Maintenance of Certification Current Status and future considerations, Study notes of Health sciences

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(eds.), The ASCRS Textbook of Colon and Rectal Surgery, DOI 10.1007/978-3-319-25970-3_70 Key Concepts • Approximately 6–12 % of physicians “fail to meet profes- sional standards of practice” as defi ned by def i cits in knowledge, disruptive behavior, systems problems impeding physicians’ care of patients, increasing physi- cian age, problems unrelated to medical care (i.e., licen- sure issues or allegations of insurance fraud), physical illness, psychiatric illness, and substance abuse. • The American Board of Colon and Rectal Surgery (ABCRS) ended time-unlimited certifi cates in 1989, and began issuing certifi cates that required diplomates in Colon and Rectal Surgery to pass a secure “recertifi ca- tion” examination every 10 years intended to demonstrate continued mastery of content suffi cient for specialty practice. • Parts I (maintenance of unrestricted license and good pro- fessional standing), II (lifelong learning and self- assessment), and IV (practice performance assessment and improvement) of the Maintenance of Certifi cation (MOC) were designed to run concurrently in repeating 3 to 5 year cycles, with successful performance on the Part III secure specialty examination required at or about every 10 years to maintain specialty certifi cation. • Part II and Part IV of MOC continue to evolve, with Part II requiring a defi ned number of CME credits that incor- porate a self-assessment activity, which physicians have to pass with a 75 % correct grade. • ABCRS’ Part II of MOC self-assessment requirement may be satisfi ed with, among other activities, completion of the Colon and Rectal Self-Assessment Program (CARSEP) every 3 years, or completion of the Surgical Education and Self-Assessment Program (SESAP), a product of the American Board of Surgery (ABS). • Part III of MOC consists of the secure high stakes exami- nation designed to assess broad knowledge of the spe- cialty (previously the “recertifi cation” exam). • ABMS and member Boards continue to receive criticism regarding the fi nancial and time burden of MOC require- ments, redundancy with other professional and regulatory requirements, and most especially lack of relevance to physicians’ practices and an absence of proof that MOC produces improved patient outcomes. Rules are not necessarily sacred; principles are. — Franklin Delano Roosevelt Introduction: How We Came To Be Here Evaluation of the literature dealing with medical error shows three major potential sources: healthcare delivery systems, insurer practices, and individual practitioners at various levels— physicians, nurses, pharmacists, and other healthcare workers [ 1 ]. The physician remains the single most identifi able individ- ual in the healthcare system—the individual who directs and coordinates the activities of nurses, pharmacists, and other healthcare workers according to the plan of care. However, exponential growth of innovation in technology, pharmacology, and new scientifi c knowledge has produced a medical care sys- tem that is far more complex than ever before, and many dis- crete parts of the whole must interact smoothly to deliver healthcare that is safe, timely, and cost- effective. Within the complexity of the modern healthcare system, physicians have recognized a gradual but progressive diffusion of autonomy affecting decisions regarding patient care. At the same time, physicians are increasingly required to accept responsibility for an ever-expanding volume of practices and regulations that take time away from patient care activities, are often frustratingly redundant, and produce little or no demonstrated improvement in healthcare delivery or patient outcomes. In general, physicians are highly educated individuals who are well used to self-directed learning as well as assessment of their knowledge and performance, having successfully 70 Maintenance of Certification: Current Status and Future Considerations Jan Rakinic and W. Donald Buie 1230 progressed through college, medical school, residency, and often fellowship training—mastering the high stakes exami- nations at each level. The vast majority go on to perform successfully on the rigorous secure cognitive Board certifi ca- tion examination in their chosen specialty. Some boards have additional requirements for certifi cation, such as oral exami- nations, medical record audits or case log reviews, or obser- vation of the candidate’s performance with standardized or real patients [ 2 ]. As physicians progress through their profes- sional careers, each has pursued ongoing educational activi- ties guided by personal assessment of his or her own relative defi cits or needs related to individual practice patterns. Over time, documentation of continuing medical education (CME) credit accrual has been increasingly required by the hospital or health system at which each physician practices. Board certifi cation initially had no expiration date. In the 1980s, the American Board of Medical Specialties ( ABMS ) , the umbrella organization for the 24 member specialty boards that certify physicians trained in ACGME-approved training programs, signaled that lifelong certifi cation with- out demonstration of ongoing mastery was no longer suffi - cient to assure the public that physicians were maintaining clinical competence and continuing to provide high quality care throughout their career. Specialty boards responded in part by no longer issuing certifi cates without expiration dates. The American Board of Colon and Rectal Surgery (ABCRS) ended the process of issuing time-unlimited cer- tifi cates in 1989, and began issuing certifi cates that required diplomates in Colon and Rectal Surgery to pass a secure “recertifi cation” examination every 10 years intended to demonstrate continued mastery of content suffi cient for spe- cialty practice. Ongoing self-directed learning continued as before, with individual physicians selecting learning activi- ties based on their assessment of their own needs. In 2000, ABMS adopted Maintenance of Certifi cation (MOC) as a policy with general standards for its member Boards (Table 70-1 ). Parts I, II, and IV were designed to run concurrently in repeating 3-year cycles, with successful per- formance on the Part III secure specialty examination required at or about every 10 years to maintain specialty cer- tifi cation. Institution of MOC was based on empiric data interpreted to determine that such a program was necessary for physicians to prove to the public that they maintained mastery of specialty content [ 3 ]. Between 2000 and 2009, ABMS and its member Boards had many discussions regard- ing the shape that Part II, Lifelong Learning and Self- Assessment, and Part IV, Practice Performance Assessment and Improvement , might take. Some stakeholders encour- aged immediate increased rigor with regard to MOC stan- dards and proof of physician engagement in MOC. However, few additional requirements were presented to individual diplomates for maintaining board certifi cation at that time. In 2009, the pace of MOC accelerated, with the process intended to be more continuous than episodic, with partici- pation required on a more regular basis. The American Board of Emergency Medicine (ABEM) , American Board of Internal Medicine (ABIM) , and the American Board of Pediatrics (ABP) moved toward requiring active MOC par- ticipation every 2 years [ 4 ]. It was made clear that ABMS expected Part II of MOC to include a defi ned number of CME credits that incorporated a self-assessment activity, which the physician had to pass with a 75 % correct grade. Importantly, while the concepts contained in the four parts of the MOC program were not new to physicians, the specifi c- ity set forth by ABMS raised a new set of challenges for practicing physicians and member Boards. The Reasoning and Evidence for Institution of the ABMS MOC Program Hawkins et al. authored a monograph explaining the theory and evidence that supported the concept and framework for the ABMS MOC program [ 3 ], stating that development of the evidence base in support of MOC is “conceptually simi- lar to validation of an assessment method and involves two related, sequential processes”. First, empiric data should determine that such a program is necessary; second, devel- opers of the program should collect evidence to see if the program is performing as it should, and use this evidence to guide continued improvement. The next several sections dis- cuss the MOC program in its current iteration and the data considered to support its institution. However, evidence regarding whether the program is exerting the desired effect remains controversial. Central to the data cited in support of the need for the MOC program are estimates that 6–12 % of physicians “fail to meet professional standards of practice” [ 5 ]. These include def i cits in knowledge [ 6 ], disruptive behavior (though this data suffers from a low survey response rate) [ 5 ], systems problems impeding physicians’ care of patients [ 7 ], increas- ing physician age [ 6 ], problems unrelated to medical care (such as licensure issues or allegations of insurance fraud) [ 8 ], physical illness, psychiatric illness [ 9 ], and substance abuse [ 10 ]. A 2009 study which used surveys, focus groups, and in-depth interviews with physicians in practice and TABLE 70-1. ABMS MOC program The ABMS program for maintenance of certifi cation has four separate parts • Part 1: Licensure and professional standing. Diplomates are required to hold a valid unrestricted medical license in at least one state or jurisdiction in the USA, its territories, or Canada • Part 2: Lifelong learning and self-assessment. Physicians participate in educational programs that meet specialty-specifi c standards set by their certifying board and that include a self-assessment component • Part 3: Cognitive expertise. Physicians must pass a high stakes exam to show they possess fundamental practice related knowledge to provide quality care in their specialty • Part 4: Practice performance assessment and improvement . Physicians compare their outcomes with peers and national benchmarks ABMS American Board of Medical Specialties J. Rakinic and W.D. Buie 1233 that require more nuanced solutions. Nevertheless, pass rates for MOC exams are high, as would be expected when testing a group of experts. Noting the high pass rates, some in ABMS adopted the stance that an examination that the majority of test-takers passed was a poor measure of continued content mastery, despite the fact that all examinees were by defi nition a highly educated and trained group of experts well versed in the majority of the content to be tested. Most member Boards did not share this view, expressing confi dence in their MOC examinations’ content and security. Interestingly, the fi rst- time failure rate on the American Board of Internal Medicine’s (ABIM) MOC exam has increased from 10 to 22 % over the past 5 years [ 26 ], with ABIM diplomates voicing a belief that the examination was being made intentionally harder to pass. While most candidates successfully passed the exam on retaking it, there was a great deal of consternation, increased costs, and more time away from active practice among diplo- mates who had not passed initially. Evidence linking successful completion of the MOC exam with improved practice or patient outcomes is largely lack- ing. One study of ABIM diplomates showed that physicians who scored in the top quartile of the ABIM MOC exam were more likely to perform processes of care for diabetes and mammography screening than physicians who scored in the lowest quartile; however, no difference was seen for lipid testing in cardiovascular disease [ 27 ]. A study evaluating data from ABIM and ABS showed similar fi ndings for sur- geons and internists: those most likely to pass the MOC exam were younger, had higher scores on the initial certifi ca- tion exam, were in group (not solo) practice, and were US graduates. However, aside from performance on initial certi- fi cation exam, the observed effects were small [ 28 ]. On the other hand, a study of ABFM diplomates showed that family physicians who maintained certifi cation performed better on the MOC exam than recent graduates, with scores reaching their highest point 28–31 years after a diplomate’s initial cer- tifi cation. Multiple comparison analyses confi rmed the trend was signifi cant; however, sub-analysis showed that while the trend remained signifi cant for US medical graduates, it did not for international medical graduates. Family physicians who did not maintain certifi cation performed signifi cantly worse on the MOC exam than recent graduates [ 29 ]. In sum- mary, although the individual and system variables that infl uence scoring on the MOC examination have been identi- fi ed, there is limited evidence that higher scores on the exam- ination are associated with higher quality patient care. Part IV, Practice Performance Assessment and Improvement, has been the most diffi cult part of MOC to address in a way both meaningful to diplomates and also not overly burdensome. As with Part II activities, individual Boards were at fi rst allowed considerable latitude in the activities each Board would accept for Part IV. For this rea- son, fulfi llment of Part IV was initially attainable without undue burden for most ABCRS diplomates , since participa- tion in NSQIP, SCIP, and a number of other regional and national databases and registries widely available in medical centers was considered acceptable (Table 70-3 ). An initial requirement for each diplomate to include patient satisfac- tion surveys in Part IV activities was placed on hold after ABMS received feedback from member Boards communi- cating concern over undue burden for diplomates in execut- ing these as prescribed, as well as implications regarding data interpretation. However, advocates of a more stringent defi nition for Part IV activities have recently gained ground at ABMS, culminating in a new plan for Part IV activities that pursue reportable improvement of individual physician outcomes data. These activities would require diplomate par- ticipation in quality improvement activities endorsed by an ABMS-approved body, along with accurate documentation of substantial participation in aspects of project design as well as execution. This degree of specifi city departs sharply from improvement activities already in wide use (such as Morbidity and Mortality Conference, and multidisciplinary disease management or service line conferences) with respect to acceptable activity structure, type and form of reported outcomes, and degree of individual participation in activity development and direction. There is considerable concern among member Boards that such requirements would pose a signifi cant burden for a large fraction of diplo- mates. Quality outcomes are dependent on a number of dis- crete factors, many of which are outside the control of an individual physician. Few diplomates in active medical prac- tice have had formal training in the methods of designing and executing a quality improvement and assessment proj- ect. Many well-designed quality improvement projects enfold a number of stakeholders that must interact to pro- duce the desired outcome, and may require years for matura- tion of data. From the diplomates’ point of view, the time and effort that would be expended in design and participation in TABLE 70-3. Registry participation accepted by ABCRS for Part IV MOC credit • ACS surgeon specifi c case log system (with tracking of 30-day complications) https://www.facs.org/quality-programs/ssr • Cancer quality improvement program (CQIP) • Florida surgical care initiative • Hospital consumer assessment of healthcare providers and systems (HCAHPS) • Mayo clinic • Michigan surgical quality collaborative (MSQC) • National cancer database (NCDB) • National surgical quality improvement program ACS (NSCIP) • Ongoing professional practice evaluation (OPPE) • Piedmont society program • Press Ganey • Surgical care and outcomes assessment program (SCOAP) (Washington State) • Surgical care improvement project (SCIP) • University health system consortium (UHC) • VHA surgical quality improvement program (VASQIP) ABCRS American Board of Colon and Rectal Surgeons, MOC maintenance of certifi cation 70. Maintenance of Certifi cation: Current Status and Future Considerations 1234 these studies represents an additional unfunded mandate, in addition to less time available for patient care activities that could impact compensation for many. ABMS has recently begun consideration of “group” or “team” MOC initiatives, chiefl y as Part IV activities, in a nod to the recognition that many of the challenges posed to practitioners are systems or team based. Design of such activities has barely begun; con- sideration of how to execute and monitor these activities remains to be seen. ABMS has set up a Multi-Specialty Portfolio Approval Program, dealing with quality projects that may be eligible for Part IV credit. The Portfolio Project began in 2009 as the “Primary Care Board QI Approval Pilot” with Mayo Clinic as the fi rst “Pilot Portfolio Sponsor.” The Portfolio Program sub- sequently became part of ABMS in 2014. The Portfolio Program does not produce quality improvement (QI) projects, but reviews proposals from outside sources, and grants approval (or not) for ABMS MOC Part IV credit for partici- pating diplomates. Potential benefi ts for Portfolio Sponsors (i.e., medical schools, hospitals, medical groups, healthcare consortiums, and the like) include having diplomates in their organization receive MOC Part IV credit for current QI initia- tives that originate in the home institution (after a favorable review by the Portfolio Project), and reduced time and effort for approval of QI projects applicable to diplomates in several specialties compared to applying to several Member Boards for project approval. The potential benefi ts for Member Boards would principally be a route for awarding ABMS MOC Part IV credit to diplomates for QI projects that receive a favorable review by the Portfolio Project, and potentially using the Portfolio Project as a more granular way to track the QI efforts of diplomates. The Portfolio Project has publicized that upwards of 6500 physicians, less than 2 % of American physi- cians currently meeting MOC requirements, have received MOC Part IV credit through projects vetted by the Portfolio Project. The cost for application and initial 2-year participa- tion in the project has recently been raised to $7500. The Portfolio Program is only one pathway for physicians to obtain MOC Part IV credit; individual Boards offer a variety of other pathways for physicians to receive MOC Part IV credit. Challenges Presented to Diplomates Physicians remain committed to lifelong learning and improvement in practice. However, MOC has received at best a lukewarm response from individual diplomates; there are many reasons. ABMS and member Boards continue to receive criticism regarding the fi nancial and time burden of MOC requirements, redundancy with other professional and regula- tory requirements, and most especially lack of relevance to physicians’ practices and an absence of proof that MOC pro- duces improved patient outcomes. Approximately 375,000 board-certifi ed physicians (about half the number that the 24 ABMS member boards certifi ed initially) currently meet MOC requirements, according to ABMS [ 30 ]. However, as of 2012, 74 % of ABIM diplomates waited until the 9th year of their 10-year cycle before taking action to recertify [ 4 ]. Results of a survey of Oregon physicians showed that 91 % of respondents were board-certifi ed; 95 % of those with time- limited certifi cates planned to recertify. However, they reported that their practice groups provided few to no resources for participation in the MOC process [ 31 ]. A study utilizing data from ABIM diplomates initially certifi ed between 1990 and 1999 showed that physicians who partici- pated in MOC tended to have higher initial certifi cation scores, were younger, were US graduates, practiced as sub- specialists and in the Midwest, worked in nonsolo practices, or were employed in counties with less than 20 % of persons in poverty [ 32 ]. A mail survey of 1693 pediatric diplomates with time-unlimited certifi cates had a response rate of 77 %, and found that while only one-quarter of generalists and 13 % of subspecialists agreed they would be willing to participate in general pediatrics MOC, fully half of the subspecialists would be willing to participate in subspecialty MOC, high- lighting the importance of MOC relevance to one’s practice. Three-fourths of both generalists and subspecialists did not agree that MOC was necessary for keeping up to date in clinical pediatrics [ 15 ]. The perception of MOC’s lack of relevance to current practice is most often raised by subspe- cialty practitioners [15; personal communications.] Physicians with fewer resources to devote to the MOC process (lack of practice support for MOC; solo practice; or practice in areas of poverty) appear to be those most at risk for non-participation, and therefore, for loss of board- certifi ed status [ 32 ]. Physicians in solo practice, international graduates, and physicians with a higher percentage of poor patients all do worse on MOC exams [ 32 ]. A study of sur- geons taking the MOC examination in 2008 showed that increased levels of peer interaction were associated with a higher score and a higher likelihood of passing the exam. Physicians in solo practice had fewer peer interactions, received lower scores, and were less likely to pass the exam. However, solo practitioners with high levels of peer interac- tion performed as well as those in group practice [ 33 ]. A study of ABIM diplomates showed that more frequent use of electronic resources was associated with modestly enhanced MOC exam performance. The authors also noted that physi- cians involved in residency education clinics and hospital inpatient practices had higher MOC exam scores than physi- cians working in private practice settings [ 34 ]; perhaps, this is related to more frequent peer interactions. A survey of American Board of Anesthesia (ABA) diplomates found that the majority perceived board certifi cation to be of value in demonstrating competence. However, the elements of Part I, Professional Standing, and Part II, Lifelong Learning and Self-Assessment, were perceived as signifi cantly more rele- vant to practice than Part III, the Cognitive Exam, or Part IV, Practice Performance Assessment and Improvement activi- ties. ABA diplomates expressed concerns about the cost and J. Rakinic and W.D. Buie 1235 complexity of MOC, a lack of evidence that MOC improves practice, and a belief that the Cognitive Exam covered topics not relevant to their current practice [ 30 , 35 ]. Other frequent critiques of the MOC program as currently designed include a lack of assessment of appropriateness of care, and insuffi - cient system-based evaluation [ 36 ]. Challenges for Member Boards The MOC standards are intended to apply equally to all mem- ber Boards regardless of Board size, available resources, or specialty. This presents several diffi culties, the most obvious being that of an unfunded mandate. Compliance with the standards requires signifi cantly more work by each Board’s support staff. Some of the subspecialty Boards have staffs as small as four full-time employees, and strategies to meet the need for the increased administrative workload are still being determined. Many Boards also recognized a need for website expansion to provide newly mandated diplomate services, as well as to house the growing body of data requiring storage as well. Website and server expansion is dependent on funds suffi cient to support the desired capacity. The function and mission of Boards is the certifi cation of specialty diplomates and related activities; fees for certifi cation-related activities and the occasional bequest have historically been the fi nan- cial foundation of most Boards, with Board resources there- fore having a direct relationship to the size of the diplomate pool. However, Boards by defi nition have a fi nite and closed membership comprised of their diplomates; no drives can be held to gain new members. As a direct result of the increased administrative and website workload which are expected to be ongoing requirements, most of the ABMS member Boards felt there was no option other than to levy MOC fees to sup- port this unfunded mandate. In the lay press, charges have been leveled at ABMS and its member boards that MOC exists largely as a revenue-raising tool. Costs for the 10-year MOC cycle range from $1250 (ABS) to $4280 (American Board of Plastic Surgery, or ABPS). Of ABIM’s total revenue of $49 million in fi scal year ending June 2012, 62 % was derived from certifi cation fees and 36 % from MOC fees [ 30 ]. In early February 2015, ABIM responded to a stream of continued strong criticism from its diplomates regarding the MOC program and suspended the Practice Assessment, Patient Voice and Patient Safety requirements (Part IV) for at least 2 years, changed the language used to publicly report a diplomate’s MOC status on its website from “meeting MOC requirements” to “participating in MOC,” and made plans to update the Internal Medicine MOC exam to better refl ect what ABIM general internists are doing in practice with plans to do so in subspecialties as well. The ABIM also rolled MOC fees back to 2014 levels with a commitment to keep them at that level until at least 2017, and affi rmed a plan to recognize most forms of Accreditation Council for Continuing Medical Education (ACCME)-approved CME for demonstration of self-assessment of medical knowledge. Many ABMS member Boards have also chosen this time to enact a moratorium on new MOC requirements, and are opening dialogues with diplomates to better assess their needs, with more user-friendly, meaningful, and value-added MOC programs as a goal. Decreasing the Burden of MOC Cook et al. proposed an integrative practice-based model for MOC, allowing Part II and IV topics to emerge from and remain embedded within the local clinical practice; directly improving patient care, ensuring that needed skills are devel- oped and maintained, and providing context to stimulate knowledge retention [ 37 ]. The authors also postulated a smoother interaction for the parts of MOC: Part II learning would prepare diplomates for Part III, and might provide skills required for Part IV; Part IV could be used to defi ne learning agendas for Part II; and feedback on Part III would also inform Part II learning agendas. ABMS recently incor- porated this last suggestion into the MOC program with an expectation that diplomates receive feedback regarding per- formance on the MOC exam to help guide their individual learning and self-assessment activities in the next cycle. It is clear that some form of individual evaluation will remain a part of the MOC process. The ABMS held a sympo- sium for its member boards in June 2014 to discuss the future of Part III. Some boards have instituted novel approaches to Part III that seem to better serve the needs of their diplomates. In Plastic Surgery, for example, diplomates complete a core section for Part III and then choose their remaining test mate- rial from three of four defi ned subspecialty areas. As of 2014, the American Board of Anesthesiology began a pilot project to revamp Part III called the “MOCA minute”. The program consisted of a continuous dynamic web-based assessment with focused content to assess knowledge and guide the dip- lomat to appropriate resources. Questions were sent out on a weekly basis and answered on line by the diplomate, who received immediate feedback in the form of the correct answer, a full critique, key points, and references. The pilot was very successful and was integrated into MOCA Part III as of January 2015. Progress will be monitored by the program; each individual will receive immediate reports on their own performance broken down by topic area to allow them to tai- lor their own MOC program accordingly. There have been initiatives external to ABMS that may work to reduce the burden of MOC for individual diplomates and improve compliance. The AMA House of Delegates passed a resolution in June 2013 to determine if periodic secure recertifi cation examination is needed, and to explore alternatives [ 38 ]. Evidence supporting alternatives to secure closed-book exams as proof of specialty knowledge content exists as far back as 1996, when Norcini et al. showed that an open book web-based recertifi cation exam was as reliable as 70. Maintenance of Certifi cation: Current Status and Future Considerations