MOC changes haven’t quieted uprising

The American Board of Internal Medicine is making several changes to its maintenance of certification requirements, but, so far, it is not enough to quell the still-growing tide of anger and resentment against the process.

The ABIM announced the changes just ahead of a July 15 "summit" with 26 specialty societies that receive certification through the organization, and outlined them in a detailed letter that was sent to internal medicine diplomates on July 28. That correspondence also responded in detail to a May 7 letter sent by the American College of Physicians (ACP) on behalf of 14 medical societies, enumerating their concerns about the process.

The American Gastroenterological Association, which attended the July 15 meeting, has a number of concerns about the administrative burden of maintenance of certification, the cost of the requirements, and implications for failing to complete a flawed process.

Dr. Lawrence S. Kim, AGAF, who’s in private practice in Denver, attended the meeting on behalf of the AGA. He noted that "gastroenterologists feel increasingly threatened by recent changes to the ABIM recertification process. We are all struggling to adapt to a brave new world of narrowing networks and ever-increasing public scrutiny. In this milieu, loss of board certification represents a true calamity to the professional lives of our physicians and in many cases, presents a truly existential threat to their livelihoods."

Recently, the AGA Governing Board discussed why the ABIM is in charge of saying what the requirements are for keeping certification in gastroenterology.

"It’s time to take charge of our profession and be proactive, setting the criteria for recertification in our specialty. To that end, AGA has joined with other societies to advocate for changes to the system. We have visited the ABIM to share concerns and push for changes to help GIs meet the requirements," said Dr. Suzanne Rose, AGA Governing Board Education Councillor.

Meanwhile, 3,000 or so physicians have signed on to a "Pledge of Non-Compliance" with the ABIM’s requirements. The pledge was organized by Dr. Paul Teirstein, chief of cardiology and director of interventional cardiology at the Scripps Clinic, La Jolla, Calif., and colleagues who have formed Physicians for Certification Change, an anti-MOC organization. Dr. Teirstein also launched a petition drive in March to overhaul the MOC process. That petition had about 18,000 signees at press time.

There are several other organizations hoping to derail or significantly change the ABIM’s requirements, including the Association of American Physicians and Surgeons, Change Board Certification, and Docs4PatientCare. In addition, many of the 26 professional societies, including AGA, whose members are certified by the ABIM, have been very organized in presenting their discontent.

The ABIM understands the frustration, said Dr. Richard Baron, ABIM president and chief executive officer, in an interview. "One of the things that people have said is that we’re not listening," he said. That is one reason why the ABIM decided to hold what he called a "listening session" on July 15. "We’re a learning organization," he added, noting that the ABIM will "continue to evolve the program," based on the feedback it receives from individuals and from professional societies, among others.

Dr. Baron also acknowledges that by presenting an entirely new MOC process this year, "our timing was not propitious." The ABIM outlined pressures on physicians in the July 28 letter, counting among them "dealing with the Affordable Care Act," fulfilling meaningful use requirements, and responding to changes in payment and practice models, including team-based care.

The ABIM is making a handful of changes to address some of the concerns, including "broadening the kinds of educational activities that can count for self-assessment of knowledge," said Dr. Baron. That is, the ABIM will be broadening the continuing medical education that will count toward the self-assessment of medical knowledge portion of the MOC requirements. Physicians must earn 100 MOC points every 5 years. At least 20 points must be self-assessment of medical knowledge and at least 20 points must be self-evaluation of practice assessment. The remaining 60 points can be either type of MOC.

There have also been a huge number of complaints about the self-evaluation of practice assessment MOC, often referred to as practice improvement modules or PIM’s. There will be less direct data collection by the ABIM, and more of a focus "on improvement activities doctors may already be doing in their practice," Dr. Baron said.

But Dr. Kim noted that it might not be that simple. Existing EMR products do not have the capability to assess most subspecialty-specific measures. "We urge the ABIM to bring its influence to bear on the health IT industry, to develop standardized templates and reports," said Dr. Kim. Ideally, maintenance of certification practice assessments will harmonize with federal quality reporting programs.

Among other things, ABIM is also looking at changes to the secure exam and whether it needs to change how it describes on its website whether physicians are meeting MOC requirements (see related story on p. 5 for more details on ABIM changes).

However, many at the July meeting questioned whether the current exam truly reflects physicians’ clinical abilities. Pass rates for the recertification exam have steadily declined over recent years for many subspecialties. AGA has communicated this concern to ABIM on several occasions, helping to instigate the new changes to ABIM’s governance and operational structure.

"AGA wants a role in determining the components of recertification. We will ensure the requirements are a reflection of competent clinical practice," said Dr. Rose.

Despite the newly announced changes from ABIM, critics remain dissatisfied.

Dr. Ron Benbassat, an internist in Beverly Hills, Calif. and a founder of Change Board Certification, said, "No one is drinking the ABIM’s Koolaid." He added, "The momentum is increasing and I believe we’re reaching the tipping point. As to what form it will take – widespread noncompliance or political or legal, I don’t have the answer."

Dr. Teirstein was a bit more muted in his criticism. "They are certainly taking many good steps. But, the devil will be in the details." He, like many physicians, said that he still sees the ABIM’s fees as a big problem. "To reestablish credibility, ABIM will need to roll back its fee schedule," said Dr. Teirstein.

The ABIM charges $1,940 for a 10-year basic internal medicine certification, which includes a secure examination for each specialty the diplomate chooses to maintain, access to all ABIM self-evaluation products, and any CME credit a physician can claim through completion of an ABIM module. There are basically four requirements: MOC participants have to take a secure exam; they have to complete a module that contains knowledge and patient management questions; another module is on practice improvement; and, a third covers a survey of patient safety and satisfaction.

The fees vary for different practices within the field of internal medicine: $2,060 for a focused practice in hospital medicine for 10 years and $2,560 for any subspecialty – including gastroenterology – for the 10 years.

"Physicians are forced to spend unreasonable time and expense to collect this data," says Dr. Kim. "The time needed to fulfill new expanded MOC requirements should not come at the expense of time spent on patient care."

The ABIM said in its July 28 letter that extensive evidence does exist that the ABIM process works – with more than half of the studies coming from non-ABIM researchers – but that maybe it hasn’t done the best job of communicating that to diplomates. However, it does say it welcomes partnering on new projects "and a broader discussion of [sic] potential research agenda."

Many say that they are in favor of requiring lifelong learning, but that the ABIM has gone about it the wrong way. Dr. Steven Weinberger, chief executive of the ACP, said that his organization wants to see more customization of the secure board exam "so that it’s more relevant to a particular physician’s practice."

Many who attended the ABIM’s July 15 meeting said that they felt like the organization had heard their concerns. But they are still waiting to see what will happen next.

The changes already announced "are a very good start," said Dr. Weinberger, who said that the ACP hopes that the ABIM board might make more changes at its meeting in August.

Likewise, Dr. Eric Green, chair of the MOC Task Force at the Society of General Internal Medicine, said that the SGIM would continue to work in cooperation with the ABIM. The question is how much the ABIM will use the input from the subspecialty societies, he said.

Dr. Christopher White, professor and chairman of medicine at the Ochsner Clinical School, New Orleans, a founding member of Physicians for Certification Change, who has signed the pledge of noncompliance, is a bit more skeptical. "I think the ABIM is going to have to be a lot less arrogant," he said, calling for more accountability by the organization.

[email protected]

The American Board of Internal Medicine is making several changes to its maintenance of certification requirements, but, so far, it is not enough to quell the still-growing tide of anger and resentment against the process.

The ABIM announced the changes just ahead of a July 15 "summit" with 26 specialty societies that receive certification through the organization, and outlined them in a detailed letter that was sent to internal medicine diplomates on July 28. That correspondence also responded in detail to a May 7 letter sent by the American College of Physicians (ACP) on behalf of 14 medical societies, enumerating their concerns about the process.

The American Gastroenterological Association, which attended the July 15 meeting, has a number of concerns about the administrative burden of maintenance of certification, the cost of the requirements, and implications for failing to complete a flawed process.

Dr. Lawrence S. Kim, AGAF, who’s in private practice in Denver, attended the meeting on behalf of the AGA. He noted that "gastroenterologists feel increasingly threatened by recent changes to the ABIM recertification process. We are all struggling to adapt to a brave new world of narrowing networks and ever-increasing public scrutiny. In this milieu, loss of board certification represents a true calamity to the professional lives of our physicians and in many cases, presents a truly existential threat to their livelihoods."

Recently, the AGA Governing Board discussed why the ABIM is in charge of saying what the requirements are for keeping certification in gastroenterology.

"It’s time to take charge of our profession and be proactive, setting the criteria for recertification in our specialty. To that end, AGA has joined with other societies to advocate for changes to the system. We have visited the ABIM to share concerns and push for changes to help GIs meet the requirements," said Dr. Suzanne Rose, AGA Governing Board Education Councillor.

Meanwhile, 3,000 or so physicians have signed on to a "Pledge of Non-Compliance" with the ABIM’s requirements. The pledge was organized by Dr. Paul Teirstein, chief of cardiology and director of interventional cardiology at the Scripps Clinic, La Jolla, Calif., and colleagues who have formed Physicians for Certification Change, an anti-MOC organization. Dr. Teirstein also launched a petition drive in March to overhaul the MOC process. That petition had about 18,000 signees at press time.

There are several other organizations hoping to derail or significantly change the ABIM’s requirements, including the Association of American Physicians and Surgeons, Change Board Certification, and Docs4PatientCare. In addition, many of the 26 professional societies, including AGA, whose members are certified by the ABIM, have been very organized in presenting their discontent.

The ABIM understands the frustration, said Dr. Richard Baron, ABIM president and chief executive officer, in an interview. "One of the things that people have said is that we’re not listening," he said. That is one reason why the ABIM decided to hold what he called a "listening session" on July 15. "We’re a learning organization," he added, noting that the ABIM will "continue to evolve the program," based on the feedback it receives from individuals and from professional societies, among others.

Dr. Baron also acknowledges that by presenting an entirely new MOC process this year, "our timing was not propitious." The ABIM outlined pressures on physicians in the July 28 letter, counting among them "dealing with the Affordable Care Act," fulfilling meaningful use requirements, and responding to changes in payment and practice models, including team-based care.

The ABIM is making a handful of changes to address some of the concerns, including "broadening the kinds of educational activities that can count for self-assessment of knowledge," said Dr. Baron. That is, the ABIM will be broadening the continuing medical education that will count toward the self-assessment of medical knowledge portion of the MOC requirements. Physicians must earn 100 MOC points every 5 years. At least 20 points must be self-assessment of medical knowledge and at least 20 points must be self-evaluation of practice assessment. The remaining 60 points can be either type of MOC.

There have also been a huge number of complaints about the self-evaluation of practice assessment MOC, often referred to as practice improvement modules or PIM’s. There will be less direct data collection by the ABIM, and more of a focus "on improvement activities doctors may already be doing in their practice," Dr. Baron said.

But Dr. Kim noted that it might not be that simple. Existing EMR products do not have the capability to assess most subspecialty-specific measures. "We urge the ABIM to bring its influence to bear on the health IT industry, to develop standardized templates and reports," said Dr. Kim. Ideally, maintenance of certification practice assessments will harmonize with federal quality reporting programs.

Among other things, ABIM is also looking at changes to the secure exam and whether it needs to change how it describes on its website whether physicians are meeting MOC requirements (see related story on p. 5 for more details on ABIM changes).

However, many at the July meeting questioned whether the current exam truly reflects physicians’ clinical abilities. Pass rates for the recertification exam have steadily declined over recent years for many subspecialties. AGA has communicated this concern to ABIM on several occasions, helping to instigate the new changes to ABIM’s governance and operational structure.

"AGA wants a role in determining the components of recertification. We will ensure the requirements are a reflection of competent clinical practice," said Dr. Rose.

Despite the newly announced changes from ABIM, critics remain dissatisfied.

Dr. Ron Benbassat, an internist in Beverly Hills, Calif. and a founder of Change Board Certification, said, "No one is drinking the ABIM’s Koolaid." He added, "The momentum is increasing and I believe we’re reaching the tipping point. As to what form it will take – widespread noncompliance or political or legal, I don’t have the answer."

Dr. Teirstein was a bit more muted in his criticism. "They are certainly taking many good steps. But, the devil will be in the details." He, like many physicians, said that he still sees the ABIM’s fees as a big problem. "To reestablish credibility, ABIM will need to roll back its fee schedule," said Dr. Teirstein.

The ABIM charges $1,940 for a 10-year basic internal medicine certification, which includes a secure examination for each specialty the diplomate chooses to maintain, access to all ABIM self-evaluation products, and any CME credit a physician can claim through completion of an ABIM module. There are basically four requirements: MOC participants have to take a secure exam; they have to complete a module that contains knowledge and patient management questions; another module is on practice improvement; and, a third covers a survey of patient safety and satisfaction.

The fees vary for different practices within the field of internal medicine: $2,060 for a focused practice in hospital medicine for 10 years and $2,560 for any subspecialty – including gastroenterology – for the 10 years.

"Physicians are forced to spend unreasonable time and expense to collect this data," says Dr. Kim. "The time needed to fulfill new expanded MOC requirements should not come at the expense of time spent on patient care."

The ABIM said in its July 28 letter that extensive evidence does exist that the ABIM process works – with more than half of the studies coming from non-ABIM researchers – but that maybe it hasn’t done the best job of communicating that to diplomates. However, it does say it welcomes partnering on new projects "and a broader discussion of [sic] potential research agenda."

Many say that they are in favor of requiring lifelong learning, but that the ABIM has gone about it the wrong way. Dr. Steven Weinberger, chief executive of the ACP, said that his organization wants to see more customization of the secure board exam "so that it’s more relevant to a particular physician’s practice."

Many who attended the ABIM’s July 15 meeting said that they felt like the organization had heard their concerns. But they are still waiting to see what will happen next.

The changes already announced "are a very good start," said Dr. Weinberger, who said that the ACP hopes that the ABIM board might make more changes at its meeting in August.

Likewise, Dr. Eric Green, chair of the MOC Task Force at the Society of General Internal Medicine, said that the SGIM would continue to work in cooperation with the ABIM. The question is how much the ABIM will use the input from the subspecialty societies, he said.

Dr. Christopher White, professor and chairman of medicine at the Ochsner Clinical School, New Orleans, a founding member of Physicians for Certification Change, who has signed the pledge of noncompliance, is a bit more skeptical. "I think the ABIM is going to have to be a lot less arrogant," he said, calling for more accountability by the organization.

[email protected]

The American Board of Internal Medicine is making several changes to its maintenance of certification requirements, but, so far, it is not enough to quell the still-growing tide of anger and resentment against the process.

The ABIM announced the changes just ahead of a July 15 "summit" with 26 specialty societies that receive certification through the organization, and outlined them in a detailed letter that was sent to internal medicine diplomates on July 28. That correspondence also responded in detail to a May 7 letter sent by the American College of Physicians (ACP) on behalf of 14 medical societies, enumerating their concerns about the process.

The American Gastroenterological Association, which attended the July 15 meeting, has a number of concerns about the administrative burden of maintenance of certification, the cost of the requirements, and implications for failing to complete a flawed process.

Dr. Lawrence S. Kim, AGAF, who’s in private practice in Denver, attended the meeting on behalf of the AGA. He noted that "gastroenterologists feel increasingly threatened by recent changes to the ABIM recertification process. We are all struggling to adapt to a brave new world of narrowing networks and ever-increasing public scrutiny. In this milieu, loss of board certification represents a true calamity to the professional lives of our physicians and in many cases, presents a truly existential threat to their livelihoods."

Recently, the AGA Governing Board discussed why the ABIM is in charge of saying what the requirements are for keeping certification in gastroenterology.

"It’s time to take charge of our profession and be proactive, setting the criteria for recertification in our specialty. To that end, AGA has joined with other societies to advocate for changes to the system. We have visited the ABIM to share concerns and push for changes to help GIs meet the requirements," said Dr. Suzanne Rose, AGA Governing Board Education Councillor.

Meanwhile, 3,000 or so physicians have signed on to a "Pledge of Non-Compliance" with the ABIM’s requirements. The pledge was organized by Dr. Paul Teirstein, chief of cardiology and director of interventional cardiology at the Scripps Clinic, La Jolla, Calif., and colleagues who have formed Physicians for Certification Change, an anti-MOC organization. Dr. Teirstein also launched a petition drive in March to overhaul the MOC process. That petition had about 18,000 signees at press time.

There are several other organizations hoping to derail or significantly change the ABIM’s requirements, including the Association of American Physicians and Surgeons, Change Board Certification, and Docs4PatientCare. In addition, many of the 26 professional societies, including AGA, whose members are certified by the ABIM, have been very organized in presenting their discontent.

The ABIM understands the frustration, said Dr. Richard Baron, ABIM president and chief executive officer, in an interview. "One of the things that people have said is that we’re not listening," he said. That is one reason why the ABIM decided to hold what he called a "listening session" on July 15. "We’re a learning organization," he added, noting that the ABIM will "continue to evolve the program," based on the feedback it receives from individuals and from professional societies, among others.

Dr. Baron also acknowledges that by presenting an entirely new MOC process this year, "our timing was not propitious." The ABIM outlined pressures on physicians in the July 28 letter, counting among them "dealing with the Affordable Care Act," fulfilling meaningful use requirements, and responding to changes in payment and practice models, including team-based care.

The ABIM is making a handful of changes to address some of the concerns, including "broadening the kinds of educational activities that can count for self-assessment of knowledge," said Dr. Baron. That is, the ABIM will be broadening the continuing medical education that will count toward the self-assessment of medical knowledge portion of the MOC requirements. Physicians must earn 100 MOC points every 5 years. At least 20 points must be self-assessment of medical knowledge and at least 20 points must be self-evaluation of practice assessment. The remaining 60 points can be either type of MOC.

There have also been a huge number of complaints about the self-evaluation of practice assessment MOC, often referred to as practice improvement modules or PIM’s. There will be less direct data collection by the ABIM, and more of a focus "on improvement activities doctors may already be doing in their practice," Dr. Baron said.

But Dr. Kim noted that it might not be that simple. Existing EMR products do not have the capability to assess most subspecialty-specific measures. "We urge the ABIM to bring its influence to bear on the health IT industry, to develop standardized templates and reports," said Dr. Kim. Ideally, maintenance of certification practice assessments will harmonize with federal quality reporting programs.

Among other things, ABIM is also looking at changes to the secure exam and whether it needs to change how it describes on its website whether physicians are meeting MOC requirements (see related story on p. 5 for more details on ABIM changes).

However, many at the July meeting questioned whether the current exam truly reflects physicians’ clinical abilities. Pass rates for the recertification exam have steadily declined over recent years for many subspecialties. AGA has communicated this concern to ABIM on several occasions, helping to instigate the new changes to ABIM’s governance and operational structure.

"AGA wants a role in determining the components of recertification. We will ensure the requirements are a reflection of competent clinical practice," said Dr. Rose.

Despite the newly announced changes from ABIM, critics remain dissatisfied.

Dr. Ron Benbassat, an internist in Beverly Hills, Calif. and a founder of Change Board Certification, said, "No one is drinking the ABIM’s Koolaid." He added, "The momentum is increasing and I believe we’re reaching the tipping point. As to what form it will take – widespread noncompliance or political or legal, I don’t have the answer."

Dr. Teirstein was a bit more muted in his criticism. "They are certainly taking many good steps. But, the devil will be in the details." He, like many physicians, said that he still sees the ABIM’s fees as a big problem. "To reestablish credibility, ABIM will need to roll back its fee schedule," said Dr. Teirstein.

The ABIM charges $1,940 for a 10-year basic internal medicine certification, which includes a secure examination for each specialty the diplomate chooses to maintain, access to all ABIM self-evaluation products, and any CME credit a physician can claim through completion of an ABIM module. There are basically four requirements: MOC participants have to take a secure exam; they have to complete a module that contains knowledge and patient management questions; another module is on practice improvement; and, a third covers a survey of patient safety and satisfaction.

The fees vary for different practices within the field of internal medicine: $2,060 for a focused practice in hospital medicine for 10 years and $2,560 for any subspecialty – including gastroenterology – for the 10 years.

"Physicians are forced to spend unreasonable time and expense to collect this data," says Dr. Kim. "The time needed to fulfill new expanded MOC requirements should not come at the expense of time spent on patient care."

The ABIM said in its July 28 letter that extensive evidence does exist that the ABIM process works – with more than half of the studies coming from non-ABIM researchers – but that maybe it hasn’t done the best job of communicating that to diplomates. However, it does say it welcomes partnering on new projects "and a broader discussion of [sic] potential research agenda."

Many say that they are in favor of requiring lifelong learning, but that the ABIM has gone about it the wrong way. Dr. Steven Weinberger, chief executive of the ACP, said that his organization wants to see more customization of the secure board exam "so that it’s more relevant to a particular physician’s practice."

Many who attended the ABIM’s July 15 meeting said that they felt like the organization had heard their concerns. But they are still waiting to see what will happen next.

The changes already announced "are a very good start," said Dr. Weinberger, who said that the ACP hopes that the ABIM board might make more changes at its meeting in August.

Likewise, Dr. Eric Green, chair of the MOC Task Force at the Society of General Internal Medicine, said that the SGIM would continue to work in cooperation with the ABIM. The question is how much the ABIM will use the input from the subspecialty societies, he said.

Dr. Christopher White, professor and chairman of medicine at the Ochsner Clinical School, New Orleans, a founding member of Physicians for Certification Change, who has signed the pledge of noncompliance, is a bit more skeptical. "I think the ABIM is going to have to be a lot less arrogant," he said, calling for more accountability by the organization.

[email protected]