MAINTENANCE OF CERTIFICATION
—MAINTAINING WHAT?
Thomas James III, MD
I
t was early December as Richard Baron,
MD, walked through the assembled group
of some sixty Delaware Valley physicians,
shaking hands and engaging in small talk. He
is the current President and CEO of the American Board of Internal Medicine (ABIM), and
he was about to be part of a program at the
Philadelphia County Medical Society (PCMS)
on Maintenance of Certification (MOC). He
was relaxed and engaging. After all, he spent nearly 30 years in
clinical practice before going to the Centers for Medicare and Medicaid Innovation, and from there to his current role at ABIM. His
demeanor was entirely different from when I saw him in April in
Florida for the American College of Physicians (ACP) Annual
Meeting. In that venue he faced a hostile crowd of several hundred
angry doctors who showed him little mercy as they peppered him
with barbed questions. But at the PCMS, he was more in his element.
The doctors all knew him—even if they didn’t agree with MOC.
The format that night at the Philadelphia County Medical Society
was intended to be balanced with a moderator from the Pennsylvania
Medical Society, a former trustee of the ACP as the protagonist, and
commenter from the American Board of Emergency Medicine—but
it soon turned into a three-on one fast break with Dr. Chuck Cutler,
an internist from the Philadelphia suburbs, taking the role of lead
protagonist flanked by the other two panel participants. As a former
ACP Trustee, Dr. Cutler expounded the view that MOC was too
expensive and created risks to the physician pursuing MOC. Dr.
Baron presented the position that quality health care comes from
life-long learning.
They both agreed on the history of the Boards. The American
Board of Medical Specialties (ABMS) was established in 1933 to be the umbrella organization
providing structure and consistency to the 24
member boards. In 2000, the member boards of
ABMS agreed to move from recertification to a
new standard, Maintenance of Certification. By
2006 all ABMS member boards had adopted plans
for moving to maintenance of certification. There
are four standard elements of MOC for all board:
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(continued on page 21)
Part III—Cognitive Expertise
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Dr. Cutler also pointed to a decline in the initial pass rate of
Part III of MOC—the cognitive portion of MOC.
The failure rate of examinations went from 5 to 17
percent over the past decade—a time where general
medical knowledge did not reflect such a decline in
pass rate. Dr. Baron pointed to the significant explo-
Part II—Lifelong Learning and Self-Assessment
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Dr. Cutler, as a practicing internist and past chair of the Pennsylvania chapter of the ACP, pointed to both the past excesses of
the ABIM and to its lack of practicing physician focus. Chuck
pointed to the absence of any internist in clinical practice on the
ABIM Board. All members of the Board are physicians in academic
practice or lay consumers. Physicians such as the medical policy
maker, Ezekiel Emanuel, who is on the ABIM Board is not certified
in internal medicine, let alone working on MOC. His argument is
that the Board of ABIM is not in touch with those in clinical practice.
Part I—Licensure and Professional Standing
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change at ABIM where the specialty boards have more responsibility
for the development of the content of their own boards meaning
that physicians within that subspecialty have a greater responsibility for the content. This is in a response to past complaints that
subspecialty boards were created more by the psychometricians
than the physicians in real clinical practice. Dr. Baron pointed to
the tremendous strides within medicine as a reason for having
Maintenance of Certification. He noted that past boards included questions on issues important to medicine in the past but no
longer relevant such as the Wasserman Reaction—something now
only mentioned apocryphally in medical school curricula. So, as
Dr. Baron argued, it is essential to the assurance that modern day
physicians have knowledge of current medicine and are practicing
in a way to care best for individual patients as well as populations
attributed to them in various ACO contracts. The advancement
in knowledge must be reflected in clinical practice. He noted that
other professional disciplines require continuous improvement to
maintain licensure. Why should not doctors, who deal in decisions
impacting morbidity and mortality not also, have to demonstrate
continuous improvement?
Part IV—Practice Performance Assessment
However, each board has adopted sufficient
differences and pass rates vary significantly. The
ABIM is considered one of the more difficult boards. Since internal
medicine has its own set of subspecialties, Rich Baron described a
Dr. Richard Baron spoke at a Philadelphia County Medical Society debate with
Dr. Chuck Cutler on wide ranging topics including the excesses at the American
Board of Internal Medicine and the physician impact of participation. Dr. Baron
is shown second from the right talking on a physician panel.
FEBRUARY 2015
19