Final Vision Commission Report Addresses MOC Concerns

Transparency, Practice Improvement Still Challenged

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The final report from the American Board of Medical Specialties’ (ABMS) Continuing Board Certification: Vision for the Future Commission recommends shifting the focus of ongoing certification from high-stakes exams while still maintaining a role for ABMS’s 24 specialty boards in determining physicians’ certification status.

The final recommendations address one of the primary concerns ASN and other physicians’ organizations raised about basing a physician’s ability to continue practicing on a single high-stakes exam. Instead, it recommends ongoing formative assessments be combined with other data on a physician’s professional standing, continuing education, and practice improvement efforts in certification decisions. It also requires that boards provide physicians who fail to initially pass such assessments a pathway to meet the standards before certification is lost.

But the report may not go far enough in recognizing the role of specialty societies in lifelong learning and continuous professional development.

“ASN affirms its position that each nephrologist choose a process of maintaining career excellence that upholds the values of the medical profession and highlights to patients and the public his or her ability to provide high-quality care,” said Suzanne M. Norby, MD, FASN, chair of the ASN Continuous Professional Development Committee and a faculty member at the Mayo Clinic College of Medicine.

On March 12, 2019, ABMS announced plans to implement recommendations from the report, including creation of collaborative task forces on remediation pathways, professionalism, advancing practice, and information and data sharing. The task forces will include representatives from professional and state societies and other external stakeholders, ABMS said in its announcement.

The announcement also noted that ABMS is committed to developing new, integrated standards for continuing certification programs by 2020, and that all 24 member boards agreed to commit to longitudinal or other formative assessment strategies and to offer alternatives to the highly secure, point-in-time examinations of knowledge.

Concerns remain

Opponents of the hotly debated maintenance of certification (MOC) are disappointed with some of the final recommendations, particularly the ongoing use of MOC instead of lifetime certification for physicians and the inclusion of practice improvement data.

Some like Lu Huber, MD, PhD, FASN, of Avera Medical Group Nephrology in Sioux Falls, SD, argue ABMS should issue lifetime certifications and leave ongoing oversight to professional associations.

“The self-regulation or self-policing of our profession should only involve physician organizations,” Huber said.

But proponents say the new recommendations may stimulate innovation and ease the process of maintaining certification for nephrologists with multiple specialties. Nephrologist Jeffrey S. Berns, MD, FASN, chair of the American Board of Internal Medicine Council, said it is important to note the recommendations do not support “continuing certification based solely on continuing medical education (CME) and state licensure.” Berns is associate dean for graduate medical education and nephrology fellowship director at the University of Pennsylvania.

“It should help guide a national dialogue about how best to keep physicians engaged in productive, lifelong learning and maintaining clinical skills over time,” Berns said. “It also stresses that a key function of ABMS boards is making summative decisions about certification status and acknowledges the notion that some diplomates may lose their certification status for failure to meet established certification standards.”

MOC by any another name

Since its creation, MOC has proved divisive, as some physicians have raised concerns about the time, cost, and clinical relevance of the programs.

“Physicians feel like their livelihood is at stake every 10 years,” explained Matthew E. Sparks, MD, FASN, assistant professor and associate program director of the nephrology fellowship program at Duke University. Sparks, who hosted a recent #AskASN Twitter chat on MOC, noted the process doesn’t account for workloads, research responsibilities, or family responsibilities and that it can affect a physician’s well-being. It also doesn’t take into account the work that most physicians do daily to keep up to date, he said.

Earlier versions of the commission’s recommendations also met with some criticism from the Council of Medical Specialty Societies (CMSS) and its 43 member specialty societies, including ASN. CMSS objected to the high-stakes exams and inclusion of practice improvement efforts in MOC. In its January 15, 2019, letter to the co-chairs of the Vision Commission, CMSS stated: “Given the significant role of specialty societies in practice improvement for their members, CMSS would be pleased to work with ABMS and the member boards on a future vision for practice improvement that would be collaborative and meaningful to practicing physicians, including participation in clinical registries.”

Huber argues that ABMS has a conflict of interest, and that the value of MOC versus continuing education has not been demonstrated.

“ABMS is a proprietary organization in the business of credentialing,” Huber said. “They should not speak for educational entities, our scientific or clinical societies, our hospitals or our state medical boards. The legitimacy of ABIM in promoting more credentialing processes such as MOC is therefore questionable, and raises significant issues, including financial conflicts.”

The Vision Commission’s final report acknowledges some concerns about MOC and provides numerous recommendations that aim to address them, starting with renaming MOC.

“A new term that communicates the concept, intent, and expectations of continuing certification programs should be adopted by ABMS in order to reengage disaffected diplomates and assure the public and other stakeholders that the certificate has enduring meaning and value,” the commission wrote.

It recommends that ABMS boards engage their diplomates in practice-relevant activities on an ongoing basis instead of at intervals of every 2, 5, or 10 years. It nixes the use of high-stakes, point-in-time exams in most circumstances.

There are many questions remaining about how these recommendations would be implemented and the effects they would have.

“If the high stakes exams are eliminated, how do we ensure that the burden to physicians in an alternative system is not even more, that it allows for them to continue to take care of patients and to be a productive member of the specialty while advancing clinical medicine and science?” Sparks asked.

Addressing another concern raised by ASN and other groups, the Vision Commission also discourages hospitals, health systems, and payers from using certification status as the sole criterion for credentialing and privileging decisions.

“That’s a good statement to have,” Sparks said, although he said the recommendation could have been stronger. He also questioned what it would mean for subspecialty certifications such as that for dialysis unit directors that are currently used as a job requirement.

The Vision Commission also urges ABMS and its boards to develop “consistent processes and requirements for continuing certification that are fair, equitable, transparent, effective, and efficient. It requires the boards to make public diplomates’ certification histories.”

But the commission’s decision to keep practice improvement in the final recommendations is likely to be controversial. Many physicians were uneasy with the idea of ABMS boards using data from their practices to assess quality improvement efforts, Sparks said, noting it might duplicate other quality improvement efforts required by payers or health systems.

“Being directly involved in extracting data from a physician’s practice is considered to be taking board certification too far,” Sparks said.

Berns countered that including practice improvement as a part of certification requirements rewards the many nephrologists engaged in quality improvement and patient safety efforts, and may expand opportunities for more to participate.

Data-driven innovation

As the recommendations move on to ABMS’s member boards, the debate about the best path forward is likely to continue. Many organizations will likely develop new continuing certification approaches to replace MOC. To help determine what is most effective, the Vision Commission recommends independent research to assess ongoing certification programs.

“It seems likely that new, innovative mechanisms to maintain certification will be developed that rely on assembling information from a variety of sources and depend less on a single test,” Berns said. He noted ABIM’s Knowledge Check-In, a two-year assessment option, is already designed this way. Internal medicine and nephrology are the specialties that have thus far piloted the Knowledge Check-In, and other options are likely to follow.

One recommendation from the Vision Commission that may be particularly helpful to nephrologists states that ABMS boards should streamline the process of maintaining certification in multiple specialties, Berns noted. This would allow clinicians to earn credit for certification in multiple specialties simultaneously. Many nephrologists maintain certifications in internal medicine and nephrology, and a growing number have certifications in critical care and hospice and palliative medicine.

“I see great opportunities for ABIM to work with ASN and other societies to craft creative learning tools that really support continuous learning with regular formative feedback and directed learning targeted at filling in knowledge gaps and keeping current one’s knowledge,” Berns said.

Sparks said he would like to see more creative approaches to certification moving forward, particularly ones that leverage everyday activities physicians are already engaged in and that have data backing their effectiveness. For example, he highlighted the American Board of Anesthesiology’s Maintenance of Certification in Anesthesiology (MOCA) Minute program, which demonstrated success in a recent New England Journal of Medicine article. The program asks anesthesiologists to answer 30 multiple-choice questions relevant to their specific scope of practice each quarter. Physicians have one minute to answer each question and receive immediate feedback on incorrect answers as well as information on relevant continuing educational offerings.

“I’d like to see ABMS take these recommendations to heart and make the changes that need to be made,” Sparks said. This should include ending high-stakes exams, implementing a fair remediation process, and developing a more thoughtful process for dual or triple certified physicians, he said.

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