Carol A. Burke, MD, FACG
Dr. Carol A. Burke

MOC: Time to Serve Our Interests

There is widespread dissatisfaction with the American Board of Internal Medicine Maintenance of Certification program within the gastroenterology community and among many other specialties within the “House of Medicine.” The American College of Gastroenterology message to the ABIM is loud and clear:  MOC in its current and proposed form places unreasonable burdens on participants in terms of unjustifiable cost and inconvenience, and detracts from patient care. Physicians should be held accountable as lifelong learners, not lifelong test takers.

The bioptic assessment of medical knowledge by a stressful, high stakes, secured recertification test whether it be at two, five or ten years, is no measure of the quality and effectiveness of the care we provide to our patients. Moreover, it does not reflect the process by which we obtain medical information to manage our patients. Increasingly, data show that providers frequently use point-of-service electronic resources to investigate differential diagnoses, optimal treatment and best practices strategies.

Consistently, diplomates advise me that many of the ABIM recertification questions continue to be irrelevant and do not reflect the common diseases and disorders we see day-to-day in our patients. The College has been hammering home this message to the ABIM for years.

Between the vexations of the EHRs, the demands of insurance companies, countless reporting requirements, and the swift transformation in payment models, the amount of time and money we are spending on regulatory and practice burdens accentuates the inappropriate demands imposed by the ABIM of maintaining Board certification.

ABIM: Talking, Not Listening

Unfortunately, in spite of consistent and widespread pressure, ABIM has not made meaningful changes to MOC. The College has participated in and facilitated opportunities for exchange with the ABIM, seemingly to no avail.  Against the backdrop of increasingly negative perceptions of MOC, ABIM is still getting it wrong.

Diplomates who recently took the GI recertification exam were slammed with an additional 60 “beta” test questions sprinkled throughout the exam that would not count increasing the exam from three to four booklets. The ABIM stunned recertifiers about three weeks before the exam to advise them to prepare for a 10 hour testing day. To throw more salt on the wounds, the ABIM convened so-called “Listening Sessions” to open community dialogue between gastroenterologists and the ABIM regarding MOC. A few of these sessions were held at the recent ACG Annual Scientific Meeting in Las Vegas. I was informed by some session attendees that the sessions were not a dialogue, but were only meant to drive diplomates to choose their preference for either a two- or five-year, high stakes, secured MOC exam. They felt that ABIM only paid lip service to openness to discussion.  It turns out that when ABIM claims they’re listening to diplomates, they instead are doing most of the talking, without regard to serving the needs of their physician constituents.

The ABIM has not heard the message that patients and providers are married to a demonstration of physician competence easily shown by a commitment to lifelong learning, not lifelong testing. While the ABIM has the tools and capacity to innovate an educational, practical, and learner-centered assessment of physician knowledge and competence, it has demonstrated no ability to think outside of the box.

MOC – A Monopoly Position

ACG is committed to minimizing the negative impact of ABIM’s monopoly position on MOC. As the sole arbiter of the requirements for recertification and the entity which also sets the price, ABIM is effectively behaving as a monopoly, while many physicians are a captive audience forced to comply and endure what ABIM requires.

The College is committed to doing all we can to fix the flawed MOC process, while at the same time pursuing alternatives – including alternative credentialing models in partnership with other organizations including our sister societies, the AASLD, AGA and ASGE.

This year, I created a Task Force on MOC chaired by Dr. Daniel J. Pambianco of Charlottesville, VA. The group is charged with expanding the College’s efforts to make MOC easier to navigate for ACG members, collaborating with other like-minded specialties and societies to pressure the ABIM to understand our position, exploring alternative recertification strategies and ensuring all implications of any alternative to ABIM MOC are fully investigated.

Stranded Over the Barrel on MOC

While ACG fully recognizes that there are significant, fundamental problems with MOC, we acknowledge that there are many ACG members – particularly those who work in large hospitals or academic centers – for whom MOC is a condition of employment.

ABIM has these physicians stranded over a barrel. ABIM MOC is a requisite for participation in some insurance plans and to maintain hospital credentialing. Opting out of MOC is not a viable option if staff privileges are in jeopardy or if compulsory MOC is linked to licensure.

State Legislative Solutions

Recently Oklahoma passed a law (SB1148 signed by Oklahoma Governor Mary Fallin in April 2016) that would prohibit MOC participation as a requirement for contracts with insurance companies, physician employment agreements and hospital credentialing.  We are aware of several states, including Arizona, Kentucky, Missouri, North Carolina and Michigan, which passed or are considering similar legislation. ACG supports bills at the state level that ensure that MOC requirements do not unduly interfere with contracting, employment or credentialing for physicians. At the same time, we will work to make sure that these efforts do not inadvertently undermine the ability to ensure that physicians doing endoscopic procedures are adequately trained – especially those who have not gone through GI training.

The ACG Board of Governors is active and engaged on state-level legislative solutions on MOC.  As part of the great work initiated by Dr. Immanuel Ho as he ended his term as Chair of the Board of Governors and which is now being championed by Dr. Costas Kefalas as Chair and Dr. Douglas Adler as Vice Chair, a group of ACG Governors is energized and empowered to explore legislative action modeled on the successful state initiatives.

ACG – Making it Easier to Meet Your MOC Needs while Exploring Recertification Alternatives

As ACG pushes for meaningful MOC reform, the College feels a strong obligation to its more than 14,000 members to offer pathways in the interim to meet their MOC requirements while we pursue an “all options” strategy that includes developing and supporting alternatives to ABIM MOC.

This approach is not inconsistent, it’s realistic. We cannot abandon our members for whom MOC is integral to their employment, licensure, credentialing or plan participation. ACG is working to make MOC meaningful, impactful, less expensive, and easy to navigate, while keeping ACG’s MOC options free as a benefit of College membership. The College offers CME credit that also provides opportunities to earn ABIM MOC credit – at no cost. At the same time, we want to see what alternatives to MOC can work for the membership.

It is our mission to serve the needs of all of our members – including those who work in environments where they do not have a choice about whether or not to participate in MOC.

This is a complex issue. We are working to arrive at nuanced solutions that will reform Board recertification so it adds value to GI clinicians and quality care to our patients.