- Email: [email protected]
Excellence in Ophthalmology
Excellence in Ophthalmology Continuous Certification R. Michael Siatkowski, MD1,2 Over the course of a century, American medical specialty boards including the American Board of Ophthalmology (ABO) have developed significant expertise in assessing physician competence on completion of postgraduate training and, more recently, in defining appropriate criteria for continuous learning and quality improvement in practicing physicians. This article explores why maintaining career-long excellence is an evolving challenge, but one that is at the heart of the ABO’s mission to protect the public by improving patient care. Ophthalmology 2016;123:S25-S29 ª 2016 by the American Academy of Ophthalmology.
No one ever entered medical school or residency training with the goal of becoming a mediocre physician. To the contrary, for millennia, prospective physicians have entered training with the intent not only to be proficient at graduation, but also to become excellent doctors who continuously improve throughout the course of their careers. Fortunately, most physicians achieve these goals and can identify easily their colleagues who havedor have notdbeen successful in this regard. Medical specialty boards have developed significant expertise in identifying and assessing criteria for initial certification as a marker for competence on completion of postgraduate training. Developing an appropriate demonstration of staying current in the profession, improving continuously, and maintaining career-long excellence is a much more challenging task, but one that is at the heart of the boards’ mission to protect the public.
The Past Self-regulation of the medical profession originated in the United States with the creation of the American Medical Association in 1847. More than 60 years later, the Flexner report extended standardization efforts to medical education. Concurrently, Edward Jackson and other leading ophthalmologists of the early 20th century began to address standardization in specialty training in ophthalmology, culminating in the formation of what would become the American Board of Ophthalmology (ABO) in 1916, and eventually the American Board of Medical Specialties (ABMS) in 1933, which today oversees 23 other medical specialty boards. Through the specialty boards, lifetime certification was conferred on diplomates who successfully completed a rigorous examination process. As early as 1940, however, the ABMS Committee on Graduate Medical Education first proposed the possibility of issuing time-limited certificates with periodic renewal. It was not until 1969 that the 2016 by the American Academy of Ophthalmology Published by Elsevier Inc.
American Board of Family Medicine became the first board to require its diplomates to recertify by issuing certificates that required renewal every 7 years. In 1974, the ABO began to study the recertification issue under the direction of Bradley Straatsma as committee chair. Minutes from one of his first meetings refer to recertification as “one of the most complex and involved topics in American medicine today.” The ABO’s original intent was to make recertification voluntary. A survey completed by more than 1800 ABO diplomates in 1976 indicated that 74% would be willing to participate in a trial recertification program. By 1978, however, diplomate enthusiasm for recertification had cooled, and an ABO forum on recertification at the annual American Academy of Ophthalmology (AAO) meeting became so contentious that participants still remember it vividly today. As a result, the ABO tabled plans to proceed with implementation, but continued to study the issue, working with the AAO to collaborate. With the continued explosion of medical knowledge, the necessity for public accountability, and the realization that, in the words of Marshall M. Parks, noncompulsory recertification would be “doomed to fail,” in 1986, the ABO voted to begin issuing 10-year, time-limited certificates in 1992. Thus, the stage was set for the first diplomates to recertify by 2002 through a process developed under the subsequent leadership of Parks, Ronald Burde, Douglas Anderson, George Beauchamp, Richard Abbott, and Lee Duffner. Readers who participated in recertification will recall the open-book Certificate Renewal Examination and the Office Record Review. The questions on the Certificate Renewal Examination covered the entire breadth of ophthalmology, without respect for the diplomate’s individual area of practice emphasis. As a result, questions often were difficult for subspecialists to answer and had little relation to the activities the doctors were performing on a daily basis. Data entry for the Office Record Review facilitated reflection on Statement of Potential Conflict of Interest and Funding/Support: See page S29. http://dx.doi.org/10.1016/j.ophtha.2016.06.014 ISSN 0161-6420/16
S25
Ophthalmology Volume 123, Number 9, Supplement, September 2016
Figure 1. The core competencies addressed by Maintenance of Certification activities.
practice patterns, but fell short of truly measuring quality processes and improving patient outcomes. In 2000, recognizing that recertification every 10 years could not promote continuous competence and practice improvement, the ABMS moved to replace it with Maintenance of Certification (MOC). The MOC program was founded on the assessment and development of 6 core competencies integral to the practice of high-quality patient care as determined by the Accreditation Council for Graduate Medical Education and ABMS (Fig 1). This process, although individualized by member boards, comprises 4 parts: (I) maintenance of an unrestricted medical license in all jurisdictions where the diplomate practices; (II) participation in lifelong learning and self-assessment activities, specifically, Continuing Medical Education (CME) and the Periodic Ophthalmic Review Tests; (III) documentation of medical knowledge and cognitive expertise relevant to one’s practice through a closed-book examination (the Demonstration of Cognitive Knowledge [DOCK] examination); and (IV) participation in ongoing Practice Improvement Modules (PIMs). These changes were implemented at the ABO under the successive leadership of C. P. “Pat” Wilkinson, David Tse, and Janet Davis.
The Present The Current Environment The MOC process, particularly in internal medicine, has come under intense scrutiny and criticism in recent years. Criticisms include diplomate cost in both dollars and time, the perception of financial benefits to the board and those who conduct MOC preparatory courses, and constantly changing rules. The challenge for the ABO, as with all ABMS member boards, is to develop a system that minimizes burden and maximizes benefit to diplomates, while also adequately conferring to the public, the profession, and external stakeholders that completion of the process is a reasonable surrogate for competent medical practice. Although currently called maintenance of certification, what the profession and the public both desire is demonstration of maintenance of competence in the things doctors do on a daily basis.
S26
Ophthalmologists understand the difficulty of accurately measuring and ensuring clinical competence, either through initial certification or the MOC process, and the hurdles involved in staying up to date in knowledge and skills. Multiple studies confirm the degradation of both cognitive and technical skills over time without purposeful efforts to combat it.1,2 Physicians rely more on pattern recognition with age, but this becomes increasingly less effective as new medical knowledge surfaces. For example, a study of internists found that there was a progressive decline in cognitive knowledge between doctors 10 versus 20 or 30 years from residency training, with the most deficient areas being changing or new medical knowledge.3 Another study of internists revealed that adherence to current hypertension treatment intensification recommendations decreased up to 20% per decade.4 In ophthalmology, the pass rate on the closed-book DOCK examination decreases from 98% to 99% for doctors 40 to 60 years of age, to 94% in for doctors in their 60s, and only 70% for doctors in their 70s. Unfortunately, we are not our own most reliable assessors; studies show that up to 70% of individuals consider themselves above average in various intellectual domains, with the greatest inflation of perceived performance among those ranking in the lowest quartile.5 The public, not surprisingly, remains quite concerned with physician quality and recognizes board certification as a surrogate for such. In a 2010 opinion research survey of more than 1000 patients, 95% stated that board certification was important, and 45% said they would change physicians if they learned that their doctor was not participating in MOC. The Current Maintenance of Certification Process In the late 2000s, the ABO began efforts to improve the MOC process. As a result, a number of changes were made to increase the value and decrease the burden to diplomates. Annual CME requirements have been decreased from 30 to 25 category I hours, and attestation has now replaced the need for diplomates to log and report CME to the ABO annually. An ophthalmology-based patient safety module has been added for part II credit. The DOCK examination has become more psychometrically valid, and diplomates choose modules so that the questions on the examination are clinically applicable to their patients. The process has added
Siatkowski
Lifelong Excellence in Ophthalmology
financial value for diplomates as well, with an annual fee of $200 for participating in MOC rather than a component for a specific fee; in addition, the ABO has collaborated with the AAO so that diplomates can receive CME credit for the patient safety module, the Periodic Ophthalmic Review Tests, and the part IV PIMs. As a result, diplomates can receive up to 47 hours of category I CME credit through the MOC process at no additional charge to them. From 2012 through 2014, the Centers for Medicare and Medicaid (CMS) recognized completion of the ABO MOC process as qualifying for Physician Quality Reporting System (PQRS) bonus credit, a process in which hundreds of diplomates participated. The most important change in the process, however, has been the focus on quality improvement as the heart of the MOC process, with a menu of activities designed to help diplomates make meaningful changes in practice that can lead to improved patient outcomes. The Office Record Review has been replaced by disease-specific PIMs. In this activity, diplomates enter selected patient data into an online ABO database and privately receive feedback on patient outcomes and compliance with preferred practices of care. Then, they are asked to identify several areas where they want to improve, to make changes in their practice, and to re-evaluate their performance. For diplomates for whom the existing PIMs do not reflect their practice patterns, the ABO has created a template from which doctors can design their own clinical or nonclinical quality improvement project based on the topics most relevant to their needs. Dozens of diplomates have done so over the last several years, creating high-impact projects that have resulted in decreased patient wait times and no-shows, improved patient experiences and medical documentation practices, and increased compliance with processes of care. For doctors practicing in institutionbased settings, the ABO recognizes combined or organizational participation in quality improvement practices for part IV credit. There is no passing grade for part IV; rather, the intent of the ABO is to provide doctors with tools to identify areas where they can improve efficiency and outcomes. The ABO considers this the heart and the true purpose of the MOC process: to improve continuously in things we do every day, despite a rapidly changing environment and explosion of new medical and surgical knowledge. Of course, all of this is moot if the MOC process does not result in meaningful improvements for both doctors and patients. Analysis of data in both internal medicine and family medicine provides evidence that positive changes can occur as a result of MOC. Ninety-three percent of surveyed internists found the part IV activity on diabetes mellitus useful and 71% said that they would change their practice patterns6; more than half of almost 7000 family physicians said they would make changes in their management of diabetes and hypertension as a result of MOC.7 To examine its own MOC process more critically, in 2015 the ABO commissioned outside experts to evaluate both quantitative and qualitative data provided by diplomates during the part IV process. These results were published recently with an accompanying editorial.8,9
The Future Initial areas targeted for evaluation are parts III and IV of MOC. Although the mean pass rate of the DOCK examination has always been between 96% and 99% and diplomates have 3 chances to pass it in a 10-year cycle, many doctors experience anxiety and frustration with the concept of a high-stakes examination. Additionally, there is the need for the examination to be performed in a secure testing center, adding further burdens both in time and cost. In part IV as well, many diplomates struggle with the time required for data entry and re-entry for the practice improvement process in the face of busy personal and professional lives. Based on diplomate feedback, the ABO is developing several pilot programs for new MOC activities. If successful, these activities could serve as alternate pathways for MOC. One pilot is similar to the successful Maintenance of Certification Assessment program of the American Board of Anesthesiology: diplomates would receive multiple-choice questions by e-mail over the course of 1 year, and questions answered incorrectly would be explained and corresponding educational material would be recommended. Areas of strength and weakness could be identified to help direct content of future items, and incorporation of new technology as well as strategies in adult learning would enhance the value of the activity and perhaps even make it enjoyable. Another pilot is modeled after one used by the American Board of Obstetrics and Gynecology. This process would focus on diplomate review of important new articles in one’s practice emphasis area that may alter processes of care, subsequently answer online questions on the material, and demonstrate how they have incorporated these changes into their practice. As technology evolves, additional improvements may be possible (both for initial certification and MOC), such as the use of branching logic in web-based clinical simulations to assess patient management strategies and the ability to provide feedback on surgical performance. Finally, the ABO is investigating the possibility of allowing diplomates to take the DOCK examination at home or in their office using web-based proctoring, thus minimizing schedule disruptions and time off from work. In addition, the ABO has condensed and shortened the PIMs significantly to decrease data entry time and has partnered with the AAO to create revised modules with elements that can be extracted from an electronic health record for the Intelligent Research in Sight (IRIS) registry (Fig 2). As information technology improves and electronic health record penetration increases, this would allow diplomates to participate in part IV in significantly less time, while also contributing to a registry. With these changes, the ABO would be well-positioned to petition CMS to recognize participation in the ABO’s MOC process as meeting standards for the highest level of Medicare reimbursement in the recently passed Medicare Access and Children’s Health Insurance Program (CHIP) Reauthorization legislation and conversion to the Merit-Based Incentive Payment System.
S27
Ophthalmology Volume 123, Number 9, Supplement, September 2016
Figure 2. Screenshot of the Amblyopia Practice Improvement Module developed by the American Board of Ophthalmology.
S28
Siatkowski
Lifelong Excellence in Ophthalmology
Summary Health care in this country is changing dramatically, and with every new advance in technology and medicine, what it takes to be an excellent physician changes as well. Economic, regulatory, and system-related pressures may challenge our ability, but not our desire, to improve continuously so that we can deliver high-quality, state-of-the art, cost-effective care to our patients. Despite these external pressuresdor, in some cases, because of themdwe understand the value and continued necessity of self-regulation of the profession by physicians, rather than regulation by government, payers, or other nonphysicians. The mission of the ABO is to protect the public by ensuring quality eye care. Both the directors and the staff of the ABO recognize the physician-diplomates as vital partners who lead the way in this endeavor. For both the diplomates and the public, the ABO remains committed to providing an increasingly convenient and clinically relevant continuous certification process that will advance excellence in eye care, and looks forward to a constructive and ongoing dialog with diplomates to achieve this goal.
References 1. O’Reilly KB. Physician quality: what’s age got to do with it? American Medical News. July 30, 2012.
2. Eva KW. The aging physician: changes in cognitive processing and their impact on medical practice. Acad Med 2002;77: S1–6. 3. Day SC, Norcini JJ, Webster GD, et al. The effect of changes in medical knowledge on examination performance at the time of recertification. Res Med Educ 1988;27: 139–44. 4. Turchin A, Shubina M, Chodos AH, et al. Effect of board certification on antihypertensive treatment intensification in patients with diabetes mellitus. Circulation 2008;117: 623–8. 5. Kruger J, Dunning D. Unskilled and unaware of it: how difficulties in recognizing one’s own incompetence lead to inflated self-assessments. J Personal Soc Psych 1999;77: 1121–34. 6. Holmboe ES, Meehan TP, Lynn L, et al. Promoting physicians’ self-assessment and quality improvement: the ABIM diabetes practice improvement module. J Contin Educ Health Prof 2006;26:109–19. 7. Hagen MD, Ivins DJ, Puffer JC, et al. Maintenance of certification for family physicians (MC-FP) self assessment modules (SAMs): the first year. JABFM 2006;19:398–403. 8. Wiggins RE Jr, Etz R. Assessment of the American Board of Ophthalmology’s Maintenance of Certification Part 4 (Improvement in Medical Practice). JAMA Ophthalmol 2016 Jul 21. doi: 10.1001/jamaophthalmol.2016.1848. [Epub ahead of print] 9. Beaver HA. The Value of Maintenance of Certification. JAMA Ophthal 2016 Jul 21. doi: 10.1001/jamaophthalmol.2016.1694. [Epub ahead of print]
Footnotes and Financial Disclosures Originally received: April 18, 2016. Final revision: June 3, 2016. Accepted: June 3, 2016. 1
Data collection: Siatkowski Obtained funding: none Manuscript no. 2016-796.
American Board of Ophthalmology, Bala Cynwyd, Pennsylvania.
2
Dean McGee Eye Institute, University of Oklahoma, Oklahoma City, Oklahoma. Presented in part at: American Board of Ophthalmology 100th Anniversary Symposium, March 2016, San Francisco, California. Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article. Author Contributions: Conception and design: Siatkowski Analysis and interpretation: Siatkowski
Overall responsibility: Siatkowski Abbreviations and Acronyms: AAO ¼ American Academy of Ophthalmology; ABMS ¼ American Board of Medical Specialties; ABO ¼ American Board of Ophthalmology; CME ¼ Continuing Medical Education; DOCK ¼ Demonstration of Cognitive Knowledge; MOC ¼ Maintenance of Certification; PIM ¼ Practice Improvement Module. Correspondence: R. Michael Siatkowski, MD, Dean McGee Eye Institute, 608 Stanton L. Young Blvd., University of Oklahoma, OK 73104. E-mail: [email protected].
S29
No one ever entered medical school or residency training with the goal of becoming a mediocre physician. To the contrary, for millennia, prospective physicians have entered training with the intent not only to be proficient at graduation, but also to become excellent doctors who continuously improve throughout the course of their careers. Fortunately, most physicians achieve these goals and can identify easily their colleagues who havedor have notdbeen successful in this regard. Medical specialty boards have developed significant expertise in identifying and assessing criteria for initial certification as a marker for competence on completion of postgraduate training. Developing an appropriate demonstration of staying current in the profession, improving continuously, and maintaining career-long excellence is a much more challenging task, but one that is at the heart of the boards’ mission to protect the public.
The Past Self-regulation of the medical profession originated in the United States with the creation of the American Medical Association in 1847. More than 60 years later, the Flexner report extended standardization efforts to medical education. Concurrently, Edward Jackson and other leading ophthalmologists of the early 20th century began to address standardization in specialty training in ophthalmology, culminating in the formation of what would become the American Board of Ophthalmology (ABO) in 1916, and eventually the American Board of Medical Specialties (ABMS) in 1933, which today oversees 23 other medical specialty boards. Through the specialty boards, lifetime certification was conferred on diplomates who successfully completed a rigorous examination process. As early as 1940, however, the ABMS Committee on Graduate Medical Education first proposed the possibility of issuing time-limited certificates with periodic renewal. It was not until 1969 that the 2016 by the American Academy of Ophthalmology Published by Elsevier Inc.
American Board of Family Medicine became the first board to require its diplomates to recertify by issuing certificates that required renewal every 7 years. In 1974, the ABO began to study the recertification issue under the direction of Bradley Straatsma as committee chair. Minutes from one of his first meetings refer to recertification as “one of the most complex and involved topics in American medicine today.” The ABO’s original intent was to make recertification voluntary. A survey completed by more than 1800 ABO diplomates in 1976 indicated that 74% would be willing to participate in a trial recertification program. By 1978, however, diplomate enthusiasm for recertification had cooled, and an ABO forum on recertification at the annual American Academy of Ophthalmology (AAO) meeting became so contentious that participants still remember it vividly today. As a result, the ABO tabled plans to proceed with implementation, but continued to study the issue, working with the AAO to collaborate. With the continued explosion of medical knowledge, the necessity for public accountability, and the realization that, in the words of Marshall M. Parks, noncompulsory recertification would be “doomed to fail,” in 1986, the ABO voted to begin issuing 10-year, time-limited certificates in 1992. Thus, the stage was set for the first diplomates to recertify by 2002 through a process developed under the subsequent leadership of Parks, Ronald Burde, Douglas Anderson, George Beauchamp, Richard Abbott, and Lee Duffner. Readers who participated in recertification will recall the open-book Certificate Renewal Examination and the Office Record Review. The questions on the Certificate Renewal Examination covered the entire breadth of ophthalmology, without respect for the diplomate’s individual area of practice emphasis. As a result, questions often were difficult for subspecialists to answer and had little relation to the activities the doctors were performing on a daily basis. Data entry for the Office Record Review facilitated reflection on Statement of Potential Conflict of Interest and Funding/Support: See page S29. http://dx.doi.org/10.1016/j.ophtha.2016.06.014 ISSN 0161-6420/16
S25
Ophthalmology Volume 123, Number 9, Supplement, September 2016
Figure 1. The core competencies addressed by Maintenance of Certification activities.
practice patterns, but fell short of truly measuring quality processes and improving patient outcomes. In 2000, recognizing that recertification every 10 years could not promote continuous competence and practice improvement, the ABMS moved to replace it with Maintenance of Certification (MOC). The MOC program was founded on the assessment and development of 6 core competencies integral to the practice of high-quality patient care as determined by the Accreditation Council for Graduate Medical Education and ABMS (Fig 1). This process, although individualized by member boards, comprises 4 parts: (I) maintenance of an unrestricted medical license in all jurisdictions where the diplomate practices; (II) participation in lifelong learning and self-assessment activities, specifically, Continuing Medical Education (CME) and the Periodic Ophthalmic Review Tests; (III) documentation of medical knowledge and cognitive expertise relevant to one’s practice through a closed-book examination (the Demonstration of Cognitive Knowledge [DOCK] examination); and (IV) participation in ongoing Practice Improvement Modules (PIMs). These changes were implemented at the ABO under the successive leadership of C. P. “Pat” Wilkinson, David Tse, and Janet Davis.
The Present The Current Environment The MOC process, particularly in internal medicine, has come under intense scrutiny and criticism in recent years. Criticisms include diplomate cost in both dollars and time, the perception of financial benefits to the board and those who conduct MOC preparatory courses, and constantly changing rules. The challenge for the ABO, as with all ABMS member boards, is to develop a system that minimizes burden and maximizes benefit to diplomates, while also adequately conferring to the public, the profession, and external stakeholders that completion of the process is a reasonable surrogate for competent medical practice. Although currently called maintenance of certification, what the profession and the public both desire is demonstration of maintenance of competence in the things doctors do on a daily basis.
S26
Ophthalmologists understand the difficulty of accurately measuring and ensuring clinical competence, either through initial certification or the MOC process, and the hurdles involved in staying up to date in knowledge and skills. Multiple studies confirm the degradation of both cognitive and technical skills over time without purposeful efforts to combat it.1,2 Physicians rely more on pattern recognition with age, but this becomes increasingly less effective as new medical knowledge surfaces. For example, a study of internists found that there was a progressive decline in cognitive knowledge between doctors 10 versus 20 or 30 years from residency training, with the most deficient areas being changing or new medical knowledge.3 Another study of internists revealed that adherence to current hypertension treatment intensification recommendations decreased up to 20% per decade.4 In ophthalmology, the pass rate on the closed-book DOCK examination decreases from 98% to 99% for doctors 40 to 60 years of age, to 94% in for doctors in their 60s, and only 70% for doctors in their 70s. Unfortunately, we are not our own most reliable assessors; studies show that up to 70% of individuals consider themselves above average in various intellectual domains, with the greatest inflation of perceived performance among those ranking in the lowest quartile.5 The public, not surprisingly, remains quite concerned with physician quality and recognizes board certification as a surrogate for such. In a 2010 opinion research survey of more than 1000 patients, 95% stated that board certification was important, and 45% said they would change physicians if they learned that their doctor was not participating in MOC. The Current Maintenance of Certification Process In the late 2000s, the ABO began efforts to improve the MOC process. As a result, a number of changes were made to increase the value and decrease the burden to diplomates. Annual CME requirements have been decreased from 30 to 25 category I hours, and attestation has now replaced the need for diplomates to log and report CME to the ABO annually. An ophthalmology-based patient safety module has been added for part II credit. The DOCK examination has become more psychometrically valid, and diplomates choose modules so that the questions on the examination are clinically applicable to their patients. The process has added
Siatkowski
Lifelong Excellence in Ophthalmology
financial value for diplomates as well, with an annual fee of $200 for participating in MOC rather than a component for a specific fee; in addition, the ABO has collaborated with the AAO so that diplomates can receive CME credit for the patient safety module, the Periodic Ophthalmic Review Tests, and the part IV PIMs. As a result, diplomates can receive up to 47 hours of category I CME credit through the MOC process at no additional charge to them. From 2012 through 2014, the Centers for Medicare and Medicaid (CMS) recognized completion of the ABO MOC process as qualifying for Physician Quality Reporting System (PQRS) bonus credit, a process in which hundreds of diplomates participated. The most important change in the process, however, has been the focus on quality improvement as the heart of the MOC process, with a menu of activities designed to help diplomates make meaningful changes in practice that can lead to improved patient outcomes. The Office Record Review has been replaced by disease-specific PIMs. In this activity, diplomates enter selected patient data into an online ABO database and privately receive feedback on patient outcomes and compliance with preferred practices of care. Then, they are asked to identify several areas where they want to improve, to make changes in their practice, and to re-evaluate their performance. For diplomates for whom the existing PIMs do not reflect their practice patterns, the ABO has created a template from which doctors can design their own clinical or nonclinical quality improvement project based on the topics most relevant to their needs. Dozens of diplomates have done so over the last several years, creating high-impact projects that have resulted in decreased patient wait times and no-shows, improved patient experiences and medical documentation practices, and increased compliance with processes of care. For doctors practicing in institutionbased settings, the ABO recognizes combined or organizational participation in quality improvement practices for part IV credit. There is no passing grade for part IV; rather, the intent of the ABO is to provide doctors with tools to identify areas where they can improve efficiency and outcomes. The ABO considers this the heart and the true purpose of the MOC process: to improve continuously in things we do every day, despite a rapidly changing environment and explosion of new medical and surgical knowledge. Of course, all of this is moot if the MOC process does not result in meaningful improvements for both doctors and patients. Analysis of data in both internal medicine and family medicine provides evidence that positive changes can occur as a result of MOC. Ninety-three percent of surveyed internists found the part IV activity on diabetes mellitus useful and 71% said that they would change their practice patterns6; more than half of almost 7000 family physicians said they would make changes in their management of diabetes and hypertension as a result of MOC.7 To examine its own MOC process more critically, in 2015 the ABO commissioned outside experts to evaluate both quantitative and qualitative data provided by diplomates during the part IV process. These results were published recently with an accompanying editorial.8,9
The Future Initial areas targeted for evaluation are parts III and IV of MOC. Although the mean pass rate of the DOCK examination has always been between 96% and 99% and diplomates have 3 chances to pass it in a 10-year cycle, many doctors experience anxiety and frustration with the concept of a high-stakes examination. Additionally, there is the need for the examination to be performed in a secure testing center, adding further burdens both in time and cost. In part IV as well, many diplomates struggle with the time required for data entry and re-entry for the practice improvement process in the face of busy personal and professional lives. Based on diplomate feedback, the ABO is developing several pilot programs for new MOC activities. If successful, these activities could serve as alternate pathways for MOC. One pilot is similar to the successful Maintenance of Certification Assessment program of the American Board of Anesthesiology: diplomates would receive multiple-choice questions by e-mail over the course of 1 year, and questions answered incorrectly would be explained and corresponding educational material would be recommended. Areas of strength and weakness could be identified to help direct content of future items, and incorporation of new technology as well as strategies in adult learning would enhance the value of the activity and perhaps even make it enjoyable. Another pilot is modeled after one used by the American Board of Obstetrics and Gynecology. This process would focus on diplomate review of important new articles in one’s practice emphasis area that may alter processes of care, subsequently answer online questions on the material, and demonstrate how they have incorporated these changes into their practice. As technology evolves, additional improvements may be possible (both for initial certification and MOC), such as the use of branching logic in web-based clinical simulations to assess patient management strategies and the ability to provide feedback on surgical performance. Finally, the ABO is investigating the possibility of allowing diplomates to take the DOCK examination at home or in their office using web-based proctoring, thus minimizing schedule disruptions and time off from work. In addition, the ABO has condensed and shortened the PIMs significantly to decrease data entry time and has partnered with the AAO to create revised modules with elements that can be extracted from an electronic health record for the Intelligent Research in Sight (IRIS) registry (Fig 2). As information technology improves and electronic health record penetration increases, this would allow diplomates to participate in part IV in significantly less time, while also contributing to a registry. With these changes, the ABO would be well-positioned to petition CMS to recognize participation in the ABO’s MOC process as meeting standards for the highest level of Medicare reimbursement in the recently passed Medicare Access and Children’s Health Insurance Program (CHIP) Reauthorization legislation and conversion to the Merit-Based Incentive Payment System.
S27
Ophthalmology Volume 123, Number 9, Supplement, September 2016
Figure 2. Screenshot of the Amblyopia Practice Improvement Module developed by the American Board of Ophthalmology.
S28
Siatkowski
Lifelong Excellence in Ophthalmology
Summary Health care in this country is changing dramatically, and with every new advance in technology and medicine, what it takes to be an excellent physician changes as well. Economic, regulatory, and system-related pressures may challenge our ability, but not our desire, to improve continuously so that we can deliver high-quality, state-of-the art, cost-effective care to our patients. Despite these external pressuresdor, in some cases, because of themdwe understand the value and continued necessity of self-regulation of the profession by physicians, rather than regulation by government, payers, or other nonphysicians. The mission of the ABO is to protect the public by ensuring quality eye care. Both the directors and the staff of the ABO recognize the physician-diplomates as vital partners who lead the way in this endeavor. For both the diplomates and the public, the ABO remains committed to providing an increasingly convenient and clinically relevant continuous certification process that will advance excellence in eye care, and looks forward to a constructive and ongoing dialog with diplomates to achieve this goal.
References 1. O’Reilly KB. Physician quality: what’s age got to do with it? American Medical News. July 30, 2012.
2. Eva KW. The aging physician: changes in cognitive processing and their impact on medical practice. Acad Med 2002;77: S1–6. 3. Day SC, Norcini JJ, Webster GD, et al. The effect of changes in medical knowledge on examination performance at the time of recertification. Res Med Educ 1988;27: 139–44. 4. Turchin A, Shubina M, Chodos AH, et al. Effect of board certification on antihypertensive treatment intensification in patients with diabetes mellitus. Circulation 2008;117: 623–8. 5. Kruger J, Dunning D. Unskilled and unaware of it: how difficulties in recognizing one’s own incompetence lead to inflated self-assessments. J Personal Soc Psych 1999;77: 1121–34. 6. Holmboe ES, Meehan TP, Lynn L, et al. Promoting physicians’ self-assessment and quality improvement: the ABIM diabetes practice improvement module. J Contin Educ Health Prof 2006;26:109–19. 7. Hagen MD, Ivins DJ, Puffer JC, et al. Maintenance of certification for family physicians (MC-FP) self assessment modules (SAMs): the first year. JABFM 2006;19:398–403. 8. Wiggins RE Jr, Etz R. Assessment of the American Board of Ophthalmology’s Maintenance of Certification Part 4 (Improvement in Medical Practice). JAMA Ophthalmol 2016 Jul 21. doi: 10.1001/jamaophthalmol.2016.1848. [Epub ahead of print] 9. Beaver HA. The Value of Maintenance of Certification. JAMA Ophthal 2016 Jul 21. doi: 10.1001/jamaophthalmol.2016.1694. [Epub ahead of print]
Footnotes and Financial Disclosures Originally received: April 18, 2016. Final revision: June 3, 2016. Accepted: June 3, 2016. 1
Data collection: Siatkowski Obtained funding: none Manuscript no. 2016-796.
American Board of Ophthalmology, Bala Cynwyd, Pennsylvania.
2
Dean McGee Eye Institute, University of Oklahoma, Oklahoma City, Oklahoma. Presented in part at: American Board of Ophthalmology 100th Anniversary Symposium, March 2016, San Francisco, California. Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article. Author Contributions: Conception and design: Siatkowski Analysis and interpretation: Siatkowski
Overall responsibility: Siatkowski Abbreviations and Acronyms: AAO ¼ American Academy of Ophthalmology; ABMS ¼ American Board of Medical Specialties; ABO ¼ American Board of Ophthalmology; CME ¼ Continuing Medical Education; DOCK ¼ Demonstration of Cognitive Knowledge; MOC ¼ Maintenance of Certification; PIM ¼ Practice Improvement Module. Correspondence: R. Michael Siatkowski, MD, Dean McGee Eye Institute, 608 Stanton L. Young Blvd., University of Oklahoma, OK 73104. E-mail: [email protected].
S29