Whether having meals with physician-relatives, attending a professional society meeting, or walking the halls of a hospital, I find that a common issue on physicians’ minds during our discussions is the American Board of Medical Specialties’ (ABMS) Board Certification process – and particularly our program for maintaining certification known as Maintenance of Certification (MOC).
Questions range from “I know you’re old enough to have grandmother status – do YOU do MOC?” (Yes) to “How can I fit this into my already insanely busy life?” Comments range from appreciation for some aspect of the program to frustration with one of the program components.
As the relatively new leader of ABMS, I welcome the opportunity to discuss issues pertaining to Board Certification and MOC. I hope this post will generate thoughtful dialogue that will result in continuing improvements to the certification process developed by ABMS and our 24 Member Boards. That, in turn, will help us render MOC more relevant and meaningful to participating physicians and will assist them in their efforts to provide quality patient care and improve our health care system.
For many years there were few, if any, requirements for maintaining ABMS Board Certification. Physicians took an exam after graduating from their residencies and thereafter had no further obligations for testing or evaluation. However, over time the error of this approach became obvious. Medical science continuously changes, and the pace of that change has accelerated.
For example, it is well known that the number of identified diseases, diagnostic options, and therapeutic interventions is constantly increasing. Studies have demonstrated that knowledge and skills decline over time  and we do not always recognize our limitations because we don’t assess ourselves very well . In the meantime, American society has demanded ongoing learning and assessment of health professionals – and documentation of those activities.
Patients do not interpret “ABMS Board Certification” as an event that may have occurred 25 years ago, but instead as a more current statement of quality. Most patients believe that it is important for physicians to maintain certification,,, and more than one million searches of physicians’ certification status were conducted last year on ABMS’ public website (www.CertificationMatters.org).
Importantly, the medical profession, wishing to retain our privilege and responsibility to self-regulate, also has called for better methods of ongoing professional review and improvement. As a result, Board Certification has changed over time to meet these needs: first, in the last quarter of the 20th century when time-limited certification was adopted and then again, approximately a decade ago when MOC was adopted by the ABMS Member Boards Community.
Critiques of MOC
MOC receives a fair amount of criticism, some deserved and some not. For example, some critics charge that there is no evidence that MOC is beneficial. Because the program is young, the amount of research on MOC-specific outcomes is necessarily limited. However, it simply is not true that there is no evidence about MOC. In fact, the ABMS Member Boards’ MOC requirements are anchored in evidence-based guidelines, national clinical and quality standards, and specialty best practices.
Physician participation in MOC activities has been linked to enhanced clinical performance and improved patient care. Practice improvement methods of the type used in MOC have been shown to improve clinical care in areas ranging from cardiology to pediatrics and covering chronic conditions such as asthma, diabetes, and depression ,,,,,,,,,.
Physicians who participate in MOC improve their interpersonal and communication skills and medical knowledge, including their ability to identify gaps in knowledge and care 11, These and other research findings are housed in the ABMS Evidence Library™ (www.abms.org/EvidenceLibrary). An important planned initiative of ABMS is to support additional research that rigorously evaluates MOC and its component parts; research that will be made available to the public.
Physicians’ lives have become increasingly complex and busy in recent years, and some criticize MOC for adding complexity in the form of time, effort, and expense. There is no question that any program of continuing development and assessment involves these things; MOC is no different. Efforts are ongoing to reduce costs and to ensure that all program elements are highly relevant and meaningful to physicians. Each Member Board is committed to ensuring that the value obtained by each diplomate merits his or her time, effort, and expense. Several Member Boards are looking at ways to make their tracking systems, websites, call centers, and other diplomate interfaces more user friendly.
A common misconception is that MOC is the same as Maintenance of Licensure (MOL) and that all physicians will be required to become ABMS Board Certified to maintain their medical license. This is simply not true. MOL, a Federation of State Medical Boards (FSMB) initiative, and MOC are distinct and separate programs that share a common conviction that ongoing physician learning and development are both a public expectation and professional obligation. Recognizing the high quality of MOC programs and the efforts made by physicians who voluntarily participate in MOC, ABMS has strongly advocated that if MOL is implemented in any state (and this has not yet happened), physicians who are participating in MOC should be deemed to have met the requirements for MOL. The FSMB has been supportive of this principle.
What Physicians Like About MOC
I regularly hear from physicians that the MOC program has helped them identify previously unrecognized weaknesses and remain up-to-date in their specialty. Learning activities used by physicians to meet their MOC requirements, whether developed by a specific Member Board, a specialty society or another education provider, are usually of high quality. Simulation exercises, chart review, and just-in-time technology-enabled learning at the patient’s bedside are only a few of the ways that adult learning principles and real-life situations are being incorporated into MOC, making it even more meaningful.
One of the most appreciated learning programs, now offered by several Member Boards, identifies key journal articles representing the most important new evidence in the discipline and provides accompanying self-assessment activities. Physicians often tell me that this program improves their patient care and teaching, as well as their own sense of “being caught up.” And although no physician has told me that he or she liked preparing for the secure exam, many have told me that, in retrospect, it was an excellent review and learning experience.
Part IV of the MOC program focuses on practice assessment and improvement. Some physicians who were initial skeptics of this part of MOC have become strong supporters. As noted above, studies have demonstrated the value of MOC in the improvement of patient care. In addition, physicians tell me that Part IV has become a means of evaluating office practice, reorganizing office systems, developing staff skills, and improving employee satisfaction.
Through their engagement in the Multi-Specialty Portfolio Program, which provides Part IV credit to physicians from multiple specialties for participating in institutional quality improvement activities, diplomates are seeing substantial improvements in their practice settings. In response to diplomate concerns about Part IV activities, work also is being done to identify additional ways for physicians to participate in Part IV activities that have the greatest meaning and relevance to their practices.
ABMS is committed to aligning the various activities of practicing physicians, and this commitment is appreciated by many. For example, the MOC Part IV programs of many Member Boards align with such quality initiatives as the Physician Quality Reporting System (PQRS), thus reducing the data collection burden on physicians and increasing their participation in quality reporting. Linking MOC to PQRS helps physicians use the latter to further improve patient care. This year and through 2014, physicians certified by many Member Boards can earn an incentive from the Centers for Medicare & Medicaid for participating in the MOC:PQRS program.
Continuing Improvement for MOC
As part of our own continuing improvement processes, ABMS and our Member Boards have spent the past year evaluating MOC. We have listened to the concerns and preferences of the public, our physician diplomates, institutional representatives, and others as we develop the 2015 Standards for the Program for MOC. These standards will be implemented by the 24 Member Boards in ways that allow appropriate specialty-based emphasis and activities. It is currently anticipated that the standards will take effect in January 2015.
In September, the Proposed Standards for the ABMS Program for MOC was posted online for public comment and is currently available through November 20th. A link has been provided on the ABMS website (www.abms.org). I encourage all readers to review the standards and provide comments.
Studies show that physicians believe in the value of MOC, and more than 450,000 physicians currently participate in MOC programs. Specialists believe that those providing patient care should maintain certification., They participate in MOC to update their knowledge,17,18 and they report positive experiences with components of MOC, such as self-directed assessment modules and examinations. 11,15,,,,, ABMS and our Member Boards are committed to continuous improvement of all aspects of the program, including the experience of the participating physician.
Why MOC? Because it is simply untenable in today’s world that a quality credential – and particularly one as meaningful as ABMS Board Certification – would be granted or used without associated expectations of continued professional development. Because it is untenable that the ABMS Member Boards would grant an initial certificate to physicians who met rigorous quality standards and not offer those same physicians a program to help them maintain and demonstrate ongoing quality throughout their careers.
MOC is part of our responsibility to our profession, our ABMS Board Certified physicians, and, most importantly, the patients, families, and communities that we all serve.
Lois Margaret Nora, MD, JD is President and Chief Executive Officer of the American Board of Medical Specialties (ABMS).
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 Hagen MD, Sumner W, Fu H. Diuretic of choice in ABFM hypertension self-assessment module simulations. J Am Board Fam Med. 2012;25(6):805-809.
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 Miller MR, Griswold M, Harris JM 2nd, et al, Decreasing PICU catheter-associated bloodstream infections: NACHRI’s quality transformation efforts. Pediatrics. 2010;125(2):206-212.
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 McClellan WM, Millman L, Presley R, Couzins J, Flanders WD. Improved diabetes care by primary care physicians: results of a group-randomized evaluation of the Medicare Health Care Quality Improvement Program (HCQIP). J Clin Epidemiol. 2003;56(12):1210-1217.
 Holmboe ES, Meehan TP, Lynn L, Doyle P, Sherwin T, Duffy FD. Promoting physicians’ self-assessment and quality improvement: the ABIM diabetes practice improvement module. J Contin Educ Health Prof. 2006;26(2):109-119.
 Wells KB, Sherbourne C, Schoenbaum M, et al. Impact of disseminating quality improvement programs for depression in managed primary care: a randomized controlled trial. JAMA. 2000;283(2):212-220.
 Sherbourne CD, Edelen MO. Zhou A, Bird C, Duan N, Wells KB. How a therapy-based quality improvement intervention for depression affected life events and psychological well-being over time: a 9-year longitudinal analysis. Med Care. 2008;46(1):78-84.
 Hess BJ, Lynn LA, Holmboe ES, Lipner RS. Toward better care coordination through improved communication with referring physicians. Acad Med. 2009;84(10 Suppl):S109-S112.
 Hagen MD, Ivins DJ, Puffer JC, et al. Maintenance of certification for family physicians (MC-FP) self assessment modules (SAMs): the first year. J Am Board Fam Med. 2006;19(4):398-403.
 Meredith LS, Jackson-Triche M, Duan N, Rubenstein LV, Camp P, Wells KB. Quality improvement for depression enhances long-term treatment knowledge for primary care clinicians. J Gen Intern Med. 2000;15(12):868-877.
 Freed GL, Dunham KM, Althouse LA; American Board of Pediatrics, Research Advisory Committee. Characteristics of general and subspecialty pediatricians who choose not to recertify. Pediatrics. 2008;121(4): 711-717.
 Lipner RS, Bylsma WH, Arnold GK, Fortna GS, Tooker J, Cassel CK. Who is maintaining certification in internal medicine—and why? A national survey 10 years after initial certification. Ann Intern Med. 2006:144:29-36.
 Levinson W, Holmboe E. Maintenance of certification in internal medicine: facts and misconceptions. Arch Intern Med. 2011;171(2):174-176.
 Holmboe ES, Lipner R, Greiner A. Assessing quality of care: knowledge matters. JAMA. 2008;299(3):338-340.
 Holmboe ES, Cassel C. Continuing medical education and maintenance of certification: essential links. Perm J. 2007;11(4):71-75.
 ABIM PIM survey results. January 2011-July 2012.
 ABIM SEP modules survey results. July 2009-January 2012.