Letter to the Editor

December 15, 2015

To the Editor, Kidney News:

Nephrologists are justifiably proud of their knowledge and skills, and most of them invest considerable effort in staying current in their practice of today’s medicine—keeping up with the rapid changes in the field since they completed their training. Having a substantive, meaningful, peer-issued credential, such as that provided by the American Board of Internal Medicine (ABIM), proudly recognizes and celebrates nephrologists’ efforts to stay up-to-date and powerfully supports the goal of preserving physician agency and autonomy at a time when both are threatened.

That is why we were disappointed to read the opinion column in December’s Kidney News by Rosenberg and Ibrahim (1) on behalf of the American Society of Nephrology (ASN) Council. We do not think it reflects a current view of many changes undertaken by ABIM as a result of substantive ongoing conversations with multiple internal medicine subspecialty societies, including ASN.

Reporting of MOC status

ABIM has always committed to ensuring that diplomates with lifetime certifications remain certified. This commitment was conveyed and reaffirmed to ASN and other societies repeatedly in 2013 before rolling out new MOC requirements. In order to make certification a more continuous credential and provide diplomates with an independent, third-party process to demonstrate to themselves and their colleagues that they are staying current with knowledge and practice, ABIM added a new reporting element in 2014—“meeting MOC requirements”—that applied to all ABIM Board Certified diplomates.

After the launch of the program in 2014, ABIM heard loudly and clearly that the “meeting requirements” language felt overly punitive and failed to emphasize the voluntary recognition the credential was meant to speak to. In response to this feedback from diplomates and medical societies (including ASN), ABIM leadership chose to change the language to “participating in MOC.” (2)

MOC activities approved for nephrologists

ABIM continues to award MOC points for the valuable CME and Practice Assessment products offered by ASN, including NephSAP and KSAP (3), and for the ASN Kidney Transplantation PIM and ASN Dialysis PIM (4, 5). This summer, ABIM also announced an effort to recognize more of what physicians are doing in practice by awarding MOC points for many CME activities, thanks to a new partnership (6) forged with ACCME. Accredited CME providers will now be able to use one unified, shared system to record information about both CME and ABIM MOC activities, giving nephrologists many more options to earn CME that also qualifies for MOC credit.

As of December 4, 2015, nearly 2500 ASN-sponsored CME activities earned ABIM diplomates MOC credit—with more than 1800 of those activities completed by physicians with a primary certificate in Nephrology. That number will grow as we approach the end of the year and diplomates complete their year-end requirements.

We encourage ASN and practicing nephrologists to be engaged in efforts to improve ABIM’s programs. As part of this process, ABIM recently solicited formal feedback from societies regarding the Assessment 2020 report (7), an independent report focused on the future of assessment. To date, ABIM has received formal feedback from more than a dozen societies and hopes to receive feedback from ASN.

Initial certification requirements

With regard to the issue of procedural documentation, members of the ABIM Nephrology Specialty Board had several conversations with leaders of the ASN Training Program Director (TPD) Executive Committee to prepare a list of procedures including placement of hemodialysis catheters, performance of kidney biopsies, and the spectrum of dialysis modalities for which ABIM and ACGME require competence be attained during training. Throughout ABIM’s history, training requirements have always been the purview of ABIM, but the Board has always worked with society colleagues to determine precisely what they should be. The Nephrology Board worked closely with ASN TPD leadership to better understand the procedural and dialysis-related experiences of nephrology trainees.

After this jointly prepared list was assembled, it was presented to the entire ASN TPD Executive Committee, which decided that this was a very important matter but recommended against a requirement for such documentation and recommended that these issues be discussed in detail at a subsequent TPD meeting. The ABIM Nephrology Board has not pursued this further.

Governance and finances

Other issues raised in the ASN editorial include ABIM governance and finances. ABIM believes that they have been transparent about the changes in the ABIM governance structure and the process to establish the specialty boards, as well as the roles and composition of the boards. A complete description of ABIM’s governance structure is available on ABIM’s website (8) and details the roles and responsibilities of the Board, Council, Specialty Boards, and Exam Writing Committees. The names of the members of the ABIM Nephrology Board (9)—comprised mostly of active ASN members—are listed publically on the ABIM website.

ABIM leaders believe that the new ABIM governance structure affords far greater opportunity for ASN and other specialty societies to shape ABIM processes and decision-making, with six ASN members in ABIM leadership positions on the Specialty Board and ABIM Council. This is far more than was the case with the prior governance structure. We believe that the new governance structure will be advantageous to nephrologists and ASN, and there have already been numerous meetings and discussions between ABIM and ASN leadership that we fully expect will continue. Various meetings have included members of ASN Council, leaders of the ASN educational community, ASN Training Program Directors (TPD) Executive Committee members, and others.

Finally, over the last two years, ABIM increased its fiscal transparency (10)—providing IRS 990 forms and audited financial reports on its website. While not a common practice for most boards and medical societies, it was felt that this was an appropriate indicator of the importance placed on transparency and effective stewardship of diplomate fees by ABIM. ABIM has invited financial scrutiny and was pleased that ASN leadership, their CFO, and ASN’s independent auditor recently spoke with ABIM’s CFO to discuss finance-related questions ASN had about ABIM.

Credentials that speak to the value and contribution of individual physicians are even more important in a world where physicians risk being seen as cogs in a machine, adding no value of their own to the overall system. Both the challenges and the value of this were accurately foreseen by some of the great nephrologist leaders of ASN and ABIM over the years and articulated very clearly by Relman, who opined: “If there is legitimate concern about the relevance of the tests used for recertification, then it should be up to the specialty boards to see that the examinations are suitable. If there is reason to believe that the testing procedures are arbitrary, unnecessarily stressful, or unfairly administered, then ways must be found to remedy these defects…. [B]ut for a profession that takes such pride in its self-imposed discipline, total abandonment of the recertification idea would be a mistake.” (11)

We want to continue to work together to redesign the MOC program so that it is a source of pride for all internists and subspecialists and something that embodies responsible self-regulation at a challenging time for all physicians. It is our sincere hope that ASN will work constructively with ABIM and other internal medicine subspecialty societies to achieve this goal. ABIM is eager to continue to work in close collaboration with ASN.

The Editorial concluded with four options ASN leadership is considering going forward, all four of which would remove nephrologists from the larger community of internal medicine and the broadly respected framework for which being “board certified” has stood. We hope ASN leadership will find a way to work with other internal medicine societies and ABIM to strengthen our community and keep nephrology firmly within internal medicine.

Sincerely,

Richard J. Baron, MD, MACP

President and Chief Executive Officer

American Board of Internal Medicine

Jeffrey S. Berns, MD, FASN

Professor of Medicine and Pediatrics

Associate Dean for Graduate Medical Education

Associate Chief of the Renal, Electrolyte, and Hypertension Division

Director of the Nephrology Fellowship Training Program

Perelman School of Medicine, University of Pennsylvania

Chair, ABIM Nephrology Board; Member, ABIM Nephrology Board Exam Committee; and

Member, ABIM Council, American Board of Internal Medicine

Stuart L. Linas, MD, FASN

Professor of Medicine

Chief of Nephrology, Denver Health Medical Center

Program Director, University of Colorado Denver Nephrology Fellowship Program

University of Colorado Denver School of Medicine

Former Member, ABIM Board of Directors (2006–2015)

Former Treasurer, ABIM Board of Directors (2012–2015)

References

1. 

Rosenberg ME, Ibrahim T. ASN’s Options for Helping Nephrologists Maintain Career Excellence. ASN Kidney News December 2015: 6–7.

2. 

American Board of Internal Medicine. ABIM Announces Immediate Changes to MOC Program. http://www.abim.org/news/abim-announces-immediate-changes-to-moc-program.aspx.

3. 

Accreditation Council for Continuing Medical Education. CME Activities, Nephrology. http://www.accme.org/MOClist.

4. 

American Board of Internal Medicine. Product Info, Demos and Ordering, PIM Selector Tool. http://www.abim.org/maintenance-of-certification/earning-points/practice-assessment/productinfo-demo-ordering.aspx#aqi.

5. 

American Society of Nephrology. Distance Learning, Practice Improvement Modules. https://www.asn-online.org/education/distancelearning/pim/.

6. 

American Board of Internal Medicine. ABIM and ACCME Announce Collaboration in Support of Physician Lifelong Learning. http://www.abim.org/news/abim-accme-announce-collaboration-in-support-of-physician-lifelong-learning.aspx.

7. 

American Board of Internal Medicine. Assessment 2020 Report. http://assessment2020.abim.org/final-report/

8. 

American Board of Internal Medicine. Governance. http://www.abim.org/about/governance/default.aspx.

9. 

American Board of Internal Medicine. Nephrology Board. http://www.abim.org/about/governance/specialty-boards/nephrology-board.aspx.

10. 

American Board of Internal Medicine. Revenue and Expenses: Where Does the Money Go? http://www.abim.org/about/revenue-expenses.aspx.

11. 

Relman AS. Recertification: Will We Retreat? NEJM 1979; 301:778–779.