Saturday, February 07, 2015

Changes to Maintenance of Certification (MOC)

The American Board of Internal Medicine's February 3 announcement came during a very busy week in hospital medicine for me and I have just now had time to process it. There is a lot to unpack. The announcement, which contains an apology and an acknowledgment that they “got it wrong,” is a welcome development but it raises many questions. Below is my very preliminary take.

What is the immediate impact?
For me, two items are significant:

Effective immediately, ABIM is suspending the Practice Assessment, Patient Voice and Patient Safety requirements for at least two years.

That is a great relief for me as I trudge through. Now I can focus on the learning activity, which is the important part. I get points for MKSAP, which I love doing and would have done anyway.

Within the next six months, ABIM will change the language used to publicly report a diplomate's MOC status on its website from “meeting MOC requirements” to “participating in MOC.”

That is in response to the problem I addressed here:

So what am I talking about? Well, for the grandfathered internists who choose not to perform the “voluntary” recertification activities the Board is coming as close to de-certifying them as they can without actually taking the certification away and having to say “Sorry. We lied.”
How does it work? It's in the way they report your certification status. Go to their website and look up the name of a grandfathered colleague (this portion of the site is open to the public). Those not participating are designated as Certified but right under that it says Meeting Maintenance of Certification Requirements: No.
What will the public think? What will credentialing bodies think? While this will confuse some people it comes across loud and clear to most as nominally certified but not really certified.

While I am thankful they softened the language they have not fully addressed the problem, which is that in a round about way they went back on their promise of lifetime certification with voluntary maintenance.

ABIM's announcement is a positive step but is it enough?
For the practice assessment and patient safety modules, perhaps the most troublesome aspect of MOC, all they did was call a moratorium. Nobody knows what they will do with this in two years. These exercises were fundamentally flawed but ABIM did not acknowledge that. All they admitted was that they launched programs that weren't ready and that docs did not find meaningful. That leads to the question of what these programs will look like once ABIM deems them “ready.” What about the apology? Does it represent appeasement or is it genuine contrition? I will take a wait and see attitude. The move by ABIM was a first step but only that. Vigorous debate of the issues surrounding MOC needs to move forward.

Despite ABIM's pledge to freeze MOC fees the accusations of financial impropriety were not addressed.
These have been nicely summarized in a series of posts over at Dr. Wes. Whether the conflicts are real or only perceived they need to be addressed by the board in a manner that will restore the credibility of their leadership. I have yet to see movement in that direction.

Questions linger about CME.
In a recent post about the MOC discussion medical journalist Larry Husten said this:

As I said, CME can play a key role in MOC, but only when the doctors pay for it themselves. To start, every effort should be taken to remove industry’s role from CME.

In his thinking that would rule out most accredited category I offerings because, as he correctly implied in the same post, most of it is funded, to one degree or another, by industry.

A very vocal group of physicians agree with Mr. Husten. But if the ABIM leaders really mean what they said in the February 3 announcement it would appear that they disagree because they say that going forward they plan to recognize “most forms of ACCME-approved Continuing Medical Education.”

But one part of ABIM's statement on CME is concerning, from the FAQ page:

We are absolutely interested in finding ways to recognize meaningful clinical work that you do in your practices to earn CME points, and we're particularly interested in recognizing CME activities for which there is evidence that they drive learning and/or change practice. Many forms of “passive” CME do not meet this standard.

This implies that we're headed back to the practice improvement modules and, even worse, that the learning points may be tied to those activities. And what kind of evidential support are they looking for? I know of no robust evidence that ties any form of CME, inside or outside of MOC, to meaningful outcomes. We all know intuitively that knowledge helps drive better patient care but the idea that these processes with all their layers of complexity can be measured in a meaningful way strikes me as naive.

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