ABIM Finally Gets It Right

[[{"type":"media","view_mode":"media_crop","fid":"33100","attributes":{"alt":"ABIM Finally Gets It Right","class":"media-image media-image-right","id":"media_crop_6442810522900","media_crop_h":"313","media_crop_image_style":"-1","media_crop_instance":"3485","media_crop_rotate":"0","media_crop_scale_h":"175","media_crop_scale_w":"118","media_crop_w":"211","media_crop_x":"2","media_crop_y":"37","style":"float: right;","title":" ","typeof":"foaf:Image"}}]]The American Board of Internal Medicine (ABIM) is not sure if the Maintenance of Certification (MOC) program accomplishes its goal of ensuring maintenance of competency. Richard Baron, MD, President of the ABIM, said in an open letter to the internal medicine community: “Effective immediately, ABIM is suspending the Practice Assessment, Patient Voice and Patient Safety requirements [of MOC] for at least two years.”¹ These areas are similar but not identical to elements of two of the American Board of Psychiatry and Neurology’s (ABPN) MOC modules. These programs for both the ABIM and the ABPN are “mandated by the American Board of Medical Specialties.” The ABIM took this action in response to concerns expressed by the internal medicine community about the time expenditures, cost, and questionable value of some MOC protocols.

Andis Robeznieks² reported on February 4, 2015, that “the AMA said in a statement that it was ‘delighted’ that the board was listening to physician concerns and that the ABIM would align the MOC program with principles the House of Delegates called for at its November 2014 interim meeting in Dallas.” The ABIM is the largest board of the American Board of Medical Specialties (ABMS). The ABMS sets the policies that all medical boards follow in establishing certification procedure. Because of its size, the ABIM’s action serves to reopen the debate on whether the ABMS’s currently mandated MOC procedures indeed work and are relevant to ensure the competency of American physicians.

How has the competency of American physicians been determined and ensured?

Formal medical education

In 1910 at the time of the Flexner³ report, it was felt that a graduate from an accredited medical school was trained enough to effectively and safely practice medicine. This was eventually altered in most states to require a 1-year hospital-based internship and still later a specialty residency. Each specialty determined the length of its residency. In the 1970s, the internship was merged into initial specialty residency programs. Today, in any number of fields, this period of training is extended further to require specialized training in a subspecialty fellowship.

Lifelong learning

With the rapid growth of medical knowledge and changing modes of medical practice, it became clear that medical education did not stop when formal training ended. To facilitate lifelong learning for physicians, continuing medical education (CME) programs were developed to ensure physician competence.

Licensure requirements and board certification

Parallel to changes in training were shifts in the timelines for assessing physician competence. All states developed mechanisms to license physicians after graduation from medical school.

Today, state licensing examinations are prepared by the National Board of Medical Examiners in conjunction with the Federation of State Medical Boards. For a state license, a physician must pass 3 examinations.

State licensing boards alone were not seen by some as a totally adequate means of assessing the abilities of medical specialists. To best inform the public of the special competencies of physicians and to ensure that after residency they had the basic competency in their field, various specialty boards were formed. The first was the American Board of Ophthalmology in 1916. Eventually, specialty boards were developed for all areas of medicine. These boards are joined by a common governance and standard-setting body-the ABMS.

Initially, the boards of the ABMS granted lifelong certificates based on varied forms of written and oral examinations. In the 1990s, this shifted under ABMS direction, and all boards granted 10-year certificates after the successful comple-tion of an examination, with a requirement that every 10 years a diplomate of a board would need to take and pass a recertification examination. Approximately 10 years later, the ABMS further changed the system of recertification, now calling it MOC. Board-certified physicians would now be required, in addition to an examination every 10 years, to participate in a number of activities each year. These included proof of ongoing learning activities relevant to their practices and varied self-assessment programs.

MOC and psychiatry

The inclusion of yearly requirements raised the question as to whether these programs added to or aided in maintaining competence of practicing psychiatrists. In 2010, I asked this question in an article in Psychiatric Times.⁴ I argued that while the required MOC programs of the ABPN added to the workload of psychiatrists, evidence to prove a positive effect on psychiatrist performance did not exist. Larry Faulkner of the ABPN and Kevin Weiss of the ABMS responded in a later article and argued simply that it did.⁵

In 2011, the American Psychiatric Association’s (APA) Assembly passed an action paper requesting that the APA review the MOC process and assess the evidence for its effectiveness. The requested review did not take place. Subsequently, the ABPN altered some of its requirements and psychiatry’s focus on MOC declined.

MOC today

That is where questions of the value of elements of current MOC programs stood until February 3, 2015. The ABIM did what the AMA did not or could not do. It directly challenged elements of the current MOC required protocols. By suspending some of the MOC requirements and not dropping them, the ABIM has avoided a direct confrontation with the ABMS. A suspension means they still stand but are not enforced. In the next 2 years, the ABIM and ABMS will have to resolve their differences and evidence will need to be presented to support the varied ABMS mandated requirements

Under the cover of the action of the ABIM, the ABPN and the APA need to reassess the ABPN’s MOC program. Where there is no clear evidence of the effectiveness of elements of the program, these requirements should, in my view, be suspended pending further review. Indeed, the ABPN and APA could ask the ABIM to participate in this essential review.

As physicians, we have a responsibility to ourselves and society to ensure our own competency and that of every medical practitioner. All practitioners must participate in activities that ensure their ongoing ability to practice their specialty.

The ABPN has a parallel set of responsibilities to its diplomates and to society. It must ensure that its procedures effectively assess the knowledge and competency of the psychiatrist it certifies. In addition, it must develop programs to effectively assess the lifelong learning and practice abilities of its diplomates. A transparent program to assess the effectiveness of these critical programs is what we need-an MOC program that facilitates these processes is essential. But, it may not be what we have.

Disclosures:

Dr Weissman is Professor of Clinical Psychiatry and Behavioral Sciences at Northwestern University Feinberg School of Medicine, Chicago.

References:

1. ABIM announces immediate changes to MOC program. http://www.abim.org/news/abim- announces-immediate-changes-to-moc-program.aspx. Accessed February 24, 2015.

2. Robeznieks A. Docs cheer as ABIM suspends parts of controversial recertification process. February 4, 2015. http://www.modernhealthcare.com/ article/20150204/news/302049939. Accessed February 24, 2015.

3. Flexner A. Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching. Boston: Merrymount Press; 1910.

4. Weissman S. Does Maintenance of Certification ensure maintenance of competency. Psychiatr Times. 2010;27(12):17.

5. Weiss KB, Faulkner LR, Weissman S. Board certification: two perspectives. Psychiatr Times. 2011; 28(5):66-67.