MOC Returns as a Hot Issue this Winter

A hallmark of medical care is the unwavering dedication of physicians and other health professionals to commit to lifelong learning. How physicians in the United States fulfill and document that commitment, however, has created growing concern among many clinicians.

A reflection of that concern is the decision by the American Board of Medical Specialties (ABMS) in December 2017 to establish a Vision Commission to “bring together multiple partners to vision a system of continuing board certification that is meaningful, relevant, and of value, while remaining responsive to patients, hospitals, and others who expect that physician specialists are maintaining their knowledge and skills to provide quality specialty care.”

The American Board of Internal Medicine (ABIM)—the organization that certifies and recertifies internal medicine physicians, including nephrologists—is one of ABMS’s 24 specialty boards. In response to a wide range of criticisms relative to recertification or maintenance of certification (MOC), ABIM announced “substantial changes” to its MOC program in February 2015.

At that time, ABIM suspended “the practice assessment, patient voice, and patient safety requirements” (Part 4 of MOC). ABIM’s estimated 200,000 diplomates, including more than 10,000 nephrologists, can still receive MOC points for Part 4 activities but are not required to participate in practice improvement to maintain their certification.

To date, neither ABMS nor the other 23 specialty boards have followed ABIM’s lead and suspended Part 4. However, ABMS and all its specialty boards (including ABIM) have made major changes to Part 3 of MOC, which uses a summative (or high-stakes) process to assess the knowledge, judgment, and skills of physicians.

For example, ABIM in 2018 initiated “a two-year assessment option, called a Knowledge Check-In (KCI), for many physicians to provide them with more convenience in meeting the assessment requirement.” According to ABIM, “KCIs take about three hours, and include access to UpToDate® during the exam.” Nephrologists who choose “KCI can take it in either a test center or online, such as from their home or workplace,” ABIM stated.

In its draft report issued in December 2018, ABMS’s Vision Commission made 15 recommendations (https://visioninitiative.org/). The report received about 2000 comment letters, with the two draft recommendations relating to Parts 3 and 4 of MOC receiving the most attention:

  • “Continuing certification status should not be withdrawn solely due to substandard performance on a single, infrequent, point-in-time assessment.”
  • “Practice improvement is an important part of continuing certification programs.”
     

Responding to the draft report and recommendations, ASN (https://www.asn-online.org/education/moc/) agreed with many of the comments made by the Council of Medical Specialty Societies (CMSS)—which consists of 43 specialty societies, including ASN, that represent nearly 800,000 physicians—and other stakeholders. In particular, ASN and CMSS urged the commission “to propose 1) pausing the use of the high-stakes, summative examination for continuing certification and 2) suspending the practice improvement component for continuing certification.”

Highlighting that “distrust exists among some diplomates regarding ABMS and its boards,” ASN President Mark E. Rosenberg, MD, FASN, stated in the society’s comment letter that “transparency, consistency, and uniform compliance are essential to addressing this concern.” ASN “is committed to working with ABMS and its boards on a pause and suspension, proposed by CMSS (https://cmss.org/), to allow the entire physician community to reach agreement on the timeline, process, and vision for reinventing continuous certification,” Dr. Rosenberg added. He concluded that ASN “stands ready to support efforts to make continuing certification a meaningful assessment program valued by physicians.”

Matthew A. Sparks, MD, FASN—who facilitated a recent #AskASN Twitter chat hosted by Nephrology Journal Club about the commission’s draft report and recommendations—summarized the discussion as follows: “I hope to see a solution that removes the high-stakes exam, incorporates credit for things we are already doing, and makes us all better physicians without fear of losing our livelihood.”

The commission is scheduled to release its final report soon. At that time, the physician community will learn how, or if, the commission will incorporate all the feedback it received. The ABMS Board of Directors will consider the final report; if ABMS is supportive, then the 24 individual boards, including ABIM, will determine how best to move forward. Ideally, ABMS and all 24 boards will agree, as will the rest of the physician community and other stakeholders.

It’s also possible that the final report will create more disagreement within ABMS, among the boards, and across the community. Even if that happens, ASN will continue to commit its resources and expertise to support nephrologists focused on maintaining excellence in care throughout their careers.

ASN Policy Statement on Maintaining Career Excellence

  1. ASN endorses the role of the American Board of Internal Medicine—as one of the American Board of Medical Specialties’ 24 specialty boards—to provide the initial certification for nephrologists.
  2. ASN supports the lifelong learning of nephrologists through educational activities and self-assessment programs.
  3. ASN believes in the right of each nephrologist to choose a process of maintaining career excellence that affirms the values of the medical profession as well as highlights to the public her/his ability to provide high-quality care.
  4. ASN opposes efforts by entities outside the medical profession to weaken the public’s faith in the ability of the medical profession to self-regulate.
  5. ASN is committed to working for its members and their patients to:
    - Improve all aspects of the assessment of professional competence.
    - Explore innovative and more efficient approaches to ensuring nephrologists provide high-quality care for their patients.

February 2019 (Vol. 11, Number 2)