|February 2008 · Vol. 20, No. 02
Maintaining our cool with Maintenance of Certification
The MOC program is now part of ObGyn life. Should you, and your patients, be pleased?
ABOG introduced MOC for ObGyns in January. One of its pillars is a proctored, secure test of your cognitive expertise.
ABMS says that MOC will reduce malpractice premiums, but it offers no evidence for that assertion
Robert L. Barbieri, MD
A new approach to specialty certification was adopted in 2006 by the 24 member organizations that constitute the American Board of Medical Specialties (ABMS). At its core, this new “maintenance of certification,” or MOC, program requires physicians to demonstrate a commitment to lifelong learning and ongoing practice assessment.
In January 2008, the American Board of Obstetrics and Gynecology (ABOG) initiated the MOC for ObGyns. It will affect all diplomates who have a certificate that was issued in 1986 or afterward. Here are the four core elements of MOC and the process that you and I will use to satisfy its requirements:
Assessment of professional standing means holding a valid, unrestricted medical license in at least one state or jurisdiction. Annually, ABOG will verify your standing with the state licensing board(s).
Demonstration of lifelong learning and self-assessment is based on your completion of continuing education programs. This section of the MOC has been, and will continue to be, completed through ABOG’s Annual Board Certification (ABC) program.
Demonstration of cognitive expertise requires that you pass a proctored, secure, “closed-book” examination. Did you think that taking high-stakes, standardized, multiple-choice tests was behind you? Sorry—in 2012, you’ll have the opportunity to relive the excitement and anxiety (and cost) of such a test! The exam must be passed once during each 6-year MOC cycle; the first exam will be given 5 years into the 6-year MOC cycle. Because the exam will be secure, you’ll have to travel to one of the testing centers provided around the United States to take it.
Practice performance assessment is demonstrated by self-assessment of the quality of care you provide to patients, measured against national guidelines and benchmarks. For ObGyns, this means completing a chart review every 6 years for as many as 10 patients in your practice, focused on 10 self-selected medical topics. The clinical practice assessment will include modules in obstetrics, gynecology, office practice, ethics, patient safety and communication, and subspecialty options. Detailed discussion of this core element of the MOC can be found at www.abog.org/pdf/MOC2008.pdf.1
MOC is clearly a big change for us
Maintenance of certification can be viewed from a number of perspectives, like any major change can be.
The scientific perspective
The ABMS believes that MOC is the path to better care. To my knowledge, however, there’s no reproducible scientific evidence, based on controlled study, that MOC improves care. Common sense suggests that lifelong learning would improve the care we provide—but that’s all there is to support the idea. This seems to run counter to standards of medical science: We don’t accept the efficacy of the pharmaceuticals we prescribe on the basis of common sense; we demand demonstration, in controlled trials, that they are superior to placebo.
From a scientific perspective, it seems prudent to first test such a major change as MOC in a controlled trial before applying it to all physicians. And why not comparatively test alternatives to MOC? One would be asking each physician to develop his, or her, own learning plan and to involve mentors and partners in the process.
On its Web site, the ABMS says that “Physicians benefit from participating in MOC because they receive focused learning based on individual practice needs, increase efficiency and reduce malpractice premiums as well as the need for duplicate assessments of credentials, among other benefits.”2 The optimism of the ABMS may have led it to over-state available scientific evidence here; to my knowledge, there’s no evidence that MOC will reduce premiums for professional liability insurance.
Also, it’s my experience that duplicate assessment of credentials is increasing as more and more agencies attempt to regulate physicians’ practice.
The professional perspective
One of the foundations of professionalism is to take personal responsibility for lifelong learning and continuous improvement of the care one provides. MOC is a paternalistic approach to ensuring lifelong learning that may undermine some facets of professionalism. For example, in response to ABOG’s ABC program, entrepreneurs have established Web sites at which physicians can, for a fee, obtain access to answers to the ABC multiple-choice exam.
The community perspective
Patients trust their physician to provide outstanding health care—trust that is well founded. The education and training pathway to specialty certification is long and arduous, and produces outstanding clinicians. Recently, however, we’ve seen a gradual but clear decline in the trust that the average patient places in her physician. So I think that patients are likely to applaud the intent of MOC, which is to ensure the quality of the physician community.
Keeping regulators at bay
MOC does have a major advantage: It reduces the likelihood that state licensing boards will issue onerous requirements focused on lifelong learning and practice assessment. If each state licensing board established unique requirements for practice assessment, physicians would confront a complex patchwork of local regulations that might be more burdensome than MOC.
What do early results show?
A few specialties have been using the principles of MOC in the recertification process for several years. Physicians who have participated in MOC have reported that, as a result of their practice assessment, they 1) implement, to a greater extent, patient flow sheets for tracking complex care processes; 2) provide better tracking of vaccinations and smoking status; and 3) use patient education materials more often.
Physicians also report, however, that MOC is time-consuming and increases the cost of certification.
Then there’s HFn (the hassle factor)
At every regulatory level, physicians face greater and greater scrutiny and bureaucratic stipulations that undermine their ability to manage both their practice and their professional development efficiently. The myriad, and often overlapping, agencies and processes that hold sway over physician practice include the following:
specialty board certification (e.g., MOC)
state licensing boards (CME requirements)
hospital credentialing (a complex process of data collection from diverse sources)
federal and state drug licensing
credentialing with each health-care insurer
professional liability insurers (completion of specified education programs to maintain insurability)
increased reporting requirements focused on “conflicts of interest.”
MOC will add to this regulatory burden and, it’s likely, grow more complex.
MOC is here to stay
One component of MOC, ABOG’s ABC program, is being used by many physicians. It’s widely perceived as enjoyable and a positive process for continuing education. My experience is that the physician–leaders at ABOG have done an outstanding job of selecting high-quality, clinically relevant articles for the ABC. Compared with other similar products, such as the New England Journal of Medicine’s continuing education program, the ABC is exceptionally well done. The ABC is time-consuming, but I found it an out-standing educational experience.
What about the other core elements of MOC, including the proctored, secure, and expensive cognitive exam? I think they will be widely viewed with disdain by ObGyns. Do you agree?
1. www.abog.org/pdf/MOC2008.pdf. Accessed January 17, 2008.
2. www.abms.org/Maintenance_of_Certification/value_of_MOC.aspx. Accessed December 26, 2007.
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