- Email: [email protected]
An Alternative to MOC?
Gastroenterology 2015;149:1607–1608
AGA BOARD STRATEGIC UPDATE An Alternative to MOC? Timothy C. Wang1 and Michael Camilleri2 1
T
he need for postgraduate medical education is probably clearer than at any time in the history of medicine. Medical knowledge continues to expand rapidly, with important clinical and scientific advances, every year, that are relevant to practice. There is now a greater emphasis than ever before on disease pathways, clinical guidelines, and quality improvement, making it important for physicians to remain current with newer recommendations and practice standards. While in most medical subspecialties, this was often done in part through maintenance of certification (MOC) and recertification by the American Board of Internal Medicine (ABIM), recent changes to the process have led to a reexamination of the recertification paradigm. The AGA commissioned a Task Force to take a fresh look at the entire process of recertification, and the White Paper by Rose S et al1 in this issue of Gastroenterology represents the culmination of this effort. From 1941 until 1989, after graduation from medical school, physicians would sit for an initial set of medical boards administered by the ABIM, and passing the exam was sufficient for board certification for the rest of their career. In 1989, certification was no longer lifetime but time-limited to only 10 years, and additional requirements (maintenance of certification or MOC) were introduced that included knowledge-based exercises and practice assessments, tasks that were time-consuming but apparently manageable. However, in 2014, the ABIM doubled the MOC points required (from 50 to 100, every 5 years) and stipulated that physicians who did not participate in this expanded program would be publicly labeled as “not meeting MOC requirements.” This change was introduced without much public comment at a time when physicians were already dealing with numerous stresses and requirements (eg, introduction of the electronic medical record, quality reporting, compliance issues) that were taking them away from the care of their patients. The change in MOC requirements was in many ways a watershed moment for many physicians in their support for the recertification process. The view by many practicing gastroenterologists was that many of the MOC requirements did not help them become better doctors and represented unnecessary paperwork and study of material that was largely unrelated to the delivery of quality care in their clinical practice. Many also resented the annual fees and what they deemed to be excessive cost for the entire process. While board certification was initially designed as simply a mark of distinction, it has grown, in some instances, to be required for hospital privileges, and thus the
recertification examination has evolved into a high stakes assessment. This was compounded by the relatively low pass-rates (w 85%) over the past 5 years for the GI Board recertification exam. The fact that board certification has become a requirement for privileges at many hospitals is surprising, given the lack of evidence that MOC has led to improved patient outcomes.2,3 Indeed, many other professional organizations (eg, lawyers, pilots) have opted for a less onerous approach to certification while still maintaining accountability. An online petition requesting a recall of MOC was signed by more than 22,000 physicians. The National Board of Physicians and Surgeons (NBPAS), a physician organization and alternative certification board, has proposed to replace MOC with a simple set of requirements that includes 50 hours of CME, an active license and hospital privileges.4 A survey by the AGA confirmed that a majority of surveyed members resented the increased demands of the new changes to MOC. Recently, the ABIM suspended, for at least 2 years, the requirement for a Part 4 practice improvement project (PIMS), but many physicians remain concerned regarding future MOC requirements. In this issue of Gastroenterology, the AGA Task Force made up of educators and practitioners has proposed an alternative solution based on the solid precepts of adult learning theory, competencies and milestones. They have labeled this alternative pathway G-APP (The Gastroenterologist: Accountable Professionalism in Practice). The proposal is based on broad agreement on competencies essential for gastroenterologists. Educational leaders from the 5 GI societies (Oversight Working Network) had established 13 Entrustable Professional Activities (EPAs) that define the broad array of tasks that define the practice of a clinical gastroenterologist.5 Based on these EPAs, the Task Force proposed to create individual pathways that would incorporate self-assessment activities that allow a high level of competency in one or more area(s) (eg, hepatology or IBD for example), while maintaining a more modest level of competency in other areas (see Table 6 and 7 in Rose et al5 for details). Thus, for example, a single expert level of competency would be sufficient when accompanied by general competency in the other 12 areas. The individualized
© 2015 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2015.08.010
AGA SECTION
Department of Medicine, Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, New York; and 2Division of Gastroenterology, Department of Internal Medicine, Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Mayo Clinic, Rochester, Minnesota
1608 Wang and Camilleri
self-assessment activities (ie, adaptive learning modules and/or practice exams) would provide constant feedback and opportunities for learning, rather than a secure exam that allows little opportunity for learning from feedback or selfimprovement. Finally, the Task Force recommended that the ABIM recognize many of the current quality improvement activities that physicians are already doing in order to meet these requirements. Overall, the proposed G-APP alternative pathway eliminates the high-stakes examination and replaces it with active and adaptive learning self-directed modules that allow for continuous feedback, and is based solidly on learning theory. As planning for the G-APP pathways goes forward, it will be important to balance educational goals with time and monetary cost, in order that many of the earlier missteps not be repeated. In addition, the authors correctly identified the need to incorporate additional tracks, for many physicians who spend less than 30% of their time in clinical practice and serve other roles in research, administration or teaching for whom designation as “not clinically active” may not be desirable. While accountability of the profession is important, the most important metric is performance in the field (clinical practice), which may not correlate with test taking. As we move forward designing new recertification pathways, it is important to keep in mind that, in the end, it may be more important that our specialists complete the learning modules successfully while enhancing knowledge. The AGA does not view as acceptable a high stakes exam that allows a learner to miss a third of the questions on exam, receive no feedback or knowledge acquisition, and still pass. The best physicians will always be the ones that look up the information that they do not know, and refer to another colleague when they are out of their depth. Our goal should be to emphasize continuous education and professional development, and enhance the care of our patients. The AGA Governing Board considers that the carefully developed EPAs already established to facilitate the appraisal of fellowship competencies serve as the initial blueprint for the next generation of MOC and that gastroenterologists define
Gastroenterology Vol. 149, No. 6
their individualized practice realm and be accountable with continuous professional development in relevant clinical areas. G-APP is flexible, individualized, promotes lifelong learning and eliminates the high stakes nature of the current process. This proposal has been communicated to the ABIM, and we welcome feedback and comment on this proposal by all constituencies: the diverse members of the AGA, and leaders of ABIM, ABMS, ACP as well as the other GI and liver societies.
References 1.
2.
3.
4.
5.
Rose S, Shah BJ, Onken J, et al. Bridging the G-APP: continuous professional development for gastroenterologists: replacing MOC with a model for lifelong learning and accountability. Gastroenterology 2015;149. Hayes J, Jackson JL, McNutt GM, et al. Association between physician time-unlimited vs time-limited internal medicine board certification and ambulatory patient care quality. JAMA 2014 Dec 10;312(22) 2014 Dec 10:2358–2363. http://dx.doi.org/10.1001/jama.2014. 13992. Gray BM, Vandergrift JL, Johnston MM, et al. association between imposition of a maintenance of certification requirement and ambulatory care-sensitive hospitalizations and health care costs. JAMA 2014; 312(22):2348–2357. Teirstein PS, Topol EJ. The role of maintenance of certification programs in governance and professionalism. JAMA 2015;313:1809–1810. Rose S, Fix O, Shah BJ, et al. Entrustable professional activities for gastroenterology fellowship training. Gastroenterology 2014;147:233–242.
Reprint requests Address requests for reprints to: Timothy C. Wang, MD, Division of Digestive and Liver Diseases, Columbia University, 630 West 168th Street, Box 83, New York, New York 10032. e-mail: [email protected]. Conflicts of interest The authors disclose no conflicts.
AGA SECTION
AGA BOARD STRATEGIC UPDATE An Alternative to MOC? Timothy C. Wang1 and Michael Camilleri2 1
T
he need for postgraduate medical education is probably clearer than at any time in the history of medicine. Medical knowledge continues to expand rapidly, with important clinical and scientific advances, every year, that are relevant to practice. There is now a greater emphasis than ever before on disease pathways, clinical guidelines, and quality improvement, making it important for physicians to remain current with newer recommendations and practice standards. While in most medical subspecialties, this was often done in part through maintenance of certification (MOC) and recertification by the American Board of Internal Medicine (ABIM), recent changes to the process have led to a reexamination of the recertification paradigm. The AGA commissioned a Task Force to take a fresh look at the entire process of recertification, and the White Paper by Rose S et al1 in this issue of Gastroenterology represents the culmination of this effort. From 1941 until 1989, after graduation from medical school, physicians would sit for an initial set of medical boards administered by the ABIM, and passing the exam was sufficient for board certification for the rest of their career. In 1989, certification was no longer lifetime but time-limited to only 10 years, and additional requirements (maintenance of certification or MOC) were introduced that included knowledge-based exercises and practice assessments, tasks that were time-consuming but apparently manageable. However, in 2014, the ABIM doubled the MOC points required (from 50 to 100, every 5 years) and stipulated that physicians who did not participate in this expanded program would be publicly labeled as “not meeting MOC requirements.” This change was introduced without much public comment at a time when physicians were already dealing with numerous stresses and requirements (eg, introduction of the electronic medical record, quality reporting, compliance issues) that were taking them away from the care of their patients. The change in MOC requirements was in many ways a watershed moment for many physicians in their support for the recertification process. The view by many practicing gastroenterologists was that many of the MOC requirements did not help them become better doctors and represented unnecessary paperwork and study of material that was largely unrelated to the delivery of quality care in their clinical practice. Many also resented the annual fees and what they deemed to be excessive cost for the entire process. While board certification was initially designed as simply a mark of distinction, it has grown, in some instances, to be required for hospital privileges, and thus the
recertification examination has evolved into a high stakes assessment. This was compounded by the relatively low pass-rates (w 85%) over the past 5 years for the GI Board recertification exam. The fact that board certification has become a requirement for privileges at many hospitals is surprising, given the lack of evidence that MOC has led to improved patient outcomes.2,3 Indeed, many other professional organizations (eg, lawyers, pilots) have opted for a less onerous approach to certification while still maintaining accountability. An online petition requesting a recall of MOC was signed by more than 22,000 physicians. The National Board of Physicians and Surgeons (NBPAS), a physician organization and alternative certification board, has proposed to replace MOC with a simple set of requirements that includes 50 hours of CME, an active license and hospital privileges.4 A survey by the AGA confirmed that a majority of surveyed members resented the increased demands of the new changes to MOC. Recently, the ABIM suspended, for at least 2 years, the requirement for a Part 4 practice improvement project (PIMS), but many physicians remain concerned regarding future MOC requirements. In this issue of Gastroenterology, the AGA Task Force made up of educators and practitioners has proposed an alternative solution based on the solid precepts of adult learning theory, competencies and milestones. They have labeled this alternative pathway G-APP (The Gastroenterologist: Accountable Professionalism in Practice). The proposal is based on broad agreement on competencies essential for gastroenterologists. Educational leaders from the 5 GI societies (Oversight Working Network) had established 13 Entrustable Professional Activities (EPAs) that define the broad array of tasks that define the practice of a clinical gastroenterologist.5 Based on these EPAs, the Task Force proposed to create individual pathways that would incorporate self-assessment activities that allow a high level of competency in one or more area(s) (eg, hepatology or IBD for example), while maintaining a more modest level of competency in other areas (see Table 6 and 7 in Rose et al5 for details). Thus, for example, a single expert level of competency would be sufficient when accompanied by general competency in the other 12 areas. The individualized
© 2015 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2015.08.010
AGA SECTION
Department of Medicine, Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, New York; and 2Division of Gastroenterology, Department of Internal Medicine, Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Mayo Clinic, Rochester, Minnesota
1608 Wang and Camilleri
self-assessment activities (ie, adaptive learning modules and/or practice exams) would provide constant feedback and opportunities for learning, rather than a secure exam that allows little opportunity for learning from feedback or selfimprovement. Finally, the Task Force recommended that the ABIM recognize many of the current quality improvement activities that physicians are already doing in order to meet these requirements. Overall, the proposed G-APP alternative pathway eliminates the high-stakes examination and replaces it with active and adaptive learning self-directed modules that allow for continuous feedback, and is based solidly on learning theory. As planning for the G-APP pathways goes forward, it will be important to balance educational goals with time and monetary cost, in order that many of the earlier missteps not be repeated. In addition, the authors correctly identified the need to incorporate additional tracks, for many physicians who spend less than 30% of their time in clinical practice and serve other roles in research, administration or teaching for whom designation as “not clinically active” may not be desirable. While accountability of the profession is important, the most important metric is performance in the field (clinical practice), which may not correlate with test taking. As we move forward designing new recertification pathways, it is important to keep in mind that, in the end, it may be more important that our specialists complete the learning modules successfully while enhancing knowledge. The AGA does not view as acceptable a high stakes exam that allows a learner to miss a third of the questions on exam, receive no feedback or knowledge acquisition, and still pass. The best physicians will always be the ones that look up the information that they do not know, and refer to another colleague when they are out of their depth. Our goal should be to emphasize continuous education and professional development, and enhance the care of our patients. The AGA Governing Board considers that the carefully developed EPAs already established to facilitate the appraisal of fellowship competencies serve as the initial blueprint for the next generation of MOC and that gastroenterologists define
Gastroenterology Vol. 149, No. 6
their individualized practice realm and be accountable with continuous professional development in relevant clinical areas. G-APP is flexible, individualized, promotes lifelong learning and eliminates the high stakes nature of the current process. This proposal has been communicated to the ABIM, and we welcome feedback and comment on this proposal by all constituencies: the diverse members of the AGA, and leaders of ABIM, ABMS, ACP as well as the other GI and liver societies.
References 1.
2.
3.
4.
5.
Rose S, Shah BJ, Onken J, et al. Bridging the G-APP: continuous professional development for gastroenterologists: replacing MOC with a model for lifelong learning and accountability. Gastroenterology 2015;149. Hayes J, Jackson JL, McNutt GM, et al. Association between physician time-unlimited vs time-limited internal medicine board certification and ambulatory patient care quality. JAMA 2014 Dec 10;312(22) 2014 Dec 10:2358–2363. http://dx.doi.org/10.1001/jama.2014. 13992. Gray BM, Vandergrift JL, Johnston MM, et al. association between imposition of a maintenance of certification requirement and ambulatory care-sensitive hospitalizations and health care costs. JAMA 2014; 312(22):2348–2357. Teirstein PS, Topol EJ. The role of maintenance of certification programs in governance and professionalism. JAMA 2015;313:1809–1810. Rose S, Fix O, Shah BJ, et al. Entrustable professional activities for gastroenterology fellowship training. Gastroenterology 2014;147:233–242.
Reprint requests Address requests for reprints to: Timothy C. Wang, MD, Division of Digestive and Liver Diseases, Columbia University, 630 West 168th Street, Box 83, New York, New York 10032. e-mail: [email protected]. Conflicts of interest The authors disclose no conflicts.
AGA SECTION