My response to ABIM’s “Assessment2020”

Two years after the rollout of its new MOC program, ABIM has heard the outcry of physicians in every form of medial despite deleting physician comments on their own website. However, except for temporary suspension of certain part of MOC, this forceful expansion of power did not stop. CMEs now are MOC-certified. ABIM also wants every EP lab to have an ABIM-certified director, a pattern that very quickly can be adapted to every other field. The complete time line of MOC can be found here.

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.