Has Momentum for Changes in MOC Shifted to Exam Boards?

Eric Seaborg
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As physicians and state medical societies continue to revolt against high-stakes maintenance of certification (MOC) tests and increased MOC requirements, more state legislatures have considered legislation to limit the use of MOC in professional requirements. This year, Tennessee and South Carolina became the fourth and fifth states to pass legislation restricting the use of MOC in areas such as licensure, reimbursement, employment, malpractice insurance, and insurance panel participation.

Legislation in more than a dozen other states died or languished in committee as the nexus for change may have shifted to the American Board of Medical Specialties (ABMS) and individual specialty boards, which are promising significant change.

“The leadership of the American Board of Internal Medicine has heard clearly that it must change,” according to Jeffrey S. Berns, MD, chair of ABIM’s nephrology board. ABIM will begin offering nephrologists and internists the option of replacing the 10-year test with an open-book every-two-year test in 2018.

And ABMS has announced a collaborative re-evaluation called the Vision Initiative commission, with the task “to provide a set of recommendations about the future of continuing board certification for consideration by ABMS.”

Rebellion brews at AMA

The movement for change has been building for years, according to Donald J. Palmisano Jr., JD, executive director and CEO of the Medical Society of Georgia, which successfully pushed for MOC-limiting legislation last year.

“The physicians had reached their limits with the high-stakes exam, and they felt frustrated by the fact that nobody was really listening to them. They had complained to their boards and their boards were not responding,” Palmisano said. “The physicians themselves got active and got their message across, and the boards are responding now. They understand that there are some challenges and they are trying to fix them.”

Palmisano said that one turning point came at last year’s American Medical Association (AMA) meeting when the CEOs of the American College of Obstetricians and Gynecologists and the American Academy of Neurology suggested that state medical societies and national specialty societies should work together toward reform to avoid creation of a patchwork of state laws regulating MOC. Their organizing led 41 state medical societies and 33 national medical specialty societies to send a letter on August 18, 2017, to ABMS stating that “concerns regarding the usefulness of the high-stakes exam, the exorbitant costs of the MOC process, and the lack of transparent communication from the certifying boards have led to damaging the MOC brand” and a “crisis” that needed to be addressed.

The letter proposed a meeting of the leadership of ABMS certifying boards, national medical specialty societies, and state medical societies on Dec. 4, 2017, the day before the ABMS and Council of Medical Specialty Societies dyad meeting in Illinois. A summary of that meeting noted that representatives from state medical societies “articulated the anger and distrust of physicians about the boards and a shared perception that the boards are dominated by academics and executives who have lost touch with the needs of the community physician.”

ABMS envisions changes

During the meeting, Lois Margaret Nora, MD, JD, MBA, then the president and CEO of ABMS, called upon the state medical societies “to hold back on further legislative action to professional self-regulation, allow the boards to work within the profession to make positive and appropriate change, and to eliminate unintended consequences including public confusion and loss of faith in the profession.” She announced the recently launched “Continuing Board Certification: Vision for the Future” initiative as an opportunity to involve state medical societies and other stakeholders in envisioning a revamped MOC process.

The initiative will be led by a 34-member commission that includes physicians and representatives of “professional medical organizations, national specialty and state medical societies, hospitals and health systems, the general public and patients, and the 24 member boards of ABMS,” according to the initiative’s website. At its first gathering, a two-day meeting in March 2018, “Commission members heard testimony on continuing certification from a wide range of stakeholders from the medical profession, including practicing physicians, ABMS member boards, medical associations and professional societies, as well as those representing the public perspective.”

The commission will hold four such meetings around the country before releasing a draft report for comment in November 2018, with final recommendations due to ABMS in February 2019.

Some specialty society leaders at the December meeting expressed suspicion that the commission could be a delaying tactic. But the Medical Society of Georgia’s Palmisano—who was selected to be a member of the commission and attended its first meeting—said he is “cautiously optimistic that the concerns of the physicians are going to be addressed.”

Checking in with nephrology

ABMS has said that all its boards are already implementing changes to “make their programs more convenient, supportive, relevant, and cost-effective,” and this includes ABIM, which is introducing an option to replace the 10-year exam. Internal medicine and nephrology will be the first specialty and subspecialty to be offered this shorter test option, called the Knowledge Check-In, beginning in 2018.

The Knowledge Check-In can be taken every two years; can be taken at home, work, or a test center; is an open book test, using UpToDate® as the permitted reference; and is offered four to six times a year. It is much shorter than the 10-year test, lasting three hours at most. A failed exam will not lead to loss of certification. Physicians will be able to take the test again two years later.

“The two-year Knowledge Check-In should be lower stress and certainly lower stakes, because you cannot lose your board certification by not doing well on one of these,” Berns said. He said that the nephrology board has been working on adjusting its exam blueprint and honing the relevance of its questions for years. “Nephrology is actually fortunate … to be the first subspecialty to be included in the Knowledge Check-In. It is because we had such a good exam pool, both in terms of quality and numbers of questions that could be rolled into this new format.”

But the approach is still a summative, pass-or-fail test rather than a formative process more aimed at learning, according to Charles Cutler, MD, an internist and former president of the Pennsylvania Medical Society, who has been a critic of ABMS’ MOC system. Cutler has also been appointed to the Vision Initiative commission.

Anesthesiologists lead the way

Cutler and other reformers often cite the American Board of Anesthesiology for successfully introducing a formative process by dropping its every-10-years recertification test and replacing it with regular online tests and learning modules called the MOCA (Maintenance of Certification in Anesthesiology) Minute. “MOCA Minute allows you to continuously assess your knowledge, fill knowledge gaps and demonstrate your proficiency,” according to the board’s website. The process is ongoing, with participants required to answer 30 questions each quarter of the year.

“The American Board of Anesthesiology polled their diplomates and asked whether they like this system or the test. Some 80 or 85% of the doctors said, ‘We like this new system. You are making us better with this,’” Cutler said.

Jin Soo Kim, ASN senior director of education, agrees that the Knowledge Check-In in its current form is a high-stakes, summative approach that does not fully address ASN’s concerns. ABIM is working with three of the larger specialty societies to develop alternatives to the summative exam, but has not yet offered the same opportunity to smaller societies.

Cutler said he has been told by the leadership of other boards that they are “moving away from a summative process and going to a sequential formative process of identifying gaps in physicians’ knowledge and filling in those gaps.”

Kim also noted that many nephrologists have a specific focus, such as interventional nephrology, but the nephrology MOC exams cover the entire field, which will contain many questions not relevant to their practices. In contrast, cardiologists, for example, can choose among exams focusing on five subspecialties. “We’ve been told that ABIM is open to exploring modularity in the future,” she said.

Kim said that although the test will be open-book, UpToDate® will be the only resource currently, despite the fact that specialty societies offer resources such as ASN’s Kidney Self-Assessment Program (KSAP). ABIM has indicated that this limitation has to do with technical issues and costs, but is open to adding more resources in the future.

Legislative efforts continue

Many state medical societies and legislators remain dissatisfied with the pace of change. According to a compilation from ABMS, 17 bills introduced or pending in state legislatures prohibit the state licensing board from requiring MOC for licensure, 16 prohibit use of MOC by health plans for reimbursement, and 15 prohibit requiring physicians to participate in MOC for hospital privileges, credentialing, reimbursement, and employment. The great majority of this legislation died or is languishing in committee.

ABMS has put resources into fighting the legislation on the grounds that it undermines the traditional professional commitment to self-regulation, the standards for specialty certification, and public confidence in ABMS board certification.

Even proponents of the legislation acknowledge their hesitation about involving the government in physician self-regulation. Frank McDonald Jr., MD, MBA, a neurologist who is president of the Medical Association of Georgia, said that it is a “slippery slope” to get the state government involved in physicians’ affairs, but his association turned to the legislature because the membership was “very frustrated” by the specialty boards adding requirements to MOC without listening to physicians’ concerns.

“Everywhere I go, I talk about what the Medical Association of Georgia is doing,” CEO Palmisano said. “This is one issue that unites physicians across the board. Everybody in the country is feeling the same way, that physicians weren’t being listened to. Even the ones that have had a good experience with their board and their MOC still get concerned that it could maybe go in a bad direction at one point. They want to make sure that doesn’t happen.”