Thursday, May 22, 2014

Maintenance of Certification in Internal Medicine: What the Population Health Community Needs to Know

Since population health provider organizations work closely with physicians, they're aware that "board certification" is an important credential.  Being "boarded" in family practice, pediatrics or internal medicine is widely regarded as evidence of extensive training.

They may not be aware of the controversy brewing over board certification in the internal medicine physician community.

The American Board of Internal Medicine (ABIM) is the certifying Board for the nation's internists.  After meeting training requirements involving years of training after medical school graduation, candidates have to pass an examination.  Once physicians do that, they have the credential that documents their expertise. 

It used to be that once you did the training and passed the test, you were credentialed as a "board certified" internist.... forever.  With increasing recognition that skills can grow stale with time, in 1990 the ABIM decided to require recredentialing on a periodic basis. 

That process has evolved under the umbrella term "maintenance of certification" ("MOC").  You can read more about that here and here, but it basically involves earning "points" through activities such as documentation of learning, participation in quality improvement, chart audits and taking a repeat test.

Unfortunately, MOC and the ABIM have become a focus of physician ire.  While the academics and organized medical societies' leaders believe in the process, many rank and file practicing physicians disagree

Among their concerns that are nicely documented here and here:

1. It takes a considerable amount of time, documentation, and paperwork to complete the 10 years' worth of continued training/chart audits and to prepare for the repeat examination.  (That's especially true thanks to the difficulty at extracting electronic records data; it also puts smaller practices at a disadvantage, since they may not have the support personnel to help with all those tasks).

2. It's also expensive.

3. If a physician doesn't pass the test, it needs to be taken again at additional cost.  Over the past five years, the failure rate has increased from 10% to 22%.  Since it's unlikely that the pool of docs entering the MOC process are dumber, that suggests the test is getting unnecessarily harder. Some physicians wonder if ABIM has a financial incentive to increase the failure rate. 

4. Unlike the initial process of board certification, there is little hard evidence that MOC-credentialed physicians  attain better patient outcomes compared to non-MOC physicians.

5. Physicians are unhappy that the MOC process does not recognize the practical wisdom that comes with decades of patient care.  It is "one size fits all" and can't be tailored to account for different practice settings.

6. There is a possibility that MOC could evolve from a voluntary exercise in professionalism to a mandatory condition of licensure, hospital/insurer participation or employment.

7. ABIM not only has a monopoly, it has no oversight. Whatever the merits, the ABIM's MOC actions are seen by some as capricious, arbitrary, disconnected to the real world and only adding to physicians' low morale.  One survey suggests a majority of practicing physicians are skeptical about the MOC.

 The Population Health Blog suspects this is a controversy that is not going away anytime soon.  Population health service providers will always be interested in helping their "orphan" patients without a PCP become engaged with a physician, and may use "board" status as one criterion for referral.  It remains to be seen if "MOC" participation should be part of that calculus.

Stay tuned!


StefaniD said...

Continuing education in any profession must be mandated so that the public knows the individual has maintained knowledge of current issues related to their profession. Physicians balking at renewing their certification is typical of a profession that has had their heads in the sand for the last two decades and like most things happening in healthcare, until the medical community decides its time to manage their own destiny, someone else will --- thankfully

Jaan Sidorov said...

"Ouch!" Stefani. The continuing education is pretty much mandated by the governing Board of the internists' profession.

I don't think the docs are balking at renewing their certification, it's just that they're concerned that the certification process is so unwieldy. They don't want it cancelled, they want it changed.

But you make an excellent point: without a credible certification process, outside forces will impose changes.