Implications of the Changes in Maintenance of Certification for ...

J Clin Endocrin Metab. First published ahead of print August 23, 2012 as doi:10.1210/jc.2012-2490

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Implications of the Changes in Maintenance of Certification for Endocrinologists Graham T. McMahon Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts 02115

t is easy to be cynical about maintenance of certification (MOC). Very few other countries have recertification requirements of their doctors; in the United States, other professionals such as lawyers and accountants are not required to take summative tests to retain their certification. Most clinicians are already actively engaged in continuing medical education (CME) (1). The certification process is widely regarded as frustrating, time-consuming, and expensive (2– 4). There has been little proof of benefit, and compliance is increasingly mandated rather than being chosen as an honorific (5). The coming months are likely to raise additional questions about the value proposition of MOC because the requirements for American Board of Internal Medicine (ABIM) board certification are changing again, with new content requirements, additional assessment expectations, and likely a higher price tag. These additional changes will leave many endocrinologists looking for clarification and deciding whether participation is likely to be worth it.

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The Premise of MOC With over 800,000 physicians in the nation, the task of ensuring that physicians practice safely and competently has traditionally fallen to a mix of state licensure and peer evaluation. It has become clear that experience alone is inadequate to maintain competence (6). Research has demonstrated that physicians may develop deficits in important skills and knowledge the further away they get from medical school and residency training. Knowledge declines over time, and clinicians routinely overestimate their competency (6, 7). State licensure is not specialty-specific and generally requires only completion of a selected number of CME ISSN Print 0021-972X ISSN Online 1945-7197 Printed in U.S.A. Copyright © 2012 by The Endocrine Society doi: 10.1210/jc.2012-2490 Received June 13, 2012. Accepted July 27, 2012.

credits and the absence of complaints. Historically, professional certification was awarded upon completion of training. Through these approaches, impaired clinicians are identified late, and often only after a harm. Several high-profile failures of professionalism have led to public debate about the profession’s ability to selfregulate and calls from Congress and the public for increased oversight and transparency (8, 9). Furthermore, surveys of the public confirmed their desire that their doctors be reevaluated regularly, and public organizations have called for additional oversight and regulation of physicians in practice. In response to these issues and with medicine changing more rapidly than almost any other field, maintenance of certification emerged to identify colleagues who meet a set of agreed-upon standards of care and professionalism, requiring valid state licensure, periodic participation in educational activities, and an examination every 10 yr. The American Board of Medical Specialties (ABMS) is responsible for setting the standards for the boards’ certification processes and making sure that these processes are carefully and objectively executed by the ABMS member boards. Certification in endocrinology, diabetes, and metabolism is performed by the ABIM. Other specialty boards, such as the American Board of Pediatrics (ABP), also certify endocrinologists in subspecialty areas. MOC was first introduced for internists graduating after 1989. Since then, MOC has required periodic self-assessment in practice with the goal of engaging practicing doctors in quality improvement. Since that time, endocrinologists have participated at approximately the same rate as other medical subspecialties. Of those endocrinologists who were certified by ABIM between 1990 and 2000, approximately three fourths have maintained their endocrinology, diabetes, and metabolism certificates. Between Abbreviations: CME, Continuing medical education; MOC, maintenance of certification.

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Copyright (C) 2012 by The Endocrine Society

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69% (hematology) and 89% (gastroenterology) of other subspecialists have retained their subspecialty certificates. Approximately half of the certified endocrinologists have retained their internal medicine certificates; in comparison, between 25% (clinical cardiac electrophysiology) and 80% (geriatrics) have retained their general internal medicine certificates (10). In the last 5 yr, 851 endocrinologists took the recertification examination, and 714 (84%) passed on their first attempt. There is insufficient evidence to make valid claims about the value of MOC. However, MOC is likely to be comparable to CME, which has been shown to be at least somewhat effective at the acquisition and retention of knowledge, attitudes, skills, behaviors, and improving clinical outcomes (1, 11–14). Studies indicate that clinicians who participate in MOC activities tend to have higher compliance with measures often used as surrogates of care quality, such as diabetes-performance indicators (15–17). However, participants self-select whether to participate in MOC or not; thus, it’s possible that these differences are as attributable to the characteristics of physicians who choose to engage in MOC as to the activities themselves. To enhance the value of board certification, the member boards made several efforts to enhance the public recognition of the “board certified” moniker. Insurers and payors are increasingly using certification status to determine payment and insurance rates.

The Current ABIM MOC Program The MOC program incorporates the following four components: professional standing, lifelong learning and selfassessment, cognitive expertise, and practice performance assessment (Table 1).


Professional standing (Part 1) requires that participants maintain an unrestricted license to practice medicine and have previously been certified in the discipline. The self-assessment of medical knowledge (Part 2) requires the learner to complete 20 MOC Part 2 points. ABIM provides several of these multiple-choice question modules on an annual basis without additional charge to those who have enrolled. Each 10-point module contains approximately 25–30 multiple choice questions. At endoselfassessment.org, The Endocrine Society offers the Endocrine Self-Assessment (ESAP) MOC, an online module containing 50 case-based questions for 20 MOC Part 2 points, or subject-specific adrenal, thyroid, bone-calcium, pituitary, and lipid-obesity modules, each with 25 questions for 10 MOC Part 2 points. The cognitive expertise element requires that participants pass a traditional knowledge examination (Part 3). These examinations are administered in a computerized format at computer-based testing centers across the United States and Canada. Each examination consists of approximately 180 questions, across a blueprint of content that is published on the ABIM website. Participants who want to retain certificates in endocrinology, diabetes, and metabolism and internal medicine need to pass both examinations. The performance in practice element (Part 4) requires learners to complete a practice audit worth at least 20 points. Patient survey and medical record review modules of relevance to clinical endocrinologists include those on osteoporosis, preventive cardiology, and several diabetes modules from varying providers. Modules for practice improvement can alternatively or additionally include modules that are based on processes such as “communicating with referring physicians” and “clinical supervision” for those supervising medical students, residents, and fellows.

TABLE 1. Key proposed changes to the ABIM’s MOC requirements

Some activity required every Formal examination Cost

Older system Current certification in endocrinology, diabetes, and metabolism Valid unrestricted license 100 points every 10 yr 20 points in self-evaluation of medical knowledge (Part 2) 20 points in self-evaluation of practice performance (Part 4) Remaining points from any combination of these 10 yr Every 10 yr $1675 ⫹ $775 for any additional exam

Payment

Lump sum only

Professional status requirements Point requirement Point distribution

Proposed system Current certification in endocrinology, diabetes, and metabolism Valid unrestricted license 100 points every 5 yr 20 points in self-evaluation of medical knowledge (Part 2) 20 points in self-evaluation of practice performance (Part 4) Some points for patient safety required Remaining points from any combination of these 2 yr Every 10 yr Approx $250/yr for first cert (lower price for add’l certs) Annual payment plan or lump sum


Endocrinologists who are not clinically active can meet the performance in practice requirement by completing the web-based “essentials of quality improvement” module. The Endocrine Society offers an endocrine-specific module, the Evaluation of Thyroid Nodules PIM, and is in the process of developing further PIMs to meet member needs.


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fication, the ABIM initially reportedly planned to subject these diplomates to the same requirements as those who were certified later. However, these plans were shelved at least in part to help mitigate the risk that a large number of physicians would retire and deprive their communities of practitioners rather than participate in what many consider to be an onerous process.

The New ABIM MOC Program ABIM recently circulated a set of proposed requirements that places new demands on participants and requires more frequent engagement with certification activities. All of the components listed above will continue. However, for certificates issued in 2014 and beyond, rather than requiring 100 points of activity every 10 yr, the board expects to require 100 points every 5 yr, and several new requirements (Table 1). Participants will be expected to complete some activity at least once every 2 yr to meet MOC requirements. The board will still require a secure examination only once every 10 yr. Consequently, certificates issued in 2014 and beyond will no longer indicate an “end date” and will have to be maintained continuously to maintain a “meeting MOC requirements” status. Lifetime certificates will be honored indefinitely; however, unless these clinicians enroll and begin participating in MOC activities, they will be listed as certified, but “not meeting MOC requirements.” Those completing fellowships will receive credit for their participation in training. The board will allow annual or onetime payment options. Clinicians who are dual-certified (e.g. internal medicine and endocrinology, diabetes, and metabolism) will have to complete secure examinations in both disciplines, but need only complete 100 points between these two areas every 5 yr.

How The Endocrine Society is Adapting The Endocrine Society is committed to meeting the educational needs of its members. The Society currently provides a suite of products to help members complete the self-assessment components of the MOC requirements written by and for endocrinologists. Modules are available at www.endoselfassessment.org. The Society recently launched a new educational strategy including investment in a learning management system that will allow individual members to track their educational activities (including CME from meetings and print products as well as MOC credits) in one place and allow automatic transfer of these activities to the ABIM’s MOC database. The strategy will also expand the number of online educational modules for adult and pediatric endocrinologists. The Endocrine Society has also redesigned is web portal for self-assessment products, endoselfassessment.org, to help members better manage their engagement in Society products, including the Evaluation of Thyroid Nodules PIM. Access to The Endocrine Society’s MOC and practice improvement modules is not currently free. Although it could be construed that the Society is leveraging external mandates to drive profits, it is worth noting that the development of these programs is expensive and time-consuming, and the products are not profit centers (18).

Effect on “Lifetime” Certification ABMS’s plan to indicate in physicians’ public profiles whether they are meeting requirements for MOC may have important influence on the educational requirements for clinicians who have been “grandfathered” into the current system. These “grandfathers” and “grandmothers” will continue to have their lifetime certification status honored. However, some insurers have reportedly indicated that they may provide cost reductions to those who actively participate and may begin to penalize clinicians who do not participate. Retaining clinical credentials in hospitals and health systems may increasingly require active participation in the certification process. Acknowledging the manifest unfairness of holding physicians to different quality standards based on age or year of certi-

Will CME Be Replaced by MOC? Unlike traditional CME, MOC points can only be attained from products developed by a highly selected group of educational providers, most of whom are the member boards (such as ABIM) and the subspecialty societies (such as The Endocrine Society). Although the review process (content is reviewed by subspecialists in that area and approved by the boards directly) may improve quality, it also adds cost that is passed on to the learner. It is likely that educational providers and institutions will increasingly seek to meet the needs of clinicians to meet their MOC requirements. The increased submissions of courses and activities are likely to strain boards’ ability to turn around approvals efficiently and to keep the cost

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of approvals low. Because the requirements for MOC content approval (central approval by specialists) are more stringent than those for CME approval, these requirements may become the new standard for educational quality.

The Coming Changes in Maintenance of Licensure In contrast to the rigorous standards for initial licensure, state boards have historically had fewer requirements to ensure that licensed physicians remain competent. In most states, physicians must show that they have obtained a minimum number of CME credits, but they are not required to get these credits in areas specifically related to their practices and are not required to demonstrate to their licensing boards whether they have applied what they have learned to enhance the quality of their work. In the last year, the Federation for State Medical Boards has adopted new policy that requires applicants to demonstrate their competency in their areas of practice in an ongoing basis and throughout their careers. The Federation has indicated that active participation in MOC activities will be considered adequate to meet the requirements of maintenance of licensure. As a result of these emerging changes, even clinicians whose certificates are valid indefinitely may soon need to begin participating in MOC activities to retain their state licenses, or participate in alternate educational programs that are approved by the state licensing board for this purpose.

Conclusions Clinicians generally want to do the right thing, but they are frustrated by what are generally considered to be externally mandated activities that are expensive, have limited relevance to their clinical work, force them to take time away from their families and their patients, and are unfair to those who were more recently certified. The ABIM is under pressure to retain its relevance and justify the high cost of certification while providing the type of high-quality educational activities that most physicians might value, and to do so with a limited budget. The ABIM’s increasing expectations of its diplomates will certainly increase the burden on participating clinicians who choose to remain certified. For clinicians who are not required to retain their certification, the new requirements may be considered sufficiently excessive that they will abandon certification for now. A large increase in participation is unlikely unless hospitals, insurers, or payors can be convinced that the certification


is sufficiently meaningful to justify creating incentive systems to encourage participation in MOC. More clinicians may turn to certification organizations that compete with ABIM and are recognized in many states, such as the American Board of Physicians. The number of participating clinicians will almost certainly increase substantially when renewing a state license requires evidence of MOC or similar activities. A larger number of participants in MOC would increase the statistical power to detect meaningful impact and, if present, provide added justification for the rigor of the program and added interest in incentivizing participation from payors. As numbers rise, price per participant may fall due to increased cost sharing. The revenue potential associated with larger numbers of participants could be sufficient to allow societies or commercial partners to create higher quality programs. Advances in technology in more widespread adoption of electronic health records may facilitate easier practice and chart audits. Until then, The Endocrine Society will be working to create efficient high-quality live and online programs that meaningfully impact on the knowledge and practice of America’s endocrinologists while helping them maintain their professional identity as board-certified physicians.

Acknowledgments I am grateful to Lorie Slass, Wanda Johnson, Robert Bartel, and Ailene Cantelmi for helpful comments on earlier versions of the manuscript. Address all correspondence and requests for reprints to: Graham T. McMahon, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, 221 Longwood Avenue, RF291, Boston, Massachusetts 02215. E-mail: [email protected]. Disclosure Summary: G.T.M. chairs The Endocrine Society’s CME and MOC Committee but has no financial interest in its products.

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