With growing resistance and boycotting
to MOC, emerging of an alternative board, and criticisms from societies such as ASN (So proud of ASN!!), ABIM did acknowledge its disconnection
with physicians. It is now planning to implement changes to MOC in their Assessment 2020.
ABIM has asked all societies to give feedbacks on this Assessment. So far I have seen the response from AAIM. It appears that there are many societies still baring the mindset of "MOC is here to stay. We have to work with it". As a practicing physician, I strongly believe that our societies have to give up this notion and start to question the legitimacy of ABMS/ABIM expanding their power without any limitation or oversight.
Here I want to give my feedback for ASN to consider when they give their response. I am encouraging every doctor to speak up and inform your society and ABIM where you stand, and what you envision the board certification should be in 2020.
Before
commenting on this “Assessment”, we need to clarify the role of different
players in health care delivery.
Certifications are to
demonstrate that the trainee has acquired an acceptable level of knowledge and
is entitled to practice in a medical specialty or subspecialty. Health care is
multi-dimensional. Using one certification to gauge every aspect of health care
delivered is unrealistic, and gives special groups the opportunity for unbalanced
influence over physicians and hospitals, and completely devoid of checks and
balances.
The ABIM is a proprietary organization in the business of
credentialing. They should not speak for educational entities, our scientific
or clinical societies, our hospitals or our state medical boards. The
legitimacy of the ABIM in promoting more credentialing processes such as MOC is
therefore questionable, and raises significant issues, including potential
financial conflicts.
Next,
let’s take a closer look at the quality of this “Assessment”.
Dr. Baron claims that the “Assessment” is made by “outside
expert”. I am not sure what he meant by “outside”. The Task force members
are certainly not representative of practicing physicians. Many have never taken the re-certification
tests they are pushing for.
There are many statements about engaging physicians that are questionable
at best and inaccurate at worst. Here are a few examples:
“…we listened to our stakeholders (physicians…)” - The ABIM
website deleted every single comment by physicians and has yet to show the
public comment session.
“…incorporated input about MOC though data” - ABIM, are any
these data public?
“…social media outreach”, “…response on social media was
steady but marginal” – they only selected what they wanted to hear
“…effort was made transparent on the
(assessment2020.abim.org) website to inform open conversation” – how was or
will this be accomplished? There is no
place to leave comments on the website every time I checked! In addition, how transparency it can be when ABIM is hiding its archives?
Based on these observations, I can’t help but
wonder how the view of this Assessment 2020 is not selective and heavily vetted. It is biased and
does not reflect practicing physicians’ opinion despite ABIM claims to the
opposite.
As a
result, our societies need to take the opportunity to defend physicians, our
profession, and importantly, to maintain the integrity of medicine in a
proactive manner. Professional societies should be the leader and real
representatives of physicians, not the follower of a self-appointed
organization with a blatant financial conflict of interest. Our societies have the responsibility to protect health
care, patients, and physicians from becoming victims of groups such as
ABMS/ABIM. The ABMS/ABIM has been shown to be an organization with no
credibility, devoid of accountability, and worst of all, no oversight
whatsoever. Therefore, it is critical for professional
societies and, to the extent it is possible, physicians, to eliminate the ABIM, and any other certifying agents’
ability and future attempts to arbitrarily raise certification requirements,
and thus appoint themselves judge and jury about our profession's ongoing
educational needs.
On this basis, the important issues
need to be addressed immediately are:
a.
Certification
should be distinct from all quality measures.
“Quality” is such an easy, catchy, hard to dispute yet hard to define goal.
It has become the passport for implementing variety of rules and regulations to
health care. In the last few years, there is exponential increase of changes,
such as “Meaningful Use”, mandating of ICD 10, etc, in addition to MOC. Not
only these are changes caused significant disruption of care delivering, they
are shameless abuse to physicians and our system. In UK. A nationwide strike is
on due to controversial contract that will be implemented for “the promise of the same
high-quality care every day of the week”. This kind of abuse is now to a critical
level. Physician groups and professional societies must take every opportunity to
establish oversight on quality measures proposed, and to advocate for
legislation to stop intrusion into health care by certification organizations,
or any organization or group, in the name of “quality”.
b.
Certification
should be distinct from any insurance reimbursements. Associating certification
by ABMS/ABIM with payment for services provided is of no value to patients or
physicians, except serving only as leverage for the ABIM to pressure physicians
in paying for and participating in MOC. The fact that ABIM has been workingwith insurance companied closely has said it all. Disconnect certification and insurance
reimbursement should again be on all professional societies' advocating
agenda.
c.
Certification
should be distinct from any credentialing, licensure and privileges managed by
each state and hospital.
d.
All
professional societies should dissociate their educational programs from the
ABIM’s MOC. None educational program should be labeled as
“MOC”.
e.
Professional
societies should accept viable alternative to ABIM to help physicians to fight ABIM monopoly.
f. Establish a
contracture relationship between certifying agents and physicians so that any
change in certification process needs to be approved by a professional society
representing majority of practicing physicians.
So, here is my breakdown response to ABIM's Assessment 2020 and a certification
plan suitable for Nephrologists:
ABIM’s
stance 1: stated mission
1.
Mission 1 - “Enhance quality of health care”.
Response: Disagree
Reasoning:
a. ABIM has
significant conflict of interest in quality measures due to its connection with
National quality forum; ABIM should not be involved with any quality measures
b. Nephrology
is a subspecialty with quality assessments highly monitored and deeply regulated
by both CMS and industry. Practice improvement and reporting is also being
performed regularly. The report itself is 259 pages. There is no reason to add more.
Recommendations:
a.
Leave
quality measures to hospitals, state boards, and payers such as CMS. The
AAIM response euphemized a
similar point. “[Do] not try to measure everything that is part of “keeping up”
and being a good physician.” AAIM also suggested more execution on the local
level.
b.
There should definitely be no more added quality measures
to avoid high cost, waste of resources, redundancy and importantly, burden on
physicians and hospitals.
2.
Mission 2 - “certifying internists and subspecialists who demonstrate
the knowledge, skills and attitudes essential for excellent patient care.”
Response:
a. Partly agree
with certifying “knowledge”;
b. Disagree with certifying “skills and attitudes”.
Reasoning:
a.
Re-certification
has not been shown to improve care after 25 years.
b.
No other
country in the world requires repeated testing to maintain “certification” yet
they have better and cheaper health care.
c.
Lifelong
learning should not be limited to one organization’s agenda or trademarked
product.
d.
A
centralized “certifying” scheme for “skills and attitude” is an attempt to
change the interactive and highly personal health care process into a machinery
assembly line. This is posed threat to the freedom of physicians and their
relationship with patients.
Recommendations:
a.
Initial
certification is acceptable;
b.
Re-certification
should be abandoned
e.
Professional
societies should work with ACCME to create robust CME programs. Many CMEs are already test based, including
ASN’s NephSap and KSAP.
f.
Procedures,
team work, etc should be evaluated by each hospital.
ABIM’s stance 2: recommendations
derived from the Assessment 2020 Task Force
1.
“Replace 10 year MOC exam with more frequent assessment”
Response:
Partly agree (with eliminating 10 year recertification test), but disagree with
more frequent assessment
Reasoning:
a.
A high stake re-certification test relies heavily on memory
and has not shown to be of benefit. All other
countries not using re-certification test have better health care outcomes.
b.
There has been a system in place for continuous evaluation
of physicians’ activity of keeping up – CME,
which has to be approved by ACCME. The activity is overseen by the hospital
credentialing committee and state medical board. Adding MOC to the process is
mere redundancy.
Recommendations:
a.
Eliminate a high stake re-certification test.
b.
Initial certification test is OK and necessary
c.
“..potential ideas
for changes of MOC” (Appendix H) are still attempts to adding more tests; ie
test “every 6 months”. We should not support any of these MOC proposals. Again,
many CMEs are test-based (ASN’s
NephSap and KSAP). MOC adds nothing but payment to ABIM, the annoyances and
distractions of performing irrelevant tasks, and taking irrelevant exams.
d.
As long as physicians are meeting CME requirements, they
should be able to remain certified.
e.
Many of our ongoing learning efforts should be taken into
consideration:
i.
ACCME approved CME activities
ii.
Professional society approved educational materials
iii.
Self-directed literature review. Potentially a system to
track physicians’ self-directed learning should be developed by specialty
societies, ACCME and journals, PubMed, etc.
iv.
Lectures
given
v.
Daily
patient care
vi.
Teaching
2.
“assessment on cognitive and technical skills”
Response: Disagree
Recommendations: This should not be required
for recertification
3.
“Recognize specialization”
Response: Agree
Recommendations: This should be left to
specialty professional societies.
ABIM’s stance 3: 3 general goals of MOC according to the 2015 standards set by ABMS
1.
Include ACGME core competencies
Response:
Disagree
Reasoning:
a.
The 6 competencies are evaluated rigorously by all
education entities (med schools, residencies, and fellowships), then by our
employees, peers, patients and state boards. It is completely redundant for
ABIM to mandate these additional evaluations.
Further, the downstream utility of these competencies outside of
education is completely unproven
b.
It is unacceptable that ABMS/ABIM can "out of the blue"
take any role in the certification process without evaluation/approval/input
from the cohort subject to these policies.
Recommendations: Limit certification to
knowledge
2.
To enhance the value of MOC
Response: Disagree
Reasoning:
a.
This is a shameless and blatant business move by the
ABMS/ABIM.
b.
MOC’s benefits have never been proven. Lacking scientific
evidence for utility, they are impractical, irrelevant, arbitrary, and
distracting to our profession, posing a significant burden to physicians.
c.
Mandating
MOC fosters distrust towards our profession, implying we are not competent without
this artificial metric.
d.
Multiple
board certifications will be highly unlikely due to the egregious time and
financial burdens of MOC. This is contrary to the goal of life-long learning.
a.
ABMS/ABIM raises unsubstantiated questions about CME; a
system that is widely accepted as a valid tool for continued learning. In addition, the fact that ABMS/ABIM can
single-handedly change recertification requirements overnight -- without physician
input -- is overwhelming proof that it is a monopoly with unfettered political
and monetary power. This behavior must
stop.
b.
There is no
reason practicing physicians should have to pay ABIM yearly and essentially buy
ABIM’s products in order to continue to work.
Recommendations:
a.
The current
MOC program, including all of parts 1-4 should be dismantled completely.
b.
Work with
ACCME and professional societies on robust CME activity.
c.
Recognize
alternative board. Give us a choice!
3.
To engage in continued quality
monitoring
Response: Disagree
Reasoning:
a.
Quality is
being monitored constantly and closely already. Adding more QI only adds
redundancy, increases unnecessary workload, contributes to physician burnout
and importantly, compromise patient care delivery, as shown by the mandatory
PIM and patient survey experience.
b.
QI has been
utilized by the ABIM as leverage for escalating certification, which serves
only the interest of the ABIM. As the
result, the ABIM has unscrupulously profited from MOC
Recommendations:
a.
There should be no engaging of MOC and quality monitoring
b.
Quality
measures should be only be performed by individual institutions (hospitals,
dialysis units, etc), state boards, networks, etc. PIM and patient surveys are
part of QI and therefore should not be demolished and disassociated with
certification.
Conclusion:
1.
Professional
societies should support initial certification and lifelong learning through
robust CME activities tailored to each individual physician’s need, and will
continue to work with other professional societies to assist Nephrologists’
need for high quality CME materials.
2.
ABIM as a
certifying organization should continue to provide initial certification.
However, re-certification has not been shown to provide any benefit to
patients, physicians, or health care. On the contrary, it has become a major
distraction to patients, physicians, and care delivery. The Assessment 2020
therefore should focus on initial evaluation of trainee’s ability of utilizing acquired
up-to-date knowledge, engaging critical clinical reasoning, and making sound
clinical decision. Recertification test and MOC should be eliminated.
3.
Health care delivery is a complicated process involving not only
physicians. The notion that a certificate of a physician would encompass every
aspect of the care patient received is impractical, self-serving, certainly
conflicted by ABIM’s financial interest. ABIM or any certifying agent’s ability
of escalating their business rapaciously is unjustified. Professional societies
should work together to advocate for stopping any intrusion to health care,
potentially working towards legislation such as a "Physician Practice Freedom Act",
which might have already started.
