May 12th, 2014

My Recent ABIM Maintenance of Certification Experience

A petition to recall the American Board of Internal Medicine’s (ABIM) changes to Maintenance of Certification (MOC) has over 14,000 signatures. The petition calls for the ABIM to revert to the old method of simply certifying physicians using a test administered every ten years.

I didn’t sign the petition, but I am also unhappy. I think the ABIM ought to eliminate the every-ten-years secured exam and go with a more continuous testing approach. And I think the whole thing is way too expensive.

I am “grandfathered in” for Internal Medicine and General Cardiology, but not for Interventional Cardiology. I could probably coast to retirement, but I decided to maintain my certification. At the last ACC meeting, I got started.

First, I went to an MOC session headed by Rick Nishimura and Pat O’Gara on valvular heart disease. I have to say that it was the best learning experience I have had in many years. The case-based format was engaging and the content was skillfully delivered. And I received 10 points of Medical Knowledge MOC credit, as well as CME credit.

Next, I sat down with an ABIM staff member who was available at the ACC meeting to ask about the Performance Improvement Module. I told her that I have worked on quality improvement at my hospital for over 20 years. I attend a monthly committee meeting where we go over a mountain of data pertaining to the quality of cardiac surgery and catheterization laboratory procedures. I said that it didn’t make sense for me to design a little performance improvement project when I was already involved in quality improvement, big time. She agreed and said that, for me, the “Completed Project Performance Improvement Module (PIM)” was the way to go.

I came home and designed my own Completed Project PIM. I had a head start because my hospital participates in the National Cardiovascular Data Registry (NCDR) and I had already signed up for the NCDR Physician Dashboard. So I had ready access to my own NCDR data to use for my PIM.

I went to the ABIM website and found my way to the Completed Project PIM. The website led me to the Measures Library, but also gave me the option to submit my own measures for approval.

If you don’t use measures in the Measures Library, you are required to submit three of your own measures and these measures require ABIM approval. My measures were:

  1. Rate of radial access procedures among my patients undergoing diagnostic cardiac catheterization and percutaneous coronary intervention.
  2. Percentage of my patients undergoing percutaneous coronary intervention (PCI) procedures that were appropriate according to published appropriate use criteria.
  3. Percentage of my patients undergoing PCI who were discharged on a statin medication.

The NCDR dashboard gave me a ready data source for these measures. Others may want to design different measures, built around the data that are available on the NCDR dashboard, or perhaps the PINNACLE registry. The ABIM requires measurement from two time periods and a minimum of 25 patients.

On the ABIM website, I had to fill in the title and description of each measure, and a reference to a guideline recommendation that justified each measure. I filled in the form and submitted my measures by hitting the submit button on the website. In less than 24 hours, I received an email from the ABIM approving them.

The website automatically knew that my measures were approved and it led me to the next step of reporting my results. It asked me a few additional questions, and that was it!  All told, over 2 days I probably put about 3 hours into the activity. With the Completed Project PIM, the ABIM acknowledged that I had already done the work. It was a matter of documenting what I have been doing already.

Let’s face it. The public will always demand that doctors are certified by an independent, objective certifying organization. None of us likes the added work that certification creates, but it is unavoidable. The changes in the ABIM requirements have created a lot of confusion, but the website helps you navigate through the changes, and for me, the ABIM staff was available and helpful.

I would rather have a series of small projects and learning modules, creating an atmosphere of continuous learning and improvement, rather than the big ten-year exam. To me, the petition asked for the wrong thing. I would eliminate the big exam and stick with the other stuff, which isn’t so bad after all.

7 Responses to “My Recent ABIM Maintenance of Certification Experience”

  1. Judith Andersen, AB, MD says:

    I agree completely with Dr Brush’s opinion and appreciate the detail he provided with regard to his own recertification strategy. Our venerable board has been slow to adopt measures taken by other newer boards ( e.g. that for Emergency Medicine), that permit/require more frequent reassessment, with review modules that permit regular updating of physician knowledge and practice — and can, in some cases, obviate the need for a single stressful recertification exam. The wave of the present is recertification, and simply objecting by petition to ABIM’s strategy is not helpful. Testing the ABIM recertification waters will be important, and ABIM will likely– given Dr Brush’s experience–be open to suggestion and modification. Most of us have had to provide evidence of directed CME to our state licensure boards to continue practicing — why should we not have to demonstrate our competence, current practice knowledge, and familiarity with quality assurance measures in some continuous fashion to out certifying board?

  2. If this were about anything other than money, the ABIM would do this for free or for a nominal charge. However, I and many others believe that this is only about having a large constant revenue stream. When those in the ivory tower ABIM lower their salaries and their perks I may consider the MOC. I think Dr Brush’s opinion is a minority opinion on this subject.

    However, as an American trained cardiologist residing overseas I neither have the time, the money, the inclination or the need for MOC. I have lifetime certification in Cardiology here where I practice. Additionally, I accumulate 10X the needed CMEs needed for maintenance of my American License. Finally, I practice with cardiologists on the cutting edge of my field. MOC is not in my future

    Edward C Horwitz DO, FACC, FACP
    Senior Cardiologist Ichilov Hospital/TAMC

  3. THe irony of this piece is that it appears more enamored with the process, than the realization of what the process is doing to patient care. Take, for instance, Dr. Brush’s own words:

    “First, I went to an MOC session headed by Rick Nishimura and Pat O’Gara on valvular heart disease. I have to say that it was the best learning experience I have had in many years. The case-based format was engaging and the content was skillfully delivered. And I received 10 points of Medical Knowledge MOC credit, as well as CME credit.

    Next, I sat down with an ABIM staff member who was available at the ACC meeting to ask about the Performance Improvement Module. I told her that I have worked on quality improvement at my hospital for over 20 years. I attend a monthly committee meeting where we go over a mountain of data pertaining to the quality of cardiac surgery and catheterization laboratory procedures. I said that it didn’t make sense for me to design a little performance improvement project when I was already involved in quality improvement, big time.”

    It seems Dr Brush loves the time off to enjoy the lectures that serves himself. Hey, why not, right? I’d like to sit and listen to good lectures all day, too.

    And why must Dr. Brush perform this busy work of MOC PIM modules if he’s already doing it elsewhere? He nicely chronicles the hours required for this laborious undertaking that detracts from a physician’s time with patients and his own family. It as if Dr. Brush loves MOC because, well, he should love MOC – instead of reaching inside and seeing how corrosive this whole mess has become to patient care. How does counting responses to a survey, or completing computer-entry tasks on ABIM’s website help patients in any way?

    Most important, he fails to mention that the NEJM Group also makes a hefty sum from its courses that it sponsors on behalf of the MOC bureaucracy.

    Why does the NEJM Group support the mission of these *private* organization that have no oversight and no direct accountability to the physicians they pretend to represent? Might it be because this cozy relationship benefits the financial and political aspirations of the members of both of these organizations? Why, for instance, does Cardiosource splash this piece to it’e entire readership without considering a similar headliner piece opposing MOC? Might there be a not-so subliminal push to forward ABIM’s agenda? Might it be to make this the only way a physician can “earn” CME by paying to play?

    When our own peer reviewed Journals enter into the business of certification as the NEJM Group has, the ethics and interests involved become suspect. Every doctor in the US would be well-advised to consider the erosion of trust that occurs when doctors’ valid desire to remain quality physicians is used as a cudgel to make them pay “The Man.”

    This whole re-certification mess is absolutely deplorable and supports the system rather than those who are crushed under the system’s weight.

  4. John E Brush, MD says:

    Thanks, Wes, for your comments. You were right to say that my piece was about process. My major point was that the MOC PIM process is feasible and not unreasonable. As I said in my commentary, I’m not happy about other aspects of the ABIM process.

    And you were right to point out that I enjoyed the MOC learning session that was led by Nishimura and O’Gara. I still enjoy learning, and that session was learning at its best. Those guys are pros. I needed to learn about what’s new with the valvular guidelines, and the MOC points and CME credit seemed like an added bonus. You said that that activity was self-serving. Not true. What I learned at that session will translate into better care for my patients.

    Your comment that all this MOC activity is corrosive to patient care was a bit over the top. All of us physicians are also patients at some point in our lives. I think you will agree that when we go to the doctor, we want to know that our doctor is qualified. Having a transparent and rigorous process to certify physician competence is not corrosive, but conducive to good patient care. Some physicians have complained that there is no proof that certification improves patient care. You could also demand a randomized trial of licensure, or of a medical school diploma. Some things, like a parachute for example, don’t need a randomized controlled trial. They have obvious face validity.

    You may know some “inside baseball” about the relationship between the ABIM and the NEJM Group. Or not. I’m not an insider here, but I do know that both the ABIM and the NEJM Group are esteemed organizations. There is just no evidence of a grand conspiracy between the ABIM and other organizations. In fact, I am told that the ABIM is quite insistent on maintaining fierce independence from other organizations, in order to avoid conflicts of interest and to retain the public trust. Honorable and ethical people work for these organizations. I think we should be more responsible about how we criticize the organizations and we should avoid baseless accusations.

    I wrote the commentary on the ABIM process because I think that what is needed in this whole discussion is more light and less heat. The ABIM needs thoughtful and constructive feedback. I see evidence that they are actively seeking constructive criticism to help them make the necessary corrections. We need to help them.

  5. Fahim H Jafary, MD, FACC, FSCAI says:

    Sorry but the PIM module on my last recertification was a monumental waste of time and to this date I don’t understand its value or why I was asked to go through the motion. The secure exam is also unnecessary as no other medical system in the world (as far as I’m aware) requires it’s physicians to take exams every 10 years and they’re just as good – but it serves and feeds an ill-founded arrogance of “we’re better than the rest”. The ONLY useful thing in the whole MOC process is the set of Q&A modules which give you a learning experience because you tend to read up on the questions you don’t know the answers to. Basically those modules are nothing more than CME, which we all do in different formats (hospital conferences, major meetings, online stuff etc.) If the ABIM has to do it’s “own” thing (to justify it’s existence or something else) then making certificate holders do questions is the best way to ensure that they’re staying up to date. Yes someone may cheat and have someone else do those questions for him/her but really? I can’t ever seeing colleagues lining up to do my MOC modules for me even if I plastered a reward notice on the wall.

    Interestingly, when the new MOC rules came about, I noted that the “grandfathers” in general made the most noise. Yet, their silence was deafening when the original recertification process was put into place in the 1990s.

    Disclaimer: I’m boarded in cardiology, interventional cardiology, nuclear cardiology and cardiovascular CT. I have recertified in the first three once already (and will in cardiac CT when the time comes as well as the rest when the next 10 years are over) because I have no choice. Doesn’t mean I support the current or previous formats of MOC; a cheaper and much simpler system of modules would have sufficed.

  6. John-

    Thanks for your thoughts. I think it is helpful to clarify a few issues. First, I have now completed my third round of recertification in both EP and cardiology. The magnitude of busy work this round was much more signficiant and lended litle extra value to me as a doctor. I agree with Dr. Jafary that the Q&A modules were the most beneficial part of the process – so I should say at the outset that there is some value to the content provided on the various MOC Q&A modules.

    But let’s be clear on one very important point: the ABMS and its 24 subsidiary member boards (which includes the ABIM) are working to tie this MOC process to hospital privileges. If this is permitted to occur (and this is now the case in many facilities), senior doctors with years of experience may lose their ability to earn a living on the basis of the ABMS’s unproven MOC process. How, then, do patient’s benefit if they lose their doctor? Are you willing to lose your ability to earn a living that you have worked your whole life perfecting because of a single 180-question timed exam? The ABIM has NEVER studied the economic and psychologic consequences to doctors who do NOT pass their MOC examination. Why? Is this ethical? This latest year, only 78% of internists passed their MOC exam and there is no concern for what this does to those doctors’ ability to practice medicine, not to mention their psychologic well-being.

    I would also like to point out that the ABMS and its member boards and their foundations are all suposedly independent non-profit organizations that are collaborating together in this endeavor with very poor conflict of interest policies. Note that Christine Cassels earned money from Kaiser Permanente and Premier, Inc while serving as President and CEO of ABIM while her fellow board members turned their cheeks to this relationship.

    The fact that NEJM group recently offered its “Knowledge Plus” learning program for about $500 that satistifes 10 MOC points the ABIM MOC process suggests more than just a “conspiricacy theory” in regard to collusion between these two groups. Like you, I suspect many doctors are unaware of the collaborative arrangement that exists between these organizations that serves to benefit both. How else to legitimize the MOC process that to have the endorsement of the most prestigious medical journal with the largest impact factor?

    Finally, I would encourage you to examine the spreadsheet of salaries that the executives running the ABMS member boards earn from our fees relative to the income doctors make in each specialty that I assembled ( Think about how much we’re being asked to pay for this process in turn.

    Then ask yourself if you’re willing to risk your ability to practice for the ABIM. I hope you now understand some of my concerns.

  7. John E Brush, MD says:

    Thank you for your clear comments. You make several important points. In my original post, I wanted to show how I easily obtained MOC credit at the ACC meeting and how I obtained PIM credit through a Completed Project PIM. But as I said in my original post, I am also not happy about certain aspects of recertification.

    I think recertification should be a continuous learning process – positive, not punitive – that encourages self-study. Having a high stakes exam every 10 years encourages cramming every 10 years, rather than effective lifelong learning. Because it is a high stakes exam, most of us travel to a review course adding considerable expense and hassle to the already high ABIM expenses. In my opinion, the ABIM’s changes should have been a give and take. While adding more frequent requirements, they should have minimized or eliminated the big exam.

    MOC learning modules should be available at the meetings that we already attend. The cost of the modules should be included in the meeting registration fee. MOC should integrate seamlessly into our existing continuing medical education.

    ABIM officials should avoid even the appearance of conflict of interest. And they should seek feedback from rank and file physicians. Richard Baron, the new ABIM CEO, came to the ACC annual meeting and participated in a “town hall meeting” with the ACC Board of Governors and Trustees. I was there. Believe me, he got an earful. He listened and I hope the session was constructive.

    As a Trustee of the ACC, I know that the College has communicated loud and clear to the ABIM that our members are not happy. The College has worked furiously to help our members navigate through these changes and to design programs that will make the MOC as painless as possible. We should all continue to provide the ABIM with constructive criticism that will enable them to improve and make this process more effective, more meaningful, less expensive, and less burdensome.