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Continuing Medical Education and Maintenance of Certiﬁcation Kevin R. Loughlin,* Tom Granatir and Gerald H. Jordan From the American Board of Urology (KRL, GHJ), Charlottesville, Virginia, Brigham and Women’s Hospital (KRL), Boston, Massachusetts, and American Board of Medical Specialties (TG), Chicago, Illinois
Abbreviations and Acronyms
Introduction: The ABMS (American Board of Medical Specialties) mandated maintenance of certiﬁcation in 2000 for its 24 member boards. The ABU (American Board of Urology) initiated the maintenance of certiﬁcation process in 2007. Methods: A literature review using MedlineÒ and a GoogleÒ search was performed using continuing medical education and maintenance of certiﬁcation as search terms to identify pertinent literature.
ABIM = American Board of Internal Medicine CME = continuing medical education MOC = maintenance of certiﬁcation
Results: The relevant literature was reviewed, and a distillation of the controversial issues regarding continuing medical education and maintenance of certiﬁcation was composed. Conclusions: The body of literature reviewed supports the conclusions that maintenance of certiﬁcation serves as the most reliable vehicle to ensure lifelong learning and continuing medical education alone is not sufﬁcient. Key Words: urology; education, continuing, medical; certiﬁcation; specialty boards; patient safety
This review aims to provide the history, rationale and context of why MOC and CME taken together provide the most reliable way to ensure lifelong learning for the physician and safety for the patient. Historical Perspective
The ABMS is composed of 24 member specialty boards. The ﬁrst board, the American Board of Ophthalmology, was incorporated in 1917 and the ABU was incorporated in Submitted for publication June 23, 2015. No direct or indirect commercial incentive associated with publishing this article. The corresponding author certiﬁes that, when applicable, a statement(s) has been included in the manuscript documenting institutional review board, ethics committee or ethical review board study approval; principles of Helsinki Declaration were followed in lieu of formal ethics committee approval; 2352-0779/16/36-481/0 UROLOGY PRACTICE Ó 2016 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
1935. The last board to join was the American Board of Medical Genetics and Genomics in 1991. The ABU deﬁned its mission as “To act for the beneﬁt of the public to insure high quality, safe, efﬁcient and ethical practice of Urology by establishing and maintaining standards of certiﬁcation for urologists.” Since 1985 all certiﬁcates issued by the ABU have been time limited certiﬁcations, which expire in 10 years. All Diplomates who had passed the process prior to 1985 are grandfathered and not required to recertify. The 2003 institutional animal care and use committee approval; all human subjects provided written informed consent with guarantees of conﬁdentiality; IRB approved protocol number; animal approved project number. * Correspondence: Department of Urology, Brigham and Women’s Hospital, 45 Francis St., Boston, Massachusetts 02115; (e-mail address: [email protected]
http://dx.doi.org/10.1016/j.urpr.2015.10.002 Vol. 3, 481-485, November 2016 Published by Elsevier
Continuing Medical Education and Maintenance of Certiﬁcation
recertiﬁcation process involved the ﬁrst group of urologists to undergo a second recertiﬁcation evaluation. In 2000 the ABMS voted to commit member boards to MOC for Diplomates with time limited certiﬁcates. MOC was an acknowledgement that physicians in practice needed more support from their professional organizations to engage in the new environment of safety and quality improvement that has become a public priority. The MOC process began for urologists in 2007. This involves an evaluation of practicing urologists in 6 areas of competency, which are medical knowledge, patient care, interpersonal and communication skills, professionalism, practice based learning and improvement, and system based medicine. The current MOC requirements are available on the ABU website (https://www.abu.org/). When MOC is fully implemented in 2017, there will be 27 remaining urologists (0.002% of the total) younger than 66 years who will hold time unlimited certiﬁcates. Regardless of whether the urologists may have an unlimited certiﬁcate, all Diplomates who achieve subspecialty certiﬁcation enter the MOC process. The MOC process allows the subspecialist to maintain his/her certiﬁcate in urology as well as in the subspecialty.
Beyond Continuing Medical Education
CME has been around in various forms for decades. Hospital grand rounds, and regional and national conferences have been part of the fabric of organized medicine throughout most of the 20th century. From the 1950s to the 1980s the pharmaceutical industry was heavily involved in CME, which led to concerns regarding informational bias.1 Because of this and other factors, CME became more regulated in terms of content and commercial support, and CME evolved into a requirement for hospital privileges and licensure. However, with time it became clear that CME had signiﬁcant limitations. Although some CME programs involved exit testing to evaluate mastery of the topic, many had no requirement other than proof of attendance. In many cases the selection of the CME topic was left to the discretion of the physician without any consideration for tailoring the CME to meet areas of weakness in knowledge or performance. As medical knowledge continued to accelerate, it became clear toward the close of the 20th century that CME alone was not sufﬁcient to provide tools for lifelong learning and self-assessment.
The Evolution of Maintenance of Certiﬁcation
In 1999 the Institute of Medicine published To Err Is Human: Building A Safer Health System.2 This report
documented the costs in human lives and morbidity as well as the economic consequences of medical errors. This publication raised the awareness of preventable medical errors. As awareness grew, it became clear that self-evaluation can be a daunting challenge. There is a robust literature addressing the particular challenges that confront physicians in the areas of self-assessment and competence. In the article, Self-Assessment in the Health Profession: A Reformulation and Research Agenda, Eva and Regehr emphasize the challenges of self-assessment.3 They contend that self-assessment should be viewed as a duality with the goal being to identify one’s weakness as well as one’s strengths. An individual may be blind to his/her personal competencies. These authors emphasize that the ability to assess strengths and weaknesses generates a balance in setting personal learning goals. They urge that physicians seek out “directed learning” whereby the individual pushes the edges of his/her knowledge instead of selecting professional development courses that merely reinforce the individual’s strength. Eva and Regehr describe the area of metacognition or the knowledge of one’s knowledge.3 Individuals tend to utilize the cue of ﬂuency (the case of understanding) in judging the extent to which they have learned material and, therefore, they often overestimate the amount that they have learned. They review the phenomenon of “social cognition,” which means that most people believe themselves to be more talented than the average person.4 Gilbert and Wilson describe this phenomenon further as the “psychological immune system,” highlighting the efforts that human beings make to maintain a sense of well-being by rationalizing and justifying threatening information.5 Garrison Keillor popularized this as the “Lake Wobegon effect,” a natural human tendency to overestimate one’s capabilities that resonates with his characterization of the ﬁctional town “where all the women are strong, all the men are good looking and all the children are above average.”6 This limitation of accurate self-assessment has been veriﬁed in studies that demonstrate that peers are better predictors of performance than individuals rating themselves in health sciences7 and psychology.8 This literature caused Eva and Regehr to conclude that “ the route to self-improvement is not through becoming a more accurate self-assessor, but through seeking out feedback from reliable and valid external sources (experts, self-administered tests, etc) and then . making a special effort to take the resulting feedback seriously rather than discontinue it.”3 A meta-analysis of 17 articles by Davis et al conﬁrms the observation that physicians have limited ability to accurately self-assess.9 Another factor that should be considered is the impact of aging on competence. Choudry et al identiﬁed the phenomenon through a literature review that aging physicians,
Continuing Medical Education and Maintenance of Certiﬁcation
although more experienced, may be at risk for providing lower quality care.10 Such observations are the underpinning of the need for lifelong learning and the rationale for MOC.
possible. The average time from battleﬁeld to the United States is now less than 4 days. During Vietnam it was 45 days. Not Without Controversy
Maintenance of Certiﬁcation Lessons from the Military
In his book, Better, Gawande reviews several aspects of military medicine that provide lessons in terms of objective assessments of performance and how application of these observations resulted in dramatic improvements in patient outcomes.11 Despite dramatic increases in the power of weaponry, battleﬁeld fatalities in the Revolutionary War, World War II, the Korean War and the Vietnam War decreased from 42% to 30% to 25% and to 24%.11 These improvements were due not only to advances in technology, such as the development of blood substitutes, freeze-dried plasma and medications, but also to objective evaluations of outcomes. Currently, the battleﬁeld death rate in Iraq/Afghanistan is 10%. What accounted for these dramatic improvements? Gawande interviewed military surgeons and found that in large measure the improvements were due to the fact that they made a science of performance.11 They found that many casualties were due to injuries to the torso and they initiated the use of KevlarÒ vests. However, when the surgeons analyzed the wound registries in the Gulf War, they found that many chest wounds occurred in soldiers who were not wearing their Kevlar vests because they were heavy and hot. Orders were issued to commanders that made them responsible for their soldiers wearing their vests and the battleﬁeld mortality rate declined. In Vietnam Colonel Ronald Bellamy analyzed battleﬁeld data and found that helicopter evacuation reduced the transport time for injured soldiers to hospital care from an average of 11 hours in World War II to less than an hour in Vietnam.11 After they arrived at the ﬁeld hospital only 3% of injured soldiers died. Civilian trauma surgeons refer to the “golden hour” during which most trauma victims can be saved if treatment is commenced. However, Bellamy observed that in combat it was the “golden 5 minutes.” This observation and self-evaluation led to the formation of Forward Surgical Teams composed of just 20 people (general surgeons, orthopedic surgeons, nurse anesthetists, nurses, medics and support personnel). They follow the troops in Humvees and can set up a fully functioning hospital with 2 operating tables and 4 ventilator equipped recovery beds in under 60 minutes. Objective evaluation of the data enabled the Forward Surgical Teams to achieve the “golden 5 minutes.” Further monitoring of the battleﬁeld data resulted in immediate stabilization with transfer to Germany or the United States as quickly as
MOC has 3 expectations for proctoring physicians, including 1) self-directed learning, 2) external assessment of their knowledge, judgment and skills, and 3) an effort to participate in improving care through measurement. However, implementation of MOC by the ABMS and its member boards has been controversial. The ABMS allows each member board to have discretionary power regarding the format of each of their MOC processes. There has been considerable opposition to MOC by some physicians. Complaints have included expense, time away from practice and assertions that the MOC process does not reliably contribute to practice improvement. The ABIM in particular met with stiff opposition from many of its members. This caused the ABIM to reconsider its MOC program and implement 5 changes, including 1) enrollment fees, 2) program language, 3) the internal medicine examination, 4) a 2-year suspension of part IV practice performance projects and 5) self-assessments.12 Teirstein voiced his opposition to MOC in a Perspective piece in the New England Journal of MedicineÔ.13 His concerns included the lack of consistent evidence that MOC participation improves patient care as well as costs and added administrative tasks. Irons and Nora replied by citing evidence that physicians cannot always accurately assess themselves.14 They stated that the MOC program was not intended to replace CME. Rather, it added practice assessment that could guide the choice of practice relevant CME and practice improvement. They emphasized that current programs are not immutable. They elaborated on this issue, saying that “MOC standards could be further reﬁned to reﬂect the changing educational and practice environments and address the needs of the physicians it is intended to support.”14 The Quality Imperative
The heart of American medicine has always been to deliver quality care. However, in the next few years American health care will evolve from a volume based, fee for service system to a value based system that rewards care integration and quality. Porter and Teisberg said, “The fundamental ﬂaw in U.S. health care policy is its lack of focus on patient value.”15 As the transformation of American medical care continues to evolve, MOC will become an even more critical component of medical practice. As a value based system continues to emerge, it is likely that there will be increasing pressure to provide evidence of quality and, therefore, value such as MOC.
Continuing Medical Education and Maintenance of Certiﬁcation
MOC should be considered an aid and not a hindrance to providing quality health care to our patients. MOC is a work in progress. It is not inﬂexible. Physicians should be encouraged to provide feedback to member boards to modify MOC where necessary to achieve its goals of lifelong learning and improvement in the quality of patient care. The new standards require the boards to obtain feedback from practicing physicians, increase the value experienced by physicians and perform their own ongoing quality improvement to enhance MOC programs on an ongoing basis. The boards wish to partner with practicing physicians to achieve these goals. References
6. Lake Wobegon. Available at https://en.wikipedia.org/wiki/Lake_ Wobegon. Accessed May 23, 2015. 7. Eva KW: Assessing tutorial-based assessment. Adv Health Sc Educ 2001; 6: 243. 8. Kolar DW, Funder DC and Colvin CR: Comparing the accuracy of personality judgment by the self and knowledgeable other. J Personal 1996; 64: 311. 9. Davis DA, Mazmanian PE, Fordis M et al: Accuracy of physician self-assessment compared with observed measures of competenceda systematic review. JAMA 2006; 296: 1094. 10. Choudry NK, Fletcher RH and Soumera SB: Systematic review: the relationship between clinical experience and quality of health care. Ann Intern Med 2005; 142: 260.
1. Continuing Medical Education. Available at https://en.wikipedia. org/wiki/Continuing_medical_education. Accessed May 24, 2015.
11. Gawande A: Better: A Surgeon’s Notes on Performance. New York: Henry Holt 2007.
2. Kohn LT, Corrigan JM and Donaldson MS: To Err Is Human: Building A Safer Health System. Washington, D.C.: Institute of Medicine, November 1999.
12. Wallon SW: MOC Watch: ABIM Says ‘We Got It Wrong.’ Medpage Today: Primary Care, February 3, 2015. Available at http:// www.medpagetoday.com/PrimaryCare/GeneralPrimaryCare/ 49858. Accessed May 21, 2015.
3. Eva KW and Regehr G: Self-Assessment in the health profession: a reformulation and research agenda. Acad Med, suppl., 2005; 80: S546. 4. Alicke MD, Klotz ML, Breitenbecker DL et al: Personal contact, individualization and the better-than-average effect. J Person Soc Psych 1995; 68: 804. 5. Gilbert DT and Wilson TD: Miswanting. In: Thinking and Feeling: The Role of Affect in Social Cognition. Edited by J Forgas. Cambridge: Cambridge University Press 2000; p 178.
13. Teirstein PS: Boarded to deathdwhy maintenance of certiﬁcation is bad for doctors and patients. N Engl J Med 2015; 372: 106. 14. Irons MB and Nora LM: Maintenance of certiﬁcation 2.0dstrong start, continued evolution. N Engl J Med 2015; 372: 104. 15. Porter ME and Teisberg EO: Redeﬁning Health Care: Creating Value-Based Competition on Results. Boston: Harvard Business School Press 2006; p 323.
In the preceding article the ABU failed to provide objective evidence to support MOC. No rationale was presented to justify the creation of this burdensome program. Where was the public outcry against practicing urologists? Where were the data demonstrating a time dependent regression of urological ability among practicing urologists? Where was the proof that MOC improves urological care? It seems that the ABU created a problem that did not exist and then devised an onerous, unproven solution to show regulators a commitment to maintaining quality care on behalf of the public. Perhaps the true reason for MOC was the irrational fear that if we do not regulate ourselves, the government will step in and do it for us. Yet the efforts of the ABU have done nothing to stop the relentless onslaught of governmental intrusion into our daily practice, including the EHRs (electronic health records) mandate, meaningful use criteria, quality metrics, CPOE (computerized physician order entry) or ICD-10. Urologists have become gloriﬁed data entry clerks who spend more time on the computer than with patients.
Once again the ABU has failed to respond in a meaningful way to the growing discontent among its Diplomates and has reconﬁrmed all of my previous objections.1 No one questions the role of the ABU in the initial certiﬁcation process to ensure competence after a lifetime of learning. It has become a rite of passage. On the other hand, once we have achieved this status and have maintained a clean record no one should question our commitment to lifelong learning, our ability to parse complex data or our ethical integrity. Stephen G. Weiss II Advanced Urology Institute DeLand, Florida Reference
1. Weiss SG II: Urologist to ABU: ‘I relinquish my certiﬁcate’ over MOC (Letter). Urology Times, July 1, 2015.
Continuing Medical Education and Maintenance of Certiﬁcation
The authors describe the history of MOC and the controversy surrounding this process. Does MOC provide concrete results in improving patient care? Teirstein would argue that this process leads to no improvements (reference 13 in article). In a meta-analysis of 33 studies 17 showed no association between MOC and positive clinical outcomes or negative outcomes while 15 showed a positive association. However, Teirstein concluded that most research methods used to study this process are inadequate. Revenue for the ABIM amounted to $55 million in 2012. Is this process increasing revenue for specialty boards? Irons and Nora reported that MOC has a positive impact on practice and patient outcomes (reference 14 in article). Multiple practice performance modules resulted in improvements in patient care areas such as diabetes, blood pressure control and asthma care. Physician self-assessment of knowledge has led to errors in the evaluation of
knowledge. The MOC process is a way to provide feedback to the physician rather than self-assessment. The ABU has done a good job thus far in keeping the MOC process as straightforward as possible. In this new era of value based care the public is demanding more scrutiny of physicians, and the safety and quality of health care. Many industries already have MOC programs to meet the demands of safety standards and public expectation. Medicine and urology are no different than these other industries. MOC is an evolving process but one that is obviously here to stay.
Michael S. Davis Division of Urology Renal Transplant Program Department of Surgery University of New Mexico Health Sciences Center
Reply by Authors
The commentators raise important issues that the ABU is eager to address. First, a commentator states that the ABU adopted MOC without justifying evidence, which is not true. To clarify, the decision to create the process of MOC was made by all of the ABMS boards in the face of signiﬁcant evidence that clinical knowledge and skills decrease with time (reference 10 in article). Recertiﬁcation began to be adopted by the boards in the 1960s and almost all boards had adopted a recertiﬁcation requirement by the late 1990s. During these decades other important research reinforced the need for an ongoing certiﬁcation program. There is substantial evidence that individuals cannot assess themselves and need external assessment to identify their knowledge and practice gaps (reference 9 in article). There is evidence of substantial variation in practice patterns that is not justiﬁed by patient factors or by differences in patient outcomes.1 There is also evidence that physicians are not consistently following evidence-based guidelines.2 All of this evidence encouraged the ABMS Member Board community to adopt the program of MOC in 2000. As 1 of the 24 member boards of the ABMS, the ABU was compelled to implement MOC or withdraw from the ABMS. This would have rendered the ABU unable to issue specialty certiﬁcates and would not have beneﬁted its Diplomates. Although the literature on MOC is at times conﬂicting, the body of relevant literature persuasively argues that MOC is far more valuable than CME alone to ensure lifelong learning and patient safety. A commentator noted that the
evidence of the positive impact of MOC is inconclusive. This is not surprising, given the evaluation challenges presented by MOC. It is a relatively young program, we do not have control groups and we have few measures of clinical effectiveness to assess physician performance in practice. Nevertheless, the ABU is committed to helping the evaluation to assure that the process offers value to Diplomates. Finally, both commentators allude to the issue of costs. In preparation for the increased time and work load required to implement MOC for the ABU full-time staff and the trustees, the ABU has aimed to make this a budget-neutral process. It should also be acknowledged that the $200 annual MOC fee has been held static since 2009. The ABU has not increased costs to Diplomates but rather has incurred expenses to build the infrastructure needed to streamline the process and make it more accessible/convenient for Diplomates to fulﬁll the MOC requirements. It should also be recognized that all trustees are unsalaried. The ABU knows that the MOC process is not perfect, nor is it immutable. The ABU has endeavored to make the process valuable to practicing urologists without making it onerous. The review of MOC is ongoing and the ABU invites Diplomates to provide feedback about the process. References 1. The Dartmouth Atlas of Health Care. Available at http://www. dartmouthatlas.org/. Accessed June 23, 2015. 2. McGlynn EA, Asch SM, Adams J et al: The quality of health care delivered to adults in the United States. N Engl J Med 2003; 348: 2635.