Maintenance of Certification (MOC)

Ok, first of all, what is “maintenance of certification”?

After 4 years of medical school, 1 year of internship, 4 years of residency, passing my board exam, and then doing a year of fellowship, I thought I was “done” with “all this stuff” [insert hand waving here]. Please understand that I knew I would have to keep learning, since the practice of medicine is a life-long learning profession, but I was hoping there wouldn’t be any more “checkpoints” in The Track. For this reason, I was aware of the Continuing Medical Education (CME) requirements, but I was not really ready for what MOC would entail.

Of course, MOC is different for different medical specialties. However, I think the “general rule” of most MOCs is a certain amount of CME, some kind of Practice Quality Improvement (PQI) or Physician Quality Reporting System (PQRS) project (or something similar), and a 10 year recertification examination. I think that’s a pretty fair assessment for *most* medical specialties.

*So what’s the big deal? Some CME, some projects, an exam. Who cares?

Well, I would agree with that sentiment at its core… as long as there was some demonstrable value to MOC. If you could prove to me that physicians that a specific amount of CME, PQI or PQRS involvement, and 10 year test helped to keep physicians as up-to-date as possible with their particular specialty, then of course, MOC has value.

Here’s the problem: I don’t think you can.

Let’s talk about each part of MOC requirement for my board (American Board of Radiology):

Licensure Valid and unrestricted in all states of practice
CME – At least 75 Category 1 CME credits in previous 3 years
SA-CME – At least 25 of the 75 Category 1 CME must be Self-Assessment CME (SA-CME)
Exam Passed appropriate ABR Initial Certification or MOC exam in the previous ten years
PQI Completed at least one PQI Project or Participatory Quality Improvement Activity in previous 3 years

Licensure:

This is understandable. You can’t practice medicine without a valid, unrestricted license. Next…

Continuing Medical Education (CME)

I think we can all agree that the idea of continuing medical education is important, essential even. However, not all CME is created equally. As a neuroradiologist, I can still get CME for my specialty (and subspecialty) that has nothing to do with either radiology or neuroradiology. CME must be relevant to the physician in order for it to be of benefit. The quality of some of the courses available are also… ummm… suspect to say the least, but are still worth a substantial amount of CME, for what I would consider minimal real-world benefit.

Nonetheless, CME is really the core of MOC in my opinion. Its implementation, however, I think needs to be fine-tuned to increase physician interaction/engagement on a more continual basis, rather than going to a 4 day course of 30 hours of lectures.

Self-Assessment – Continuing Medical Education (SA-CME)

This is a subsection of CME which involves “self-assessment” which basically means the course you are taking has some form of question/answer segment. Whether this is an online test, or pen and paper test, or what have you, at some point in the course the information presented was tested.

This is also important I think, however, in those 4 day, 30 hour courses, you are looking at a pretty lengthy test, like 100 questions or so. That is a ton of information in a short amount of time, which must be regurgitated right afterwards. Do you know what that’s called? It’s called CRAMMING. Most of that information will be systemically dumped after the test… with only a few tidbits of new information to be gained from that monster CME course.

So, like CME, SA-SME is important, but needs to be changed in how it is implemented.

Passing Initial Certification or MOC exam in the previous ten years

So, this is basically saying, you need to take a MOC exam every ten years. This examination could test you on any number of subjects with the scope of the entirety of radiology.

Essentially, it’s like taking your boards over again. Should be easy right? You’ve been a board certified radiologist for 10 years right? True, but what if you were THE neuroradiologist of your group and only read neuro exams for the last 10 years. The last time you read a mammogram was in residency. You could (and probably will be) tested on mammography because it’s considered “general radiology”, but yet is completely irrelevant to your daily practice. Also, a significant amount of the material that you could be tested is not that common in everyday practice, and you will have likely forgotten some of the differentials. So what do you do?

You study. For a certification you already have. Likely a month or a few months before the test.

And you will more than likely pass it…  and nothing will have changed in the way you practiced radiology the previous ten years, or probably even the next ten years. Not particularly fruitful.

I’m not saying the examination itself is bad. I understand what it tries to do. However, once again, it comes down to its relevance to the individual. I think this is difficult to tailor given the scope of medicine (radiology in this instance), and the infinite variety in how physicians can choose to practice their specialty.

Practice Quality Improvement (PQI)

The idea behind this particular portion of MOC had good intentions. Let’s make our physicians get together and try to figure out how to make themselves better… and let’s make it part of their MOC. I think it was envisioned to essentially “crowdsource” small incremental changes for the betterment of radiology as a whole. However, this is something akin to forcing physicians to do research. Most physicians don’t like research (unless they are in academia). Additionally, creating and maintaining your own PQI project had vague requirements and confused many physicians. For this reason, a number of services became available in order to fulfill the PQI requirement. The most common one I hear about is RADPEER which is run by the American College of Raidology (ACR). However, there are a ton of databases now, which can be found here. Becoming a member of these databases helps you fulfill the requirement.

These databases are great for acquiring information and internal Quality Assurance (QA), but I don’t think they are making the impact that PQI was created to make. More so than that, it doesn’t necessarily identify the problem a physician has, or how to improve on it. Another issue is when changing jobs, your current group might use RADPEER with a group identifier. However, once you leave, you are no longer part of the group identifier, and need to find another way to fulfill your PQI requirement.

Overall, good intentions, but difficult to show results. However, it did have the side effect of creating great databases to be used, but I am not sure it has significantly impacted the way radiologists practice on an individual basis. I am unsure how to make PQI relevant to individuals on a daily basis.

*Ok, so now what then?

Well, by now everyone has read about the hub-bub of the American Board of Internal Medicine (ABIM) and its host of issues. I think the straw that broke the camel’s back was changing MOC to become an even more arduous and tedious task in combination with the allegations that the ABIM had been mishandling money. This led to a group of physicians trying to certify themselves, with the establishment of National Board of Physicians And Surgeons (NBPAS). This “alternative board” is interesting to say the least. It does a good job in side-stepping the “initial certification” issue, by only certifying diplomates of already established boards. Essentially, they are positioning themselves to be an alternative to the MOC, but not to the initial certification. A wise choice, in my opinion.

The ABIM responded by apologizing and making changes to their MOC. – 2-3-2015.

More press came out about the ABIM. “The Ugly Civil War in American Medicine”. – 3-27-2015

Then the American Board of Anesthesiology (ABA) dropped their 10 year MOC. – 9-10-2015

• Dropping the 10 year MOC for the MOCA Minute™ pilot (30 questions per calendar quarter (120 per year)).
• Increased options for Improvement in Medical Practice (IMP), which I assume is their version of PQI.

This change was applauded by many.

Then the ABIM responded by creating a task force to Change the MOC exam, Focus assessments on cognitive and technical skills, and Recognize specialization. 9-16-2015

The ABIM then announced another option for MOC which sounds similar to the ABA’s pilot program. – 5-6-2016

Then, my board, the American Board of Radiology (ABR), decided to do away with the MOC exam as well. – 5-18-2016

Essentially, the ABR is planning to adopt a pilot similar to the ABA’s with regular, but short, interactions consisting of questions relevant to their practice profile.

I am cautiously optimistic for this change. 

Like I outlined above, in my opinion, the most important part of MOC and CME is relevance to real-world practice. Teach me something new or update me on something that is important, relevant to me, and that I can integrate it into my daily practice immediately:

“It’s not called Posterior Reversible Leukoencephalopathy anymore…? It’s called Posterior Reversible Encephalopathy Syndrome (PRES) now…? and all the neurologists use that terminology now? Great. I’ll use that from now on so we’re all on the same page.”

Note: This example happened a long time ago… but it illustrates my point.

However, the American Board of Psychiatry and Neurology (ABPN) has no plans for any significant changes currently. – 4-22-2016

The article seems to think psychiatrists are happy… however, if you look at the 12 comments, all of them seem to be pretty unhappy with the MOC in general.

I hope that the ABPN decides to change their MOC as well, for my wife’s sake.

TL;DR

MOC had good intentions, but was difficult to implement given its scope.

The 10 year recertification exam does not really do what it set out to accomplish.

I am cautiously optimistic about the new ABR MOC requirements.

Up-to-date information with relevance to the individual is the key.

ABPN, if you’re reading, please change your MOC too.

What do you guys think? Is MOC a good thing or a bad thing?

Should we abandon MOC completely or is it worth saving?

Should we all just join the NBAPS?

Let me know.

-Sensei

Agree? Disagree? Questions, Comments and Suggestions are welcome.

You don’t need to fill out your email address, just write your name or nickname.