When the American Board of Internal Medicine (ABIM) announced changes to its Maintenance of Certification (MOC) process in early 2014, the response was overwhelmingly negative. Individual physicians and medical societies criticized ABIM for adding significant time and expense to MOC, and loudly challenged the program’s effectiveness, relevance, and value.
After months of backlash, ABIM issued an apology in February and rolled back or delayed some of the MOC changes. In a letter to diplomates, ABIM President and Chief Executive Officer Richard J. Baron, MD, acknowledged that some of the criticism of ABIM was legitimate and that “some believe ABIM has turned a deaf ear to practicing physicians.” He said, “We got it wrong and sincerely apologize. We are sorry.”
Despite ABIM’s apology, the conversation about MOC continues to rage—and for good reason.
Though the medical community needs a formal process like MOC to ensure that physicians at all stages of their careers are knowledgeable, qualified, and capable of handling their patients’ care, it’s not clear that the current MOC process delivers those outcomes. I’m certain there are individuals who, over the course of seven or 10 years, complete their training modules, pass an exam, and still do not practice according to the most current, evidence-based guidelines. Just because we know the information needed to pass an exam doesn’t mean we actively use that knowledge to deliver quality care to patients.
To bridge this gap, certifying organizations like ABIM and the American Board of Family Medicine (ABFM) should consider how to better integrate the MOC process into physicians’ daily practice of medicine, so that actual patient care and outcomes are used to determine whether or not an individual is recertified.
Done well, this integration would solve multiple problems.
New Approach Required
Instead of measuring our test-taking ability, it would tie certification directly to how we care for patients: weighing whether or not we use current, evidence-based practices to achieve optimal outcomes. It also would address the problem of testing physicians’ knowledge on topics that fall outside their normal scope of practice. For example, as I have focused my career in hospital medicine, I no longer practice in pediatrics or OB/GYN, but those topics are still included in my family medicine board examination. When I was recertified in 2013, I spent a lot more time preparing for that section of the exam than for the areas in which I practice daily.
In fact, a better-integrated MOC process could help reduce the significant investment of time and money associated with recertification. Not only do most physicians need to take time off from practicing to prepare for the exam, but we also must bear the direct costs of the test itself, along with the necessary test preparation materials.
According to a study released in July by the University of California at San Francisco and Stanford University, ABIM’s latest MOC requirements will cost individual physicians more than $23,600 over 10 years, with the costs in some subspecialties exceeding $40,000. Of those costs, $9 out of every $10 is associated with the demand the process makes on a physician’s time. In announcing the study, the lead author said, “We estimate that ABIM MOC will cost 33.7 million physician-hours over 10 years. Efforts to reform MOC and lower its costs should focus on making the most efficient use of physician time.”
A Simple SPARK
Until MOC is reformed, physicians seeking recertification have no option but to continue under the current process. To help members with test preparation, SHM has launched SPARK, an online tool to prepare physicians for the ABIM/ABFM Focused Practice in Hospital Medicine (FPHM) exam. It is available to SHM members at a significant discount. SPARK features 175 vignette-style, single best answer, multiple-choice questions, complete with answers, cohort comparison, discussion, references, and quizzing capabilities. This first edition targets gaps in other available tools like palliative care, ethics and decision-making, patient safety, peri-operative care, consultative co-management, quality, cost, and clinical reasoning.
The first iteration of SPARK has launched. From here, we will expand SPARK to include preparation materials for the remainder of the family medicine/internal medicine sections of the MOC exam. As the only FPHM MOC preparation tool created by hospitalists for hospitalists, we believe SPARK provides an effective and more affordable alternative to the test preparation tools offered directly through ABIM and ABFM.
Although the concept of MOC is a valid one, the process should be improved to ensure that physicians maintain the knowledge necessary to deliver high quality care. As we work toward further reforms, we hope SPARK will ease the preparation process for our members.