the ABIM decided to hold what he called a "listening session" on July 15. "We’re a learning organization," he added, noting that the ABIM will "continue to evolve the program," based on the feedback it receives from individuals and from professional societies, among others.
Dr. Baron also acknowledges that by presenting an entirely new MOC process this year, "our timing was not propitious," given the many challenges physicians now face. The ABIM outlined those pressures in the July 28 letter, counting among them "dealing with the Affordable Care Act," fulfilling meaningful use requirements, and responding to changes in payment and practice models, including team-based care.
Dr. Steven E. Weinberger, executive vice president and CEO of the ACP agrees that the ABIM’s timing was pretty poor. He said that there had been a "low to medium level of concern" about MOC for years, but the new requirements announced in January catalyzed the complaints and were "an important tipping point." Added Dr. Weinberger, "To some extent, this was in part the straw that broke the camel’s back."
The ABIM is making a handful of changes to address some of the concerns, including "broadening the kinds of educational activities that can count for self-assessment of knowledge (Part 2)," said Dr. Baron. That is, the ABIM will be broadening the continuing medical education that will count toward the MOC requirements.
Dr. Steven E. Weinberger
There have also been a huge number of complaints about the self-evaluation of practice assessment. There will be less direct data collection by the ABIM and more of a focus "on improvement activities doctors may already be doing in their practice," Dr. Baron said.
Among other things, ABIM is also looking at changes to the secure exam and whether it needs to change how it describes on its website whether physicians are meeting MOC requirements.
Critics are still not satisfied.
"This is nothing more than offering band-aids for gaping wounds," said Dr. Jonathan Weiss, an internist in Middletown, N.Y. "This is the ABIM trying to throw some bones to quiet down the rabble, given the unexpectedly strong pushback they are trying to deal with," he said, adding that he believes that the current process "is too flawed to be fixed."
Dr. Ron Benbassat, an internist in Beverly Hills, Calif., and a founder of Change Board Certification, goes even further. "No one is drinking the ABIM’s Kool-Aid," he said. "We’re on the right side of the truth here, and they know it," he said, adding, "The momentum is increasing and I believe we’re reaching the tipping point. As to what form it will take – widespread noncompliance or political or legal – I don’t have the answer. But we’re getting there."
Dr. Teirstein was a bit more muted in his criticism. "They are certainly taking many good steps. But, the devil will be in the details." He, like many physicians, said that he still sees the ABIM’s fees as a big problem. "To reestablish credibility, ABIM will need to roll back its fee schedule," said Dr. Teirstein.
The ABIM charges $1,940 for a 10-year basic internal medicine certification, which includes a secure examination for each specialty the diplomate chooses to maintain, access to all ABIM self-evaluation products, and any CME credit a physician can claim through completion of an ABIM module. There are basically four requirements: MOC participants take a secure exam; they have to complete a self-assessment of knowledge; they have to assess their practice by applying quality measurement and using the resulting data to improve their practice; and they must assess patient safety and/or include the "patient voice," which could, for instance, consist of a survey of patient satisfaction.
The fee is $2,060 for a focused practice in hospital medicine for 10 years, and $2,560 for any subspecialty for the 10 years.
But it’s more than just a financial cost, say physicians. There’s also an opportunity cost, said Dr. Eric Green, chair of the MOC Task Force at the Society of General Internal Medicine. "When you are doing MOC, what are you not doing?" he asks.
"It’s about a process that seems arbitrary, a little bit burdensome, and perhaps not achieving what we all want, which is the best care for our patients," said Dr. Christopher White, professor and chairman of medicine, the Ochsner Medical Center, New Orleans, in an interview.
Dr. White, who is a founding member of Physicians for Certification Change, has signed the Pledge of Non-Compliance. He is currently certified, and at age 63, wonders if it’s worth the time and effort to recertify in 2019, when he is next due. "It is a good idea that we continually educate physicians and that physicians have continuous improvement," said Dr. White, but he said he questions whether the ABIM process is the best way. "There’s no evidence that this works, or there’s value," he said. The American College of Cardiology has offered to partner with the ABIM in getting some answers to the evidence question, said ACC President Patrick O’Gara in an interview. "I’m hopeful that our offer to partner to do research will be taken seriously," he said. Although more evidence will "go a long way toward answering this question about relevance," it would be a long-term project, said Dr. O’Gara, who is also director of clinical cardiology at Brigham and Women’s Hospital, Boston.
The ABIM said in its July 28 letter that extensive evidence does exist – with more than half of the studies coming from non-ABIM researchers – but that maybe it hasn’t done the best job of communicating that to diplomates. However, it does say it welcomes partnering on new projects "and a broader discussion" of potential research agendas.
Many say that they are in favor of requiring lifelong learning, but that the ABIM has gone about it the wrong way.
The ACC would like to find a way "to modify the methodology" ABIM is using to achieve that goal, Dr. O’Gara said. Cost is also a big concern for cardiologists, and especially subspecialists, he said. An interventional cardiologist, for instance, not only has to pay for and pass the general cardiology exam, but also a secure board exam in the subspecialty. In an ACC survey this spring, 90% of the 4,400 respondents said they were concerned about the cost of MOC.
The Society for Cardiovascular Angiography and Interventions (SCAI) is concerned about the impact on its members, too, and has formed a work group to "develop an action plan to spur MOC reform," according to a statement. "We believe that maintaining physician competence is of the highest importance," said Dr. Alan Yeung, chair of the MOC Working Group, in the statement. "It is the current process and products for facilitating maintenance of board certification that are not acceptable."
"The problem is not the lofty goals of maintenance of certification, it’s the implementation of it," agreed Dr. Green. The SGIM is also concerned about the one-size-fits-all approach that ABIM seems to be using. The SGIM has a lot of members who are administrators or physician scientists, and the MOC modules as constructed currently aren’t necessarily meaningful to their practice, said Dr. Green, who is also the program director for the internal medicine residency at Mercy Catholic Medical Center, Philadelphia.
Dr. Weinberger of the ACP said that his organization also wants to see more customization of the secure board exam "so that it’s more relevant to a particular physician’s practice." Many who attended the ABIM’s July 15 meeting said that they felt like the organization had heard their concerns. But they are still waiting to see what will happen next.
The changes already announced "are a very good start," said Dr. Weinberger, who said that the ACP hopes that the ABIM board might make more changes at its meeting in August. "This is clearly a work in evolution," he said, adding that the ACP would continue to work with ABIM.
Likewise, Dr. Green said that the SGIM would continue to work in cooperation with the ABIM. The question is how much the ABIM will use the input from the subspecialty societies, he said.
"I left the [July 15] meeting with the impression that they are generally interested in receiving this information, in processing it, and in determining with their board what’s the best pathway forward," said Dr. O’Gara.
Dr. White, however, is a bit more skeptical. "I think the ABIM is going to have to be a lot less arrogant," he said, calling for more accountability by the organization.
ABIM’s changes to MOC
The new set of changes to the maintenance of certification process announced by the American Board of Internal Medicine represented the first time the organization had responded to the many concerns being voiced by individual physicians and representatives of the 26 societies that receive certification through the ABIM.
The changes were contained in a July 28 letter. Among other things, the ABIM said that it will be more transparent in how it governs, and how it reports its income and expenses, and that it will set up a more formal process for communication among those specialty societies and the ABIM’s boards. The group also said that in August, its board will "discuss website language for ‘meeting MOC requirements’."
The ABIM agreed with a recommendation from the American College of Physicians and 14 other medical societies that it should convene a conference dedicated to addressing the concerns about MOC and that it should focus on working with various societies to identify problems and solutions.
The organization also said it is open to research projects that can help determine whether MOC has any impact on the physician workforce.
Some other changes:
• The ABIM is streamlining the process for validating products from other organizations that can be eligible for credit toward Part 2 (medical knowledge). The ABIM will accept products that are Accreditation Council for Continuing Medical Education–accredited, and it will align its standards with the American Medical Association’s PRA "Category 1 standards, journal-based continuing medical education (CME), test item writing, and Internet point of care learning." The revised program is expected to be available later in 2014.
• If a diplomate takes an exam before his due date and fails, he will have an additional year to pass before being reported as "not certified" or "not meeting MOC requirements."
• Each ABIM specialty board will decide whether underlying certifications are required in each tertiary specialty and conjoint board. A decision is expected by 2015.
• The ABIM acknowledges that the "patient survey" requirement has been confusing. The name will be changed to the "patient voice" and will be designed to ensure that physicians are doing their best to incorporate that voice into their work. There will be four pathways for completing the requirement, including a survey. Specialty boards will determine which options are the most appropriate for each specialty. The deadline for the completion of the patient voice requirement is 2018.
• The organization said it will look into options for discounting its fees for diplomates who want to complete some of their MOC requirements with other groups. However, it said that it might not be able to offer a very deep discount. "We will commit to researching and brainstorming other fee structures," said the ABIM.
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