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- Robert Shor, MD, FACC, Chair, ACC Board of Governors∗ ()
- ↵∗Address correspondence to:
Dr. Robert Shor, American College of Cardiology, 2400 N Street NW, Washington, DC 20037.
Unless you are part of the 5% of cardiologists who noted in a recent College-wide survey that they are “not at all familiar” with the new Maintenance of Certification (MOC) requirements from the American Board of Internal Medicine (ABIM), you have undoubtedly heard about what has now been termed by many as the “MOC crisis” (MOC survey distributed by U.S. American College of Cardiology [ACC] chapters to chapter members from April 9, 2015, to May 4, 2015; a total of 3,380 completed surveys were submitted by ACC members). There continues to be much confusion, anger, and frustration over MOC. What is fact and what is fiction? What role can the ACC play in the certification/recertification process? How did we get here, and what is the ACC doing about this mess now?
The American Board of Medical Specialties (ABMS) was established in 1933. Its mission is “to serve the public and the medical profession by improving the quality of health care through setting professional standards for lifelong certification in partnership with Member Boards” (1). Three years later, the ABIM was formed in 1936 under the ABMS umbrella to establish more uniform standards for physicians and to answer a need from the public interest. ABMS sets the policy and ABIM (or the other subordinate organizations) are left to interpret and implement the policies.
Last year, the ABIM instituted widespread changes and a radical set of new requirements and standards for MOC. The modifications apply to all physicians, including those who received lifetime certification prior to 1990. Suffice it to say, the extreme revision of standards sparked—and continues to spark—heated and immediate responses from across all ABIM-covered physician specialties. Part of the fire has to do with new revelations and an understanding of the rules and their implications for physicians. In cardiology, multiple ACC-sponsored polls have shown that the vast majority of cardiologists have serious concerns about the validity, relevance, utility, and associated financial and opportunity costs of meeting these revised requirements. ACC members have clearly expressed their frustration and dissatisfaction with the process and have proposed several alternative approaches. Our 2014 MOC member survey was instrumental in informing the ACC leadership and helping direct future actions.
In direct response to the concerns and the frustrations of its members, the ACC’s leaders have responded in a forceful manner in a series of high-level meetings with ABIM’s Board of Directors and chief executive officer over the last 1.5 years. Many of these meetings have occurred in concert with other internal medicine subspecialty societies that were also negatively affected by the MOC changes. The results of these meetings were frequently discussed in an open way by the ACC’s Immediate Past President Patrick O’Gara, MD, MACC, in multiple papers online and as Leadership Pages in the Journal, as well as letters to members, member-focused conference calls, and more.
In July 2014, the ABIM responded to these efforts by modifying the MOC policy and committing to the following:
• Providing a 1-year grace period for those who have attempted but failed to pass the secure examination;
• Updating its governance and financial information on its website;
• Ensuring a broader range of continuing medical education options for medical knowledge and skills self-assessment (part II);
• Providing more feedback regarding test scores;
• Evolving the “patient survey” requirement to a “patient voice” requirement and increasing the number of ways this requirement can be met;
• Reducing the data collection requirement for the practice assessment requirement; utilizing performance improvement activities already in place and minimizing the time and complexity of data input; and
• Investigating changes in the secure examination to increase relevance with specific attention to exploring applications for practice focus areas (“modular examinations”) and open-book examinations.
In August 2014, the ACC released a statement saying “that the ABIM’s mission as a standards-setting organization differs from its own mission as an educational organization. The ACC strongly supports the ideals of lifelong learning and continuous professional development. The College and its members are acutely aware of the need to continuously maintain the public trust by transparently demonstrating ongoing competence as guided by the principles of high-value patient care. Our membership holds itself to the highest professional standards. The ACC is an educational organization in which the ongoing learning of our members is accorded strategic priority. Educational activities must be designed and delivered in ways that enhance provider performance and improve patient outcomes” (2).
Since then, the College has worked to provide free web-based MOC modules and navigation tools to ACC members via its MOC Information Hub at http://www.ACC.org; expand part IV MOC modules through ACC programs, such as the National Cardiovascular Data Registry's inpatient registries and the PINNACLE Registry; create mechanisms for ACC members by which patient safety and patient survey requirements can be efficiently fulfilled; and continue to encourage bidirectional communication and engagement among members through chapters, sections, and councils. The College established a monthly ACC Journal Club to allow members to earn MOC points through a web-based, virtual discussion of recently published practice-changing research.
Fast forward to earlier this year. The ABIM published its now famous “ABIM mea culpa” letter to the physician community in February that began with the simple statement, “Dear Internal Medicine Community, ABIM clearly got it wrong. We launched programs that weren’t ready and we didn’t deliver an MOC program that physicians found meaningful. We want to change that.…We got it wrong and sincerely apologize. We are sorry” (3). As of that communication, the ABIM suspended part IV for at least 2 years; changed language used to describe a physician’s MOC status from “meeting MOC requirements” to “participating in MOC”; froze MOC fees at 2014 levels for at least 2 years; and said it would recognize most forms of Accreditation Council for Continuing Medical Education–approved continuing medical education by the end of 2015.
More recently, ACC leadership published a letter signed by all current and most recent past ACC leadership, entitled, “Urgent Message from ACC Leadership Regarding MOC.” The letter stated: “All of us continue to be troubled by the complex situation presented by the changes in re-certification by the [ABIM] over the past year. We have heard clearly that our members are unhappy, and many are dissatisfied with ACC actions to date. Our approach to the issue has been careful and deliberate, perhaps leading to the assumption that the ACC is not adequately addressing the problem. The current ACC approach is as follows: We respect the intelligence of our members in analyzing the best path for continuing education/certification individually and realize that it may not be the same for each of us; we are not wedded to one solution for all” (4).
Furthermore, we recently became aware of another implication of the 2014 ABIM MOC rules that required newly graduated fellows who have successfully completed their initial certifying examination to also sign up for ABIM MOC or be listed as “not certified.” Although we were informed that there is “no initial fee” for the new graduates to sign up, this is inconsistent with the way other members are listed as “not participating in MOC.” This change can affect the ability of these physicians to work and is unacceptable. Many have articulated that passing the initial certifying examination should equate to “certified” and participating in lifelong learning and MOC should be separately listed as either “participating” or “not participating in MOC.” We have been in frequent contact with the ABIM to repeal this provision of their 2014 rules and hope to see some quick action from the ABIM. Indeed, we hope to see reversal or revision by the time this comes to print.
Furthermore, the ACC has established 2 active task forces charged with finding a solution—or solutions—that meets the needs of its members. First, an ACC Task Force led by Dr. O’Gara is focused on continuing to provide input to the ABIM to see if the proposed temporary changes become permanent and to see if their processes can further improve to the extent that they are helpful and acceptable to members. In the most recent survey of ACC members, approximately 40% of respondents expressed a desire for the ACC to work with the ABIM to revise the MOC requirements and develop more part II materials (28%).
A second ACC Task Force led by ACC President-Elect Richard Chazal, MD, FACC, is aggressively exploring an alternative board or boards. More than 65% of respondents from our 2015 member MOC survey wanted us “to explore assuming the recertification process.” Potential possibilities could include: new board(s); working with already established alternate boards and/or other organizations; working within or without ABMS framework; and other solutions. Having the ACC assume certification (51%) and removing MOC as a requirement (40%) remain the most desired MOC revisions, according to ACC members.
Each task force is expected to present its initial findings and recommendations at the College’s Board of Trustees meeting in August. Although we are working as rapidly as possible, we want to be cautious, because we realize the great complexity of the situation. In the interim, all of us have alternatives. These include joining a new board, waiting to see a final ABIM proposal, and waiting to see if an alternate ACC board is feasible and/or needed.
As chair of the ACC’s Board of Governors, I am proud of the work my fellow governors and Chapter members are doing as part of this broader national effort to find the best possible solution. No matter which path we choose, it will take time to get to our destination—but rest assured, we will get there together.
- American College of Cardiology Foundation
- ↵American Board of Medical Specialties. ABMS mission statement. Available at: http://www.abms.org/about-abms/governance/abms-mission-statement/. Accessed June 9, 2015.
- ↵O’Gara PT. ACC response to ABIM’s MOC requirements. ACC in Touch Blog. June 2, 2014. Available at: http://blog.acc.org/post/acc-response-abims-moc-requirements/. Accessed June 9, 2015.
- ↵American Board of Internal Medicine. ABIM announces immediate changes to MOC program. February 3, 2015. Available at: http://www.abim.org/news/abim-announces-immediate-changes-to-moc-program.aspx. Accessed June 9, 2015.
- ↵Williams KA Sr., Chazal R, Walsh MN, et al. Urgent message from ACC Leadership regarding MOC. ACC in Touch Blog. April 24, 2015. Available at: http://blog.acc.org/post/urgent-message-from-acc-leadership-regarding-moc/. Accessed June 9, 2015.