Letter to the Editor

Maintenance of Certification an evolving process

I'd like to thank Molly Cooke, MD, FACP, for articulating the need for Maintenance of Certification (MOC) in the October 2013 ACP Internist (“Maintenance of Certification is needed, but it needs to change,” page 5). As president and CEO of the American Board of Internal Medicine (ABIM), I believe certification and MOC are a tangible expression of professional self-regulation and an important part of what Dr. Cooke refers to as our “social contract” with patients. Maintaining our certification reflects a commitment to our patients and to the profession that we know what we need to know and do what we need to do to provide high-quality care.

However, I also agree with Dr. Cooke that the ABIM MOC program needs to be better. We share Dr. Cooke's goal for MOC to be “a process that minimizes burdens and ensures value to participating physicians.” In direct response to diplomate feedback to make the exam more relevant and reflective of actual physician practice, ABIM has several initiatives under way to address many of the issues Dr. Cooke raises.

For example, because physicians today rely on supplemental resources in making clinical decisions, ABIM is exploring psychometrically valid ways to provide resources typically accessed via the Internet to physicians during exams and determine their appropriate use in testing. Other enhancements, such as embedding high-quality audio exhibits in the exam questions and adding the ability to zoom in on images, have already been implemented in some ABIM exams and will be expanded to others as appropriate. Additional enhancements being explored include incorporating computer-based clinical simulations and the ability for physicians to reference specific formulas, such as the Framingham risk calculator, during the exam.

Citing the evidence that physicians are often unaware of what they do not know, Dr. Cooke emphasizes the need for physicians to receive feedback through mechanisms such as knowledge testing. To make the secure exam a more helpful feedback mechanism, ABIM will be introducing enhanced exam score reports that provide physicians with more detailed exam performance data on their strengths and weaknesses in the clinical content domains measured in the exam. Through research and physician focus groups, ABIM is exploring the level of detail and categories of information that physicians would find most useful to inform their ongoing learning.

Dr. Cooke also emphasizes the need for physicians to be engaged in quality improvement, which is an important component of MOC. Many of the quality improvement activities in which physicians are already engaged in their own practices and health systems will meet that requirement of MOC; for physicians who choose to use ABIM's quality improvement tools (our Practice Improvement Modules), we are working to make them more beneficial and easier to use and to assure that they align with national quality measures.

To further enhance the relevance of our assessments, we have convened the Assessment 2020 Task Force, which includes a broad array of experts from both inside and outside the profession of medicine. This Task Force will be directly seeking input from our diplomates and other members of the public about what skills a physician needs now and will need in the future. We encourage internist feedback via the Assessment 2020 website. ABIM's offerings will continue to evolve to reflect different knowledge and practice expectations and different technologies for assessment and to find ways to recognize high-value activities physicians are already doing. And our Council has recently decided to expand our specialty/subspecialty board membership by requiring that all boards have at least one internist member who is engaged in non-academic community practice, as well as requiring that each board have at least two at-large non-internist members, one a member of the interprofessional health care team, the other someone who can bring the patient or caregiver perspective. So ABIM is diversifying the skill set of those on our boards to assure that our products are relevant and meaningful to diplomates and the public.

Dr. Cooke acknowledges that “constructing high-quality, psychometrically valid items for high-stakes tests ... is inevitably expensive.” We're very careful in establishing our fees, which are among the lowest of the specialty boards. Starting in 2014, we're also giving diplomates the option of paying for MOC on an annual basis instead of paying in a lump sum every 10 years.

As Dr. Cooke points out, it is important for internists to maintain knowledge of a core of internal medicine, which is why the internal medicine MOC exam continues to assess knowledge across the breadth of the discipline. However, maintaining certification in most internal medicine subspecialties does not require maintaining certification in internal medicine, and ABIM encourages diplomates to maintain certification only in the areas relevant to their practice.

A well-functioning certifying board needs to be insulated without being insular, listening carefully to those who seek to meet our standard yet remaining independent and evidence-based in the standards and processes we set. We believe that conversations about the value of MOC are healthy and can only make MOC better. ABIM is committed to transparency and will be making more and more information available on our website relating to our finances, our test development process, the charters and composition of our committees, commercial relationships of board directors, and the experience of our diplomates with our process as reported in ongoing surveys.

Dr. Cooke is right: MOC is necessary, but it also needs to improve. We're committed to making MOC better, and we welcome your feedback to help us make it the program it should be, a process that is meaningful to both physicians and the patients we serve.

Richard J. Baron, MD, MACP
Philadelphia