Maintaining the sanity of maintenance of certification

If you were with your fellow internists at Internal Medicine 2014 in April, then you enjoyed another great meeting. Each year, the meeting takes on its own unique atmosphere of interest and discussion in response to events of the day and the ever-changing practice and academic environment of the internal medicine community. This year, the hallway murmurings between sessions more times than not were about the new Maintenance of Certification (MOC) requirements and what ACP is going to do about them.

As you know, MOC is a program initiated by the American Board of Internal Medicine (ABIM) that requires demonstration of ongoing attainment of medical knowledge, practice assessment of quality, patient safety, patient surveys, and verification of credentials (holding a valid license to practice medicine). It also requires that participants pass a secure exam every 10 years. This last requirement seems to be causing the greatest angst.

Presently, we have 70,000 certified ACP members, 41,000 of whom took boards after 1990 and are now required to recertify every 10 years by taking a secure exam. The remaining 29,000 certified members were certified before 1990 and thus have a “time-unlimited certification,” but all must participate by signing up on the ABIM website and paying $193 annually to be listed as “Certified, Meeting MOC Requirements,” regardless of whether they intend to take the secure exam. I'm told that about 125,000 internists have enrolled so far, and the deadline for doing so was extended to the end of April. This is a rolling process, and to meet requirements enrollees must earn some points every 2 years, earn 100 points every 5 years, and do a patient survey as well as a patient safety module every 5 years.

For many busy internists, MOC is overly complex, burdensome, and costly at many levels, especially when multiple recertifications may be needed, which is true for many of our members. Those who are less clinically active or have a focused practice are concerned about how these requirements relate to their professional lives and if they can be successful.

At both the Board of Governors and Board of Regents meetings prior to and during Internal Medicine 2014, MOC was heavily debated. There was concern expressed that MOC is overly burdensome and expensive, without compelling evidence that it makes for better internists or improves clinical outcomes. Anecdotally, MOC is also felt to contribute to physician dissatisfaction, anger, and burnout. Several of ACP's leaders serve or have served on ABIM, and those who support a rigorous MOC process rightly argue that it is our civic duty, consistent with our contract with society, that we ensure competency and excellence in our ranks; they feel that MOC helps us meet that obligation. Counterarguments are that MOC further distracts from the professional commitment to patient care and, for many, the very ability to continue medical practice.

There is good reason to be worried. The failure rate on the secure recertification exam has been increasing for first-time takers. In 2013, an amazing 22% failed compared to 10% 5 years ago, with a steady increase in the number of failures for first-time takers observed each year. It should be noted that the ultimate pass rate for all first-time takers was over 90%, but why such a progressively high failure rate in the first round? This question needs to be explored seriously and objectively.

Another question that comes to mind is why U.S. internists are seen as uniquely different compared to our colleagues in virtually every other country when considering the need to ensure competency. At Internal Medicine 2014, we held an international forum representing internal medicine organizations and societies from more than 30 countries around the globe. Some have large memberships that work in robust medical systems, while others do not. Both private and academic internists were represented. All shared the same passion for ensuring clinical excellence in their members and having primary concern for patient welfare. Virtually every country represented had an ongoing certifying process that was tightly monitored, either by the government or a professional society, and several common themes emerged:

• Clinical competency is primarily based on successful (high-quality and safe) practice and demonstration of continuing medical education (CME) requiring numerous (80 to 100) hours of CME each year relevant to physicians' primary clinical activity or specialty;
• CME requirements are lessened if the physician moved away from clinical practice (administration, teaching, etc.), but a certain minimum of CME is still required;
• Maintenance of certification is often but not always linked to credentialing;
• In some cases financial incentives are provided when minimum CME requirements are met;
• Peer review is generally utilized to measure competency;
• Emphasis is on clinical management and communication skills, as well as knowledge; and
• Universally, there is no requirement to take a secure recertification exam, though in some countries it is voluntary as a means for CME.

What struck me while hearing about MOC in other countries is that clinical outcomes and cost of health care in the U.S. are for the most part no better, and indeed frequently are not nearly as good, as those enjoyed by our international colleagues.

How can we improve the process and modify requirements to make MOC more palatable, educational, and constructive for everyone concerned, especially our patients? More specifically, what can the College do to better serve our members preparing to participate in MOC? We already have many products available to help, including MKSAP, Annals of Internal Medicine, and various tools for self-assessment and quality improvement. Check out “ABIM Maintenance of Certification Process” for more details about how you can navigate the process to meet your specific needs. It's very informative and extremely helpful!

I firmly believe that everyone involved in this discussion on both sides of the table shares certain core values and precepts, namely the primacy of patient welfare and the pursuit of achieving and maintaining professional excellence. After all, are we not all internists? These are the grounding principles upon which we should begin and end the discussion. As internists, we are guided by the same precepts, whether representing ACP or ABIM.

We also share membership and leadership in both organizations. Leadership and members of both organizations care deeply about these issues and feel strongly that professional competence and patient safety must be maintained. We speak the same language, but we are approaching the problem from different perspectives organizationally. To be successful, we must find a way to bridge the gap by together holding fast to what we share professionally while objectively assessing all viewpoints.

I can assure you that the College will continue to explore all options in meeting the needs of our members in the service of our patients. We will also continue to do what we can to find common ground with everyone at the table in hopes of moving the dial on the MOC process and making it more educational, professionally fulfilling, and relevant to what we actually do in the practice of medicine.