FEATURE
MOC Machinations
“ If there are no consequences to an assessment , people will not focus on it and they won ’ t gain benefit ,” Dr . Baron said . “ Physicians wouldn ’ t be able to say , ‘ Hey , here are some areas I know very well and here are some that I may not know as well .’”
Where Do Things Stand ?
In the years since ABIM ’ s initial MOC shake-up , several state legislatures have attempted to uncouple MOC from hospital insurance contracts . States are considering or have passed legislation that would protect physicians who do not fulfill ABIM or other board MOC requirements by prohibiting health plans , hospitals , or licensing agencies from requiring the certification .
For example , Oklahoma recently passed a law that prohibits discrimination based on whether a physician has maintained board certification . 12 Effective in November 2016 , the legislation prohibited the Oklahoma Allopathic Medical and Surgical Licensure and Supervision Act from mandating a physician to secure MOC as a condition of licensure , reimbursement , employment , or admitting privileges at a hospital in the study .
Dr . Baron noted that the certification has never been required for licensure in any state , though ABIM does require licensure to achieve certification .
“ That is a common misconception ,” he said . “ About 80 percent of licensed physicians are board-certified and 20 percent are not . Individual health-care institutions make the decision about who gets to do what in their hospital or health system . They are responsible for making those decisions , with patient welfare in mind .” Dr . Lichtin said he is distressed that the process has entered the political sphere . “ I like the idea that doctors can police themselves ,” he said . “ I don ’ t think society is going to be better served living in a state where the state legislature has determined the certification process .”
But , he acknowledged that he , and all hematologists , have to work within the existing MOC environment . “ If you are up for recertification , take the every-10-year exam or the every-two-year exam to prove that you can maintain your certification ,” Dr . Lichtin said . “ That is what we have to do because that is the landscape right now .”
REFERENCES
1 . American Board of Internal Medicine . Assessment 2020 Task Force findings to focus discussion of changes to ABIM certification and maintenance of certification . Accessed June 22 , 2018 , from http :// assessment2020 . abim . org / final-report .
2 . American Board of Internal Medicine . ABIM announces immediate changes to MOC program . Accessed June 22 , 2018 , from www . abim . org / news / abim-announces-immediate-changesto-moc-program . aspx .
3 . American Board of Internal Medicine . MOC assessments in 2018 . Accessed June 22 , 2018 , from www . abim . org / maintenance-of-certification / moc-faq / moc-assessments . aspx .
4 . Hudis CA . Changes to MOC : new pathways for assessment . ASCO Connection . Accessed June 8 , 2018 , from https :// connection . asco . org / node / 83021 .
5 . American College of Cardiology . Internal medicine organizations to explore new options for physicians maintaining board certification . Accessed June 29 , 2018 , from www . acc . org / latest-in-cardiology / articles / 2017 / 09 / 07 / 14 / 52 / internal-medicine-organizations-toexplore-new-options-for-physicians-maintaining-board-certification .
6 . American Board of Internal Medicine . First-time taker pass rates – maintenance of certification . Maintenance of certification exam pass rates 2008-2017 . Accessed June 8 , 2018 , from www . abim . org /~/ media / ABIM % 20Public / Files / pdf / statistics-data / maintenance-of-certification-pass-rates . pdf .
The MOC landscape might shift again in the near future , and ASH will continue to work with the ABIM Hematology Board ( of whom the majority of members are also members of ASH ) as it explores the feasibility of developing focused modules for the Hematology Knowledge Check-Ins .
“ The MOC process is a way to assure society that doctors are up to date , but it has been the subject of much anxiety and controversy ,” Dr . Lichtin said . “ I hope there comes a time when hematologists and ABIM can reach a mutual understanding of how to prove that we are continuously learning .”— By Leah Lawrence ●
7 . Teaching Excellence in Adult Literacy ( TEAL ). TEAL center fact sheet no . 11 : adult learning theories . Accessed June 9 , 2018 , from https :// lincs . ed . gov / sites / default / files / 11 _% 20 TEAL _ Adult _ Learning _ Theory . pdf .
8 . Gray B , Vandergrift J , Landon B , et al . Associations between American Board of Internal Medicine Maintenance of Certification status and performance on a set of healthcare effectiveness data and information set process measures . Ann Intern Med . 2018 June 12 . [ Epub ahead of print ]
9 . McDonald FS , Duhigg LM , Arnold GK , et al . The American Board of Internal Medicine Maintenance of Certification examination and state medical board disciplinary actions : a population cohort study . J Gen Intern Med . 2018 March 7 . [ Epub ahead of print ]
10 . Lipner RS , Young A , Chaudhry HJ , et al . Specialty certification status , performance ratings , and disciplinary actions of internal medicine residents . Acad Med . 2016 ; 91:376-81 .
11 . Gray BM , Vandergrift JL , Johnston MM , et al . Association between imposition of a Maintenance of Certification requirement and ambulatory care-sensitive hospitalizations and health care costs . JAMA . 2014 ; 312:2348-57 .
12 . Oklahoma Text Search and Retrieval System . Enrolled Senate Bill No . 1148 . Accessed June 22 , 2018 , from http :// webserver1 . lsb . state . ok . us / cf _ pdf / 2015-16 % 20ENR / SB / SB1148 % 20 ENR . PDF .
SIDEBAR 2
Exploring Alternative Pathways
To address medical societies ’ and health-care providers ’ concerns with its MOC program , ABIM could look to alternative models being explored by other certifying boards . Despite having access to the same data about physician self-assessment that ABIM does , these organizations reached markedly different conclusions about the need for summative assessments or punitive measures . All of these include periodic , low-stakes , formative assessments that ASH advocates .
The American Board of Anesthesiology ( ABA ) was a pioneer in creating alternative pathways : In 2014 , it launched its MOC in Anesthesiology Minute ( MOCA Minute ) program , an interactive platform designed to replace MOC Part 3 . 1 MOCA Minute was originally designed as a tool to help ABA diplomates prepare for certification exams , but eventually replaced part of the MOCA examination . The option allows diplomates to assess their knowledge continuously , fill knowledge gaps , and demonstrate proficiency by answering 30 questions per quarter .
MOCA Minute questions can be answered over time and , in fact , diplomates cannot answer more than 30 questions per calendar quarter . After each question , the diplomate receives the rationale for the correct answer and links for more information . If the MOCA Minute performance standard is not acquired in the year certification expires , a proctored exam is required to retain certification .
Similarly , the American Board of Pediatrics ( ABP ) has developed a Maintenance of Certification Assessment for Pediatrics ( MOCA-Peds ), an online , non-proctored assessment platform . 2 Each quarter , ABP diplomates receive 20 timed , multiple-choice questions that they can answer from their personal computers . Once the questions are complete , the respondent receives immediate feedback on correct and incorrect responses , as well as rationale and references for the correct responses . If diplomates do not pass the MOCA-Peds by the end of the fourth year of ABP ’ s five-year MOC cycle , they must sit for a proctored exam .
Earlier this year , around the same time that ASCO and ABIM announced their new collaborative pathways , the American Board of Medical Specialties voted to make the American Board of Obstetrics and Gynecology ( ABOG ) pilot literature-based assessment program a permanent option for its diplomates . 3 This option measures physicians ’ knowledge through the ABOG ’ s Lifelong Learning and Self-Assessment ( LLSA ) component , which requires participants to read a total of 180 selected articles and answer 720 corresponding questions over a six-year period .
If physicians perform well on the LLSA component through years one through six of a 10-year MOC cycle , they can receive credit for meeting the MOC external assessment requirement . While diplomates must also continue to meet other MOC standards , the LLSA program will help physicians “ realize savings by not paying the external assessment fees … and not losing a full day away from their practices and patients in order to fulfill the external assessment requirement ,” according to an ABOG press release . 3
These are all examples of formative evaluation , where the intent is to monitor learning and provide ongoing feedback , said Alan Lichtin , MD , a hematologist at Cleveland Clinic and chair of ASH ’ s MOC Working Group .
Joseph Mikhael , MD , MEd , chief medical officer of the International Myeloma Foundation and professor at City of Hope Cancer Center in Duarte , California , also cited the Canadian MOC program ( through which he maintains certification ) as an example of formative learning . The program requires participants to complete a certain number of activities to earn credits in each five-year cycle . These activities reflect the type of work the physician does , Dr . Mikhael said , and can be earned in a variety of manners including attending CME lectures , searching the literature , and participating in learning activities .
“ There is a component of trust in the Canadian program , although people can be audited ,” he said . “ Because it is not exam-based , it more accurately reflects what I do on a regular basis and is much more clinically relevant .”
REFERENCES
1 . The American Board of Anesthesiology . Part 3 : MOCA Minute . Accessed June 9 , 2018 , from http :// www . theaba . org / MOCA / MOCA-Minute .
2 . The American Board of Pediatrics . MOCA-Peds . Accessed June 22 , 2018 , from https :// www . abp . org / mocapeds .
3 . American Board of Obstetrics and Gynecology . From pilot to permanent : ABOG ’ s program offering an innovative pathway integrating lifelong learning and self-assessment and external assessment is approved . Accessed June 29 , 2018 , from https :// www . prnewswire . com / news-releases / from-pilot-to-permanentabogs-program-offering-an-innovative-pathway-integratinglifelong-learning-and-self-assessment-and-external-assessmentis-approved-300648728 . html .
42 ASH Clinical News July 2018 Bonus Mid-Year Edition