ABIM Releases New “Blueprint” for Maintenance of Certification Exam

Based on input from more than 400 nephrologists, the American Board of Internal Medicine (ABIM) revised the specifications for its maintenance of certification (MOC) exam. Effective for the fall 2016 exams, the changes are more of a recalibration of attention to certain topics than a significant shift of focus.

“The previous MOC exam blueprint was set primarily by the exam committee based on their best estimate of what was seen by the ‘typical’ nephrologist,” said Jeffrey S. Berns, MD, FASN, chair of the ABIM nephrology board. The exam outline, or “blueprint,” was updated “in response to information from a large group of diverse nephrologists regarding what they saw frequently in practice and what they thought was important for the practicing nephrologist to know even if not seen frequently.”

ABIM board-certified nephrologists were asked to fill out a detailed survey rating the frequency and importance of a large variety of conditions and topics in their practices. The ABIM committee also determined the relative frequency of patient conditions by analyzing documented national health care data, such as that of Medicare patients.

Berns said that the comment process revealed that the previous blueprint was not far off the mark, so the changes in the percentages of questions on certain topics are not great. The 10 subject areas remain the same.

“The new blueprint increases the percentage of the MOC exam questions in the content area of chronic kidney disease (from 20% to 23%) and acute kidney injury/ICU nephrology (from 14% to 15%). There are small decreases in the percentage of questions related to acid-base and potassium disorders, glomerular and vascular disorders, and pharmacology,” said Berns, who is professor of medicine and pediatrics at the University of Pennsylvania.

Survey participants were also asked to rate topics on a three-point scale of low, medium, and high importance. “The new MOC exam will have no questions on topics of low importance, no more than 25% will be on topics of medium importance, and at least 75% will be on topics of high importance,” Berns said.

ABIM began the revision process because of feedback from physicians that MOC assessments should better reflect what they see in practice. The revision “is part of the larger effort by the ABIM to modify the current MOC process and make it more relevant to practicing nephrologists,” according to Mark Perazella, MD, FASN, professor of medicine at Yale University school of medicine who served a six-year term on the ABIM nephrology exam committee that ended in 2013. He helped design the former MOC blueprint (the one that was revised), but was not involved in this new redesign. “The blueprint represents a roadmap that diplomates can use to focus their attention when preparing for the MOC exam,” he said.

Designing a good roadmap and exam is a careful balancing act, according to Melanie Hoenig, MD, an assistant professor at Harvard Medical School who heads the ASN Kidney Self-Assessment Program: “If rare diagnoses are not considered at all, individuals studying for the certification exam may limit their studies and avoid consideration of these topics. This has the potential to result in an inability to recognize clinical syndromes which represent rare diseases. The blueprint does not appear to exclude rare disorders, but instead seems to seek to reassure participants that the rare disorders will represent a small percentage of the examination. In addition, the emphasis is on the recognition—diagnosis and testing—rather than items easily identified with a Google search, such as epidemiology of rare conditions and prognosis.”

“The new blueprint has the potential to be more practical and allow the traditional ‘zebras’ to receive less attention. For example, topics considered of ‘low importance’ in the blueprint will not be on the examination. There are very few topics in this category, but examinees can be certain that there will be no questions on the pathophysiology of Fabry’s disease (though there could be a question on diagnosis) and no questions regarding ‘the pathophysiology of desensitization’ in the setting of a renal transplant,” Hoenig said.

According to the ABIM website, the more than 400 nephrologists who contributed to the survey with topic ratings provided a representative sample of nephrologists in terms of age, gender, time spent in direct patient care, and geographic region. In rating the importance of conditions, they considered factors that included the risk of a significant adverse outcome; cost of care and stewardship of resources; common errors in diagnosis or management; effect on population health; effect on quality of life; and when failure to intervene could deprive a patient of significant benefit.

The overall structure of the exam is unchanged. It is composed of 240 single-best-answer multiple-choice questions, of which a small number are new questions being tested for use in future exams that do not count in the examinee’s score.

Although many ASN members participated, ASN did not participate formally in the revision of the blueprint. A full explanation of the new roadmap can be found at http://www.abim.org/∼/media/ABIM%20Public/Files/pdf/exam-blueprints/maintenance-of-certification/nephrology.pdf.

October/November 2016  (Vol 8, Issue 10/11)