Maintenance of Certification (MOC) programs are a source of irritation and controversy in medical communities today. The American Board of Medical Specialties (ABMS), representing 24 specialty member boards, notes that prior to the 1970s, board certification of a physician provided them with lifetime credentials. These written and sometimes oral exams were designed to test for basic competence in that particular specialty. (This was analogous to medical licensure based on an individual passing the three parts of the examinations given by the National Board of Medical Examiners [NBME]. In 1992, this exam was superseded by the U.S. Medical Licensing Examination [USMLE], sponsored by the Federation of State Medical Boards [FSMB] and the [NBME]). As recognition that the science and practice of medicine underwent substantial and sometimes rapid changes over time, efforts were begun to assure that diplomates of the various specialty boards were, in fact, still competent to practice their specialties. Initially, the individual state boards of medicine required 50 to 150 hours of continuing medical education (CME) for each cycle of license renewal. Attendees at CME courses were given a Certificate of Attendance by the program sponsors, which could be used to verify individual participation. I ran a CME program for 25 years and noted that many registrants would duly sign in each morning, and then shortly leave to play golf!
The ABMS also recognized the shortcoming of the “Honor System” of CME and encouraged their member boards to begin issuing time-limited certificates. These required their diplomates to periodically recertify, usually in the form of an examination that tested the physician’s medical knowledge and cognitive skills. These recertification exams were the source of anxiety and consternation to those who had to take them. The ABMS and their member boards also realized that this approach mimicked that used for initial certification, in which the individual is tested in all aspects of the specialty. However, many practices involve super-specialization. For example, in my own field of diagnostic radiology, we have individuals who solely practice neuroimaging, musculoskeletal imaging, body imaging, etc. Orthopedists specialize in trauma, sports medicine, joint replacement, hand surgery, etc. Recertification exams needed to be oriented to this additional specialization. And so, the ABMS felt that a different approach was needed – one that evaluated not only the diplomate’s knowledge, but also their professionalism and commitment to practice improvement. Thus, the birth of MOC.
The American Board of Radiology (ABR) was one of the first to institute MOC for diplomates initially certified in Diagnostic Radiology (DR) in 2002. Prior to that time, all certificates were for life, and ABR was one of the few boards that did not have recertification in DR. (They began requiring recertification for Radiation Oncology [Radiation Therapy] in 1993). All MOC programs follow the guidelines of the ABMS which provides a four-part framework for Member Boards to use: (1) Professionalism and Professional Standing, (2) Lifelong Learning and Self-Assessment, (3) Assessment of Knowledge, Judgement and Skills (some form of formal examination) and (4) Improvement in Medical Practice. The emphasis is on professionalism – how physicians practice safely and ethically; on patient safety - reducing harm and complications; performance improvement – using the best evidence and practices for treating patients; and on judgement – assessing not only what physicians know, but what they do with that knowledge.
Each member board sets its own guidelines for compliance. Parts 1,2 and 4 are similar for all specialties. Professionalism and Professional Standing requires a valid and unrestricted license in all states of practice. Lifelong Learning and Self-Assessment requires a minimum of 75 Category 1 CME in the previous three years. (Most states require 50 hours yearly for licensure.) The ABR further requires that at least 25 of those Category 1 hours be self-assessment. Improvement in Medical Practice requires the individual to complete at least one Practice Quality Improvement (PQI) project in the previous three years.
Where the specialties diverge is in Part 3, Assessment of Knowledge, Judgement and Skill. Most specialties have some form of written or oral exam every five to 10 years. The ABR abandoned this examination in 2017 with the institution of their Online Longitudinal Assessment (OLA). Under this program, diplomates create a practice profile of the areas that most closely fit what they do in practice. They will be given two question opportunities online each week, relevant to their selected practice profile. Questions are oriented toward the daily practice of the diplomate, focusing on entities the individual would likely encounter daily rather than on esoterica. (I can personally attest to the practical aspect of these questions, since I wrote them for the ABR for many years.) Diplomates have a limited amount of time to answer the question and they immediately learn whether they answered correctly. In addition, they receive a brief discussion of the correct answer as well as one or more references. This program is designed to have minimal impact on the diplomate’s workday and requires no time away from work or travel expense. Further, there is the potential for retesting areas of weakness.
Naturally, since MOC compliance can potentially affect hospital credentialing, reimbursement from insurers, as well as state licensure, MOC has encountered opponents and resistance. Some claim that there are no high-quality data to support that MOC improves medical care. Others have noted the costs (the ABR charges $340 each year). One of the more outspoken groups is the National Board of Physicians and Surgeons (NBPAS), an “alternative certifying body.” NBPAS claims that they are low cost and they do not require an intensive recertification process. “Certification” by NBPAS requires applicants to be gradates of an accredited school of medicine or osteopathy, be certified by one of the member boards of ABMS, hold an unrestricted medical license and obtain 50 hours of CME annually. They advocate ending the high-stakes examination components of MOC, an end to requiring Quality Initiative/Practice Improvement components of MOC, a reduction in fees charged for MOC, but retention of the Professionalism (licensure) and CME components of MOC. NBPAS has made inroads in having their “diplomates” gain credentialing in hospitals.
The ABMS has not been idle during the controversy over MOC. In December 2018, they issued a draft report, “Continuing Board Certification: Vision for the Future,” in which recommendations for were listed for improving the MOC process. They believe that “continuing certification programs should support diplomates in their efforts to stay current in the specialty, provide high-quality patient care and be better doctors.” Among their recommendations are that “continuing certification should constitute an integrated program with standards for professionalism, assessment, lifelong learning and practice improvement.” These assessments should identify knowledge and skill gaps as well as help diplomates learn advances in their specialties. While they emphasize that member boards have a responsibility and an obligation to change a diplomate’s certification status when the standards are not met, they also recommend that member boards also have clearly defined remedial pathways to enable such diplomates to meet the standards in advance of loss of certification. Further, “continuing certification should be structured to expect diplomate participation on an annual basis.” Regarding this last recommendation, I note that the ABR adopted this feature for their MOC in 2017, before the draft was published.
The full report may be accessed online at https://visioninitiative.org/wp-content/uploads/2018/12/Draft_Commission_Report_for_Public_Comment_20181211-1448.pdf.
So, where does that leave us? Our health systems are moving toward integrated clinical care that emphasizes patient engagement, safety and quality improvement with the goals of improving patient outcomes and reducing health care costs. States also are recognizing the importance of lifelong learning in any professional practice and are demanding accountability from health care practitioners in assuring compliance. Prior to 1990, one could obtain a medical license “by reciprocity” with another state in which the individual was licensed. Often, that initial license was obtained based on the results of the National Boards or USMLE. Around 1990, many states agreed to licensure “by reciprocity” only if the applicant had passed some form of competency examination by a certifying body (state exam or board exam). All states have required CME for physicians to maintain their licenses. However, many states are considering or are requiring physicians to be enrolled in a MOC program. Like it or not, I’m afraid MOC is here to stay. It is incumbent on our specialty boards to make the process as palatable and as painless as possible while still assuring that their diplomates are providing the best patient care possible.