Maintenance of Certification

Maintenance of Certification (MOC) is a controversial process of keeping physician certification up-to-date through one of the 24 approved medical specialty boards of the American Board of Medical Specialties (ABMS) as well as some of the medical specialty boards of the American Osteopathic Association (AOA).^[1] The MOC process is controversial within the medical community, with proponents claiming that it is a voluntary program that improves physician knowledge and demonstrates a commitment to lifelong learning. Critics claim that MOC is an expensive, burdensome, and clinically irrelevant process created primarily as a money-making scheme for the ABMS and often used as a requirement for hospital employment, hospital privileges, and insurance reimbursements.^[2] In fact, the Association of American Physicians & Surgeons (AAPS) has filed an antitrust suit against the ABMS to end the MOC program and prevent attempts to link MOC to medical licensing.^[3] ABMS argues that board certified physicians deliver higher quality care than their non-certified colleagues and that board certification is correlated with:

• Higher performance on a broad range of quality measures^[4][5][6]
• Implantations by a nonelectrophysiologist were associated with a higher risk of procedural complications and lower likelihood of receiving a CRT-D device when indicated compared with patients whose ICD was implanted by an electrophysiologist.^[7]
• Better outcomes and more reliable care^[4]
• Higher quality of care for acute myocardial infarction(AMI)^[8]
• 15% lower mortality in myocardial infarction^[9][10]
• Higher rates of some preventative services^[10]

It is important to realize that most of the studies quoted are of low scientific quality since they are observational in nature and not double-blinded. Furthermore, most of these studies are funded and performed by those supported by ABMS and various specialty boards who have significant conflicts of interest. Additionally, the ABMS has a significant financial conflict of interest in its MOC promotion.

The Maintenance of Certification program is designed to help physicians keep abreast of advances in their fields, develop better practice systems, and demonstrate a commitment to lifelong learning. Whether or not the MOC program accomplishes any of its goals is a matter of intense debate. There are many physicians who feel MOC is a worthless program forced on them to raise funds for the ABMS and its specialty boards.

Maintenance of Certification and the medical community

Many major medical organizations have expressed support for the Maintenance of Certification program as a potential means of facilitating physicians' continuous professional development and measuring physicians' continued competency, including the following:

• The American Board of Medical Specialties (ABMS)
• The American Osteopathic Association (AOA)
• The American Medical Association
• The American Hospital Association (AHA)
• The National Board of Medical Examiners (NBME)
• The Federation of State Medical Boards (FSMB)
• The Council of Medical Specialty Societies (CMSS)
• The Accreditation Council for Graduate Medical Education (ACGME)
• The Association of American Medical Colleges (AAMC)
• The Educational Commission for Foreign Medical Graduates (ECFMG)

Maintenance of Certification competencies

The Maintenance of Certification program strives to assess the six general competencies identified through the ACGME Outcome Project and subsequently required in medical residency program evaluations:

• patient care and procedural skills
• medical knowledge
• practice-based learning and improvement
• interpersonal and communications skills
• professionalism, which is tautologically described by the ABMS as participating in MOC
• systems-based practice

Maintenance of Certification components

Maintenance of Certification incorporates the ACGME competencies through four program elements:

• Professional Standing: Physicians must have a valid, unrestricted license to practice medicine and confirmation of good standing in their local practice community.
• Lifelong Learning and Self-Assessment: Through examinations and other assessment methods developed by ABMS member Boards, medical societies, and others, physicians assess their clinical and practical knowledge. This component stimulates learning, requires that physicians document their learning, and ensures that physicians keep up with the rapidly evolving medical knowledge essential to quality patient care.
• Cognitive Expertise: Physicians are required to pass a closed-book, proctored examination in their specialty area that assesses critical aspects of clinical knowledge and judgment in scenarios like those encountered in physician practice. This examination evaluates not only what physicians know, but how they use what they know to promote health, diagnose and treat illness effectively and efficiently. Many physicians suspect that these closed book exams are unnecessary and of little value in the era of smart phones and immediately available internet access.
• Practice Performance Assessment: Physicians use tools to self-assess their performance in medical practice, with an emphasis on patient care quality, measurement, and documented quality improvement. These assessment tools include various Practice Improvement Modules (PIMs) that evaluate physicians' performance in a clinical area relevant to their practice, compare their performance to clinical guidelines, help them to develop a plan to improve important aspects of their practice, and assess the impact of that improvement plan. As of Feb 3, 2015 the practice performance assessment of the American Board of Internal Medicine has been suspended for two years since so many internists found the process not worth the time necessary to complete this assessment.

Maintenance of Certification and other stakeholders

Some health plans are implementing programs that recognize and reward physicians who are actively participating in Maintenance of Certification activities.^[11] ABMS member boards are actively working with other health care organizations to advance quality initiatives and reduce measurement redundancy through recognition of physicians' Maintenance of Certification program participation. A growing number of hospitals and health systems are beginning to use Maintenance of Certification components to engage physicians in quality improvement. While many physicians feel participating in the Maintenance of Certification program is an expensive waste of time, more than 450,000 physicians are engaged in MOC activities.^[12]

Studies suggest that board-certified physicians provide improved quality of patient care and better clinical outcomes than those physicians without board certification,^[7] including a 15% reduction in mortality rate among heart attack patients treated by board-certified physicians.^[8] Considering a recent meta-analysis that shows a decline in physician performance associated with the time elapsed since the physician's initial training,^[13] it is essential for physicians to participate in programs such as Maintenance of Certification in order to keep current with medicine's expanding knowledge base and technical advances, and to apply this knowledge to quality improvement in their medical practice. There is, however, no evidence MOC participation has any effect on this alleged age-related decline in performance and no evidence MOC is as good as any other intervention or no intervention. Maintenance of Certification strives to help physicians and other health care stakeholders address the critical need to enhance patient safety and patient care quality.^[14] There is no evidence to support any efficacy for maintenance of certification in enhancing patient safety and patient care quality. It is important to recognize the extensive conflicts of interests in studies funded by and performed by ABMS and specialty board employees.

Studies have shown that a physician’s ability to independently and accurately self-assess is poor,^[15] that more clinical experience does not necessarily lead to better outcomes of care^[16] and that fewer than 30% of physicians examine their own performance data and try to improve.^[17] The MOC program structure strives to address these concerns with a sound theoretical rationale via the six ACGME competencies framework and a respectable body of scientific evidence, and to address its relationship to patient outcomes, physician performance, validity of the assessment or educational methods utilized and learning or improvement potential.^[18] A study presented at the AcademyHealth conference in June 2013 found a correlation between an MOC requirement and reduced cost of care and emergency department visits; this paper is currently under review. There are no data suggesting MOC is in any way superior to a number of self-assessment programs, sponsored by physician specialty societies, that are significantly less expensive than MOC.

See also

• American Board of Medical Specialties (ABMS)
• American Osteopathic Association Bureau of Osteopathic Specialists (AOABOS)

References

External links

• Official ABMS Maintenance of Certification Website
• http://www.changeboardrecert.com