Earlier this year the American Board of Internal Medicine (ABIM) made sweeping changes to its maintenance of certification (MOC) program. The board suspended Practice Assessment, Patient Voice, and Patient Safety requirements. The changes also include attempting to make the exam more reflective of what physicians in practice are doing, keeping fees at 2014 levels through 2017, and allowing most forms of continuing medical education (CME) as proof of self-improvement.
In a series of letters to the American Board of Psychiatry and Neurology (ABPN) and American Board of Medical Specialties (ABMS), Paul G. Mathew, MD, FAHS, Staff Neurologist at the John R. Graham Headache Center at Brigham and Women's Hospital, and Instructor at Harvard Medical, has argued similar changes be put in place for neurologists. Practical Neurology™ spoke to Dr. Mathew to learn more about his campaign.
To start off could you talk a little about MOC in general?
The process of board certification was established in the 1930's. Physician specialty societies came together to ensure residents were on par with their colleagues across the country by establishing a certain core level of knowledge that each physician should have to practice effectively. The boards began as an exam taken upon completion of residency to designate those successful as “board-certified” for the entirety of their careers.
This changed in 1994 when certifying boards began issuing time limited certificates lasting 10 years, and requiring physicians to pass an updated test to maintain their “board-certified” status every decade of practice. The previously awarded lifetime certifications were grandfathered. This of course was a very hypocritical decision, because it subjected older physicians to a lower standard than younger physicians. Ironically, older physicians who are further removed from residency are the ones who tend to be more out of date with current practice.
In 2007, the MOC program was established. In addition to passing a recertification exam every 10 years, physicians needed to complete self-assessment modules and practice-improvement modules. Many physicians have equated this to unnecessary “homework” that did not demonstrate anything practical. Quoting the ABMS, “the change from recertification to MOC strengthened the program and guaranteed that physicians were current in ways not immediately available for testing.”
This is a loaded statement. “Guaranteed” is almost never used in the practice of medicine and it is inappropriately used here as well. Secondly, the data supporting the implementation of these modules is sketchy and not independent. Using the personal improvement modules as one example, the applying physician picks the colleagues and patients to evaluate him or her. Naturally this can allow cherry picking for favorable results, and ultimately nothing useful is demonstrated.
The introduction of Part IV seemed to be a tipping point. What happened?
Though not eager, the vast majority of physicians were willing to take a board recertification exam every 10 years if that was the cost to continue practicing. But Part IV was the straw that broke the camel's back. As physicians, we have to balance our time between patient care, research, teaching trainees, family, and social commitments. There is a constant push from every direction for us to see more patients, while complying with meaningful use, and preparing for the changes of ICD-10. On top of that, we are expected to attend 100s of hours of CME. Physicians like myself could not accept paying yearly fees to maintain a portfolio, buying modules for self-assessment, as well as administering performance improvement surveys to colleagues and patients.
What are the ABMS and ABPN getting wrong? How do these changes affect neurologists?
There are a couple of examples of how the board exams are failing to accomplish their original mission. A colleague of mine, an adult anesthesiologist, can expect to be tested on pediatric anesthesiology despite knowing he will never practice in pediatrics. This is a huge volume of information that is not clinically relevant whatsoever to his clinical practice, but brute memorization of this irrelevant information will make him a more capable adult anesthesiologist in the eyes of the board.
Hitting closer to home, the neurology examinations test pathology. We are expected to view microscopic slides of brain tumors and muscle fibers, and identify the pathology. The vast majority of neurologist in the United States have never used a microscope as part of their clinical practice. If there was a patient with a brain tumor identified on MRI, I would send the patient to a neurosurgeon, and the neurosurgeon would either take a biopsy or remove the entire mass. This biopsy/mass would then be reviewed by a pathologist, who would identify the pathology. Testing neurologists on microscopic images would be like testing neurologists on neurosurgical technique. Although interesting, neither is relevant to the clinical practice of a neurologist.
The other side of the coin is the exam does not necessarily reflect some parts of clinical practice. It is not uncommon for physicians to think during an examination, “this is what I would do in the real world, but I know this is the answer the board wants me to select.”
How strong is the evidence in favor of MOC?
The literature in support of MOC programs is lacking. From the start, there should have been better research to demonstrate that these programs are effective, rather than blindly implementing them to masses of physicians. While advocating for MOC reform, one administrator suggested I put MOC requirements through the rigors of scientific review to prove these programs are ineffective. That ridiculous suggestion would be akin to introducing a drug to the market and only later testing for efficacy and side effects.
The amount of money the boards accumulate is surprising. What's your take on their salaries and spending?
I try to make this argument based on principle and the merit of these modules, but it's impossible to ignore the financial aspects. The cost to take the boards by some estimates ranges from $5,000 to $10,000 when factoring time off from work, the cost of travel, test preparation, and paying for the examination. It is mind blowing that salaries hovering near the million-dollar mark, luxury condominiums, and all expense paid trips are the expenditures not of a Wall Street firm, but a “non-profit” board tasked with helping doctors uphold best practices. At some point our maintenance of certification became the board's maintenance of lifestyle. I have advocated that board members of a non-profit medical board should make no more than what they would have made as a practicing physician in their respective discipline.
The impact is worse yet for physicians who are board certified across multiple specialties. A cardiac electrophysiologist will take the internal medicine boards, and three years later take the cardiology boards, and three years later take the electrophysiology boards, before the process reboots and starts again. The time, money, and patient care lost are too much of a burden to bear. A recent study estimated that the cost of MOC over a 10 year period for an individual physican can range from $15,000-$40,000 depending on the specialty.1
Keep in mind the effects on patient care when waiting times to see such specialists can already be several months without even considering the added wait times due to maintaining triple board certification.
You have written several open letters to the ABPN and ABMS. What has been the response?
After hearing disappointing responses from a few professional societies—professional societies, it should be noted, that are/were also profiting from selling these MOC programs—I felt compelled to take action.
I started a petition in June, 2014 calling for the repeal of Part IV of MOC. In February, 2015 the ABIM made an announcement that they were suspending Part IV. Since that announcement, I have issued nine letters to both ABMS and ABPN with over 1,200 signatures of neurologists requesting that Part IV be repealed from the MOC program, and to revert back to the 10 year exam as the requirement for re-certification. In addition to the petition, state neurological societies from New York, Washington, Texas, Pennsylvania, and California issued position statements of support.
Once this critical mass was established the AAN also issued a position statement on March 7 calling for the repeal of Part IV, which was followed by a similar statement by the American Psychiatric Association on March 16. I was very surprised to see that after all of this support, the ABPN very quickly issued a statement that same month stating they were unable to make any changes due to ABMS mandates. On that same day ABMS issued a statement that they were fully committed to every element of the MOC program, and had no interest in making any changes.
I equated the kind of stubbornness by ABMS and ABPN to a politician ignoring his/her constituents despite an overwhelming consensus on a referendum. This was truly a case of the tail trying to wag the dog. Like so many other things that plague the practice of medicine, this is what happens when administrators that are detached from the practice of medicine are calling the shots. Then again, I should not be surprised. The ABMS and its affiliate boards have enjoyed an unchallenged monopoly over the practice of medicine for decades while generating record profits. Why would they ever think that physicians would unite to seek a better alternative?
What's the solution to all this?
When the ABMS and its affiliated boards ignore their diplomates and the professional societies they are supposed to be serving, there needs to be a better alternative. The National Board of Physicians and Surgeons (NBPAS) was established purely for the purpose of board recertification, and I was nominated as the neurology representative for the advisory board. Instead of going through the MOC process every 10 years, the NBPAS re-certifies physicians based on having initial board certification by ABMS, possession of an active license, completion of 50 CME credits over the course of two years, and their clinical privileges in the certified specialty having not been permanently revoked. Physicians are then board recertified for two years. This is done at half the cost of the current ABMS examination (not including other ABMS re-certification associated expenses) and eliminates the unnecessary hoops that are currently in place for ABMS board re-certification. It is important to point out that the NBPAS advisory board is made of voluntary physicians that do not receive a cent. If this is a moneymaking scheme, I'm in the wrong business. Another advantage is that NBPAS can re-certify diplomates based on CME in their primary specialty in addition to any ABMS sub-specialties in which they have been ABMS board certified.
In addition to a growing number of diplomates, the number of hospital systems that accept NBPAS as an acceptable alternative for board certification is growing. Getting these systems on board is critical, but unfortunately many physicians are taking a backward approach to support: once my hospital accepts NBPAS, I will join. The NBPAS is a grassroots movement, which means the more physicians that join, the more powerful it will become. If there is a critical mass of NBPAS certified physicians at a particular hospital that petition the credentialing committee to accept NBPAS, the hospital will likely accept it.
On a fundamental level, think of becoming a diplomat of NBPAS like making a political action committee (PAC) donation. By joining the ranks of NBPAS, physicians are empowering the practice of medicine to find a logical escape hatch from the time consuming, expensive, unproven, and exhausting process of ABMS/ABPN MOC. If your ABMS/ABPN certification is not set to expire any time soon, there is no harm in being dual boarded. My ABPN certificate is only set to expire in 2020, but I decided to re-certify in advance with NBPAS to make a point.
What are your thoughts on the criticism around the formation of the NBPAS?
The ACP has made several criticisms against the NBPAS. One of their issues is setting the bar at 50 CME credits every two years. Because some states require no CME credits for state licensure, we wanted to set the bar high enough so there is a standard, but no so high that we would restrict people from becoming diplomates.
One of the ACP's other comments centers on litigation. If you are named in a liability lawsuit and are not board certified, they argue, how will that stand up in court? If you are negligent, and you make a negligent mistake, no piece of paper on your wall is going to sway a jury. In addition, if you look at these board websites, they offer verbiage disclaiming board certification is not a guarantee of any level of performance.
Another incorrect statement the ACP made advises doctors that they forfeit their board certification if they become a member of the NBPAS and do not recertify with the ABMS. This is in a way false because part of the NBPAS recertification process is that the doctor was initially board certified with ABMS, so NBPAS is merely an extension of the doctor's initial certification. n
1. Sandhu AT, Dudley RA, Kazi DS. A Cost Analysis of the American Board of Internal Medicine's Maintenance-of-Certification Program. Ann Intern Med. 2015 Jul 28. doi: 10.7326/M15-1011.