The American Board of Internal Medicine's suspension of controversial provisions of its maintenance-of-certification program has specialists of all types looking for alternatives to the MOC programs now required by the 24 members of the American Board of Medical Specialties.
“I don't know of a specialty where the physicians are happy with their maintenance-of-certification program,” said Dr. J.P. Abenstein, a Mayo Clinic anesthesiologist who serves as president of the American Society of Anesthesiologists.
The American Board of Internal Medicine suspended parts of its MOC program and apologized after many internists and subspecialists complained it was a waste of time and money. “ABIM clearly got it wrong,” Dr. Richard Baron, ABIM's CEO, said in a letter posted on the board's website Feb. 2. “We launched programs that weren't ready and we didn't deliver an MOC program that physicians found meaningful.”
The ABIM won't revoke internists' board certification if they don't complete the suspended elements. Those who have met all requirements except for the self-assessment portion will get a new certificate this year. The group said it would have “new and more flexible ways for internists to demonstrate self-assessment of medical knowledge” by the end of this year, and that the exam will be revised to be “more reflective of what physicians in practice are doing.”
“These changes all reflected where we were in agreement with the internal medicine community that we weren't getting this right,” Baron said in an interview. But, he added, it's still important for physicians to have “publicly recognizable ways” such as board certification to demonstrate their knowledge and competence.
Baron said the ABIM's goal is to make the MOC fit more closely into physicians' general practice. “We didn't have enough pathways for enough doctors to fit with the work they do every day,” Baron acknowledged. The ABIM has certified the competency of some 200,000 physicians in internal medicine and 20 subspecialties.
The American Board of Medical Specialties issued a statement noting its support for the ABIM in its effort to make its MOC program more meaningful for physicians. The ABMS also stated how the goal of its 2015 MOC standards is to provide doctors with a relevant, user-friendly and meaningful process. It added that, in making the changes, the ABIM showed it was listening to the internal-medicine community.
The Accreditation Council for Continuing Medical Education, the entity that monitors and assesses the legitimacy of continuing medical offerings, was staying neutral on the issue. "We agree that ACCME-accredited CME is an important part of the resources utilized by the ABMS, and its member boards, in the evolving implementation of maintenance of certification,” Dr. Murray Kopelow, ACCME president, said. “As the maintenance of certification system evolves, we will continue to seek opportunities to support it.”
Dr. Clif Knight, vice president of education for the American Academy of Family Physicians, said his specialty is different from most in that it never offered lifetime certification. Family medicine doctors needed to recertify every seven years long before time-limited certification or maintenance-of-certification programs were ever considered.
“In the family-medicine community, there's acceptance of the recertification process because it's always been like that,” Knight said. “But we do have concerns from our members about the time commitment, the expense and whether there's any evidence to support the benefit of maintenance of certification.”
Meanwhile, the controversy over the ABIM's MOC requirements has boosted the business of a physician who launched an alternative certification board and could motivate other specialists to seek alternatives to their certifying boards.
Dr. Paul Teirstein, the chief of cardiology at the Scripps Clinic in San Diego, has developed an alternative certification board known as the National Board of Physicians and Surgeons. He said the NBPAS has received hundreds of applicants and he expects that to grow into thousands. His group's board members include Dr. Eric Topol, chief academic officer for Scripps Health, and Dr. Daniel Einhorn, a past president of the American College of Endocrinology and the American Association of Clinical Endocrinologists.
The effort was rolled out just two weeks ago and is ready to certify the nonsurgical specialties recognized by the 24-member American Board of Medical Specialties. He expects surgical-specialty certification to be ready soon.
Teirstein welcomed ABIM's suspension of some of its MOC requirements and its CEO's apology. “We see that he's listening—and that's terrific,” Teirstein said. But he added that the ABIM's MOC requirements remain “onerous, not clinically relevant, and too expensive… We have no intention of replacing the ABIM but we're happy to provide an alternative.”
Teirstein published an essay in the Jan. 8 New England Journal of Medicine suggesting that 25 hours of annual continuing medical education programming was a sufficient replacement for MOC.
That disturbed patient-safety advocate Rosemary Gibson, who argues in favor of addressing MOC's shortcomings without ending the entire program. “The public is interested in knowing, perhaps more than ever, if they have a competent doctor,” she said. “We're rolling back to the lowest common denominator.”
“If airline pilots wanted to roll back (their recertification) requirements, it would be front-page news,” she said. “I think there should be a public debate on this—not just among physicians.”
Doctors generally are not fond of any comparison between doctors and pilots. Abenstein said doctors daily face situations comparable to taking off and landing planes with three failing engines and no landing gear, while pilots may face such emergencies once in a career. “No one in medicine wants to protect incompetent or bad doctors,” he said. “But the question is: What is the most appropriate process to judge an individual's competency?”
Teirstein, who's a certified pilot, argues that the assessment process pilots go through is far more meaningful than MOC. While MOC involves sitting in front of a computer, pilot assessment is “one-on-one with simulators or actual flights.”
Mothers Against Medical Error founder Helen Haskell argues that the idea of replacing MOC with CME is one that shouldn't get off the ground. “I am dismayed to see this effort sandbagged,” Haskell said. “I think it's a terrible idea. Most CME that I have seen is very undemanding and it is certainly not systematic.”
Baron doesn't see MOC going away and contended that the ABIM's standards will be seen as “stronger, higher and more credible” than those of any competing certifying organization that emerges. “We'll provide a framework for doctors to know they are keeping up,” he said. “Doctors will need to represent to the public and, in some cases, to their employer that they're keeping up.”
Follow Andis Robeznieks on Twitter: @MHARobeznieks