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The American Board of Internal Medicine: Evolving Professional Self-regulationThe American Board of Internal Medicine

Richard J. Baron, MD; and David Johnson, MD
[+] Article and Author Information

This article was published online first at www.annals.org on 13 May 2014.


From the American Board of Internal Medicine, Philadelphia, Pennsylvania, and University of Texas Southwestern Medical Center, Dallas, Texas.

Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M13-2478.

Requests for Single Reprints: Richard J. Baron, MD, American Board of Internal Medicine, 510 Walnut Street, Philadelphia, PA 19106; e-mail, rbaron@abim.org.

Current Author Addresses: Dr. Baron: American Board of Internal Medicine, 510 Walnut Street, Philadelphia, PA 19106.

Dr. Johnson: Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, G5.206, Dallas, TX 75390-9030.

Author Contributions: Conception and design: R.J. Baron, D. Johnson.

Analysis and interpretation of the data: R.J. Baron.

Drafting of the article: R.J. Baron, D. Johnson.

Critical revision of the article for important intellectual content: R.J. Baron, D. Johnson.

Final approval of the article: R.J. Baron, D. Johnson.

Administrative, technical, or logistic support: R.J. Baron, D. Johnson.


Ann Intern Med. 2014;161(3):221-223. doi:10.7326/M13-2478
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Recent changes in the board certification process are a topic of much debate. This commentary presents the American Board of Internal Medicine's perspective on changes in the certification process and their importance to professional self-regulation.

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Question regarding data source
Posted on May 20, 2014
David L Keller MD
independent
Conflict of Interest: None Declared
Dr. Baron has written "There is a good deal of research demonstrating the value of
our knowledge and practice assessment modules....diplomates who complete them report they are valuable, and that they learned something about their clinical domain or their practice." His predecessor also wrote very similar statements. I have always wanted to ask if the data source for that research is the survey form completed by the physician after taking the module's exam and before receiving credit? If so, a powerful bias is introduced because if the physician were to state that he or she learned nothing of value from the module, ABIM would be justified in denying CME and MOC credit for it. We have all been in that position - can anyone honestly say that they did not worry about not receiving credit for the module if they gave it too low a rating? Can Dr. Baron assure ABIM diplomates that, even if they give the module the lowest possible rating and state that they learned nothing of value from it, they will still receive full credit for completing it? That assurance should be printed in bold type above the surveys, which should be administered after the diplomate has been awarded their MOC and CME points for the module. Personally, I find the factual learning modules to be excellent learning experiences; my complaint is focused on the so-called Practice Improvement Modules, which are widely detested due to the large amount of busy work involved and the lack of value (in my experience) of the information gathered. Most physicians' practices are constantly rated by their employers, their patients and their payors. We do not need ABIM piling-on. Stick to teaching and testing medical knowledge, which reasonable internists should agree that ABIM does very well.
ABIM responds
Posted on May 22, 2014
Richard J. Baron, MD, MACP
CEO, ABIM
Conflict of Interest: None Declared
In response to Dr. Keller, yes, I can assure ABIM diplomates that they will get credit for their PIM participation regardless of their response to the survey- the process of awarding credit for PIM participation is not affected by any responses to the survey. I would encourage all diplomates to complete the survey as honestly as they can- it helps us make the program better. I will work with our staff to sort out the best options we have for communicating that to diplomates going through the PIM submission process as quickly as we can and thank you for that suggestion.

We have indeed received some critical feedback about the “busy work” associated with completion of some of our PIMs, and we are in the process of re-designing them in a way that emphasizes the focus on improvement and reduces substantially the data entry burden. We do have an option for physicians who receive quality data about their practices to skip the time-consuming data collection component of the PIM, and we also offer a mechanism for physicians who have already completed a QI project to report that to us for credit. More than 20% of our diplomates currently make use of one of these two options. For more information about these options, go to http://www.abim.org/maintenance-of-certification/requirements/practice-assessment/productinfo-demo-ordering.aspx, then choose “self-directed PIM” or “completed project PIM” in the box at the top.

Changes in the design of part 4 are an example of the ways in which ABIM is listening to diplomate feedback and re-designing programs accordingly; we need to do a better job communicating those changes, and I appreciate Dr. Keller raising the question and making his suggestion..
Comment
Posted on May 27, 2014
Paul Kempen, MD
None
Conflict of Interest: None Declared

This is in regard to : 1) Baron RJ, Johnson D. The American Board of Internal Medicine: evolving professional self-regulation. 2014 May 13. doi: 10.7326/M13-2478. [Epub ahead of print] fter going through the submission process for a manuscript, I am further astounded that the conflict of interests were not elicited from the authors. This is a serious breach of ethics and I look forward to your reply directly from your editorial board as well as publication and reply from the authors in your journal/website.

All Corporations should require COI disclosure of incomes, including the Boards. The recent opinion article from the American Board of Internal Medicines (ABIM) CEO and chairman of the board read like simple (unpaid) advertisement for their product line (Maintenance of Certification) and its development.(1) The opposing editorial failed to address obscured conflicts of interests (COI), as the Annals method of leaving COI disclosure separately, at an online site. Identified COI remained undisclosed under the International Committee of Medical Journal Editors (ICMJE) guidelines: Financial relationships (such as employment, consultancies, stock ownership or options, honoraria, patents, and paid expert testimony) are the most easily identifiable conflicts of interest and the most likely to undermine the credibility of the journal, the authors, and of science itself. (2) Both Drs. Baron and Johnson, (as employees of the ABIM, which claims the highest ethical behaviors) each receive 6 figure salaries, creating COI based on that statement. It is completely possible to be working for a non-profit organization gratis, while the significant incomes may not be obvious to all readers. Dr. Baron is further listed as: President and Chief Executive Officer of ABIM & ABIM Foundation. (3) Upon reviewing the disclosures provided, I found no mention of the ABIM Foundation (ABIMF) or associated income in Dr. Baron’s disclosure. The ICMJE form specifically requests such third party income declaration. Separation of the ABIM and ABIMF missions/financing is not possible, given the common purposes and highest ranking leadership of Dr. Baron in both organizations. Because the most recent available IRS 990 form lists only Dr. Barons predecessor, it is unclear (yet likely) if the large payments are still paid for his leadership of the ABIM ($590,064.00) as well as the Foundation ($196,687.00). I would ask for clarification at this time, as the ABIMF is a separate corporation from the ABIM. It is further quite likely that the ABIMF actively supports the ABIM, given the negative $45 million ABIM net worth, offset by the ABIMFs $68.8 million net worth, as declared in 2011 IRS 990 forms. Income disclosures regarding all employment is needed, because of clear proprietary information in these ABIM productions. Comparing both authors’ declarations, it is remarkable that no COI was declared by either author, given the significant incomes both receive from the ABIM to specifically promote their products and mission. The failure to disclose is widespread for all American boards, as exemplified in the recent Journal of the American Board of Family Medicine (JABFM) article, also promoting their recertification:

 Conflict of interest: none declared. (1) Here, James C. Puffer, is identified as Senior author, while also known to be the current President and Chief Executive Officer of the ABFP and the EXECUTIVE EDITOR of JABFM, earning between $6-700,000.00 from the ABFP (available corporate IRS 990 forms-part VII). It is time to require clear COI on all Board employees’ publications in print directly in the articles. Better still, such advertisements should require advertisement fees and clear identification as the advertisement they represent.

1) Baron RJ, Johnson D. The American Board of Internal Medicine: evolving professional self-regulation. 2014 May 13. doi: 10.7326/M13-2478. [Epub ahead of print]

2) Centor RM, Fleming DA, Moyer DV. Maintenance of Certification: Beauty Is in the Eyes of the Beholder. Ann Intern Med. 2014 May 13. doi: 10.7326/M14-1014. [Epub ahead of print]

3) The International Committee of Medical Journal Editors (ICMJE): Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals* Updated December 2013. Available at: http://www.icmje.org/icmje-recommendations.pdf accessed 5/23/2014.

4) ABIM website: Executives. Available at: http://www.abim.org/about/executives.aspx accessed 5/23/2014 5) Schulte BM, Mannino DM, Royal KD, Brown SL, Peterson LE, Puffer JC. Community size and organization of practice predict family physician recertification success. J Am Board Fam Med. 2014 May-Jun;27(3):383-390.

The Monetary Cost of the ABIM MOC program
Posted on August 11, 2014
Robert S. Brown, MD
Beth Israel Deaconess Medical Center
Conflict of Interest: None Declared

Baron and Johnson (1) have defended the American Board of Internal Medicine (ABIM) maintenance of certification (MOC) process from a rising tide of criticism from board certified internists, well described in an accompanying editorial (2) and pursued by the American College of Physicians. The overwhelming majority of physicians who are not required to re-certify have voted with their feet. They fail to see the value to their patients to merit the time involved, citing irrelevancy of the requirements to the needs of their practice. As a grandfathered” nephrologist who has enrolled in the MOC program, I feel compelled to comment upon the value of the program in monetary cost relative to what the ABIM is delivering. As a long-term training program director, I had always been concerned by the high costs of the ABIM certifying examination required by graduating medical residents, $1,365 for the internal medicine (IM) exam, and for fellows, another $2,200-2,830 for a subspecialty exam (3). In an era of electronic transmission testing, the costs should have fallen greatly, considering that most smartphone apps, often as complex as these exams, can be profitably delivered for $0.99-9.99.
So what am I paying for in the MOC program to certify in IM and nephrology? The Table shows the monetary costs of the program over the 10 years from 2014-2023. For the first 5 years, my yearly fees total $1,765 for which the ABIM will only record 100 points of learning and review activities. This seems to be an exorbitant cost for this aspect of the program. For the next 5 years, a similar total fee will pay for recording of another 100 points of activities and for taking exams in IM and my subspecialty. To assess an approximation for the cost of the examinations, the addition of certifying in both IM and a subspecialty only adds the second examination to the program. Therefore, I assume that the added $970 ($3,530 less $2,560) is what the ABIM assigns to the IM exam and $1,590 ($3,530 less $1,940) assigns to the subspecialty exam. I contend that these fees are quite high and the remaining $970 that can be attributed to the recording and certifying cost of the program is unconscionable. Let’s hope that the ABIM lowers these fees by 50% or more before those for whom the MOC is not as voluntary as it is for me will have to pay them.

References
1. Baron RJ,Johnson D. The American Board of Internal Medicine: evolving professional
self-regulation. Ann Intern Med. 2014;161:221-223. doi:10.7326/M13-2478.

2. Centor RM, Fleming DA, Moyer DV. Maintenance of certification: beauty is in the eyes of the beholder. Ann Intern Med. 2014;161:226-227. doi:10.7326/M14-1014.

3. American Board of Internal Medicine. ABIM Certification Exam Cost. Accessed at http://www.abim.org/exam/cert-cost.aspx on 7 Aug 2014.
4. American Board of Internal Medicine. Maintenance of Certification Guide. Accessed at http://www.abim.org/maintenance-of-certification/default.aspx on 7 Aug 2014.

Table: ABIM Requirements and Fees for MOC (4)

 

Year

MOC Requirement

Fees per Year*

2014

None

$194 for internal medicine

$256 for a subspecialty

$353 for both

2015

Complete any MOC activity**

$194 for internal medicine

$256 for a subspecialty

$353 for both

2016-2017

Complete any MOC activity**

$388 for internal medicine

$512 for a subspecialty

$706 for both

2018***

Complete 100 points plus a patient survey activity, and a patient safety activity

$194 for internal medicine

$256 for a subspecialty

$353 for both )

2019-2022

Complete any MOC activity** every 2 years

$776 for internal medicine

$1,024 for a subspecialty

$1,412 for both

2023***

Complete 100 points plus a patient survey activity, and a patient safety activity and

Pass the Internal Medicine MOC examination for IM only
Pass a Subspecialty MOC examination for a subspecialty only or

Pass both exams for IM and a subspecialty

$194 for internal medicine

$256 for a subspecialty

$353 for both

 

*One can pay the ABIM upfront the full 10-year fee of $1,940 for internal medicine, $2,560 for a subspecialty, or $3,530 for both to avoid fee increases

** Either practice assessment or medical knowledge activity points

***Over each of the two 5 year periods from 2014-18 and 2019-23, there is a requirement of 100 points which must include 20 points of medical knowledge, such as ABIM Annual Update modules (or learning modules from other sources such as NephSAP from the American Society of Nephrology), and 20 points of practice assessment, such as ABIM PIMs Practice Improvement Modules® plus a patient survey activity, such as an ABIM Patient Voice in Communication (35 patient surveys) or a Hypertension or Diabetes PIM (25 patient surveys and 25 chart reviews), and a patient safety activity, such as the ACP: Annals of IM Patient Safety.  For those without patient care activities, completion of an alternative activity, such as a quality improvement initiative, may be used to meet practice assessment MOC requirements.

To the Editor
Posted on August 12, 2014
Edward Volpintesta, MD
Bethel, CT
Conflict of Interest: None Declared
Although Richard J. Baron, MD and David Johnson, MD (1) may not realize it (or maybe they do) but the boards were never meant to be mandatory.
This incontrovertible fact makes the moral basis for maintenance of certification (MOC) questionable to say the least.
It is disappointing that the Annals which would never knowingly publish a scientific paper that contained such a conspicuous factual omission, saw fit to publish their essay.
It is just as disappointing( and misleading to its readers) that no mention was made of this serious omission in the editorial comment (2).


1.Baron RJ, Johnson D. The American board of internal medicine: evolving professional self-regulation. Ann Intern Med. 2014;161:221-223.
2.Centor RM, Fleming DA, Moyer DV. Maintenance of certification. Ann Intern Med. 2014;161:226-227.
What We Learn From Reading
Posted on August 14, 2014
Joseph J Weiss MD
private practice
Conflict of Interest: None Declared
WHAT WE LEARN FROM READING
This letter concerns the editorial: The American Board of Internal Medicine: Evolving Professional Self- Regulation; Ann Intern Med v61:p221-223.
I want to respond to the authors' words in paragraph 4, page 1: "Most internists practicing today would be unfamiliar with and perhaps unable to pass the first ABIM examination, a written essay test with 8 questions (Figure)."
That statement is unwarranted and unfair.
It is unwarranted because the authors are in no position to state that physicians today could not pass that examination; the authors give no documentation that they gave the test or any questions in it to even one present day ABIM board certified physician. The authors are unfair as physicians interested in whether they could pass the examination cannot respond. Figure is so small and faded that it is impossible for a physician, even with a magnifying glass, to see the questions let alone answer them.
What physicians learn from such ABIM statements is that before we can discuss MOC with ABIM we need an ABIM that is less righteous and more reasonable.

Joseph J Weiss MD,FACP

Good intentions?
Posted on August 14, 2014
Timothy Kleinschmidt MD
St. Luke's Hospital Duluth, MN
Conflict of Interest: None Declared
Quote: “The road to hell is paved with good intentions”—Saint Bernard of Clairvaux

To the editor:

Baron and Johnson (1) lay out a self-congratulatory defense of ABIM and its Maintenance of Certification requirements. It is fitting that the lead article in the same issue on August 5, 2014, by Rhon and colleagues (2) reported on the equivalence of corticosteroid injection and manual physical therapy for shoulder impingement This well done study offers two options for the ABIM board members who have shoulder pain after repetitively patting themselves and each other on the back.

Centor (3) in this same issue makes the point that there is a disconnect between the ABIM view and the practicing internist’s viewpoint and that the board may be suffering from overestimating the benefits and underestimating the costs and risks of the program. Centor also notes that internists feel time pressure from many professional fronts, many of these pressures developed by other groups with regulatory power. Things like EHRs, meaningful use, pre-authorizations and a myriad of other burdens are frequently put forth by regulatory groups. Groups that overestimate the benefits and underestimate the risks and burdens of the regulations they unleash on the practicing physician.

Baron and Johnson (1) describe the composition of the ABIM as now requiring two non-internist public members and a “minimum of one practitioner [I hope they mean physician] whose primary practice is in a non- university, community setting.” This is barely a step in the right direction and I propose an alternate composition for this and any other governmental or other regulatory board with the power to add burdens with unproven or overestimated benefits. Namely, that 75% of board members be clinicians who work a minimum of 40 hours weekly in the clinical setting.

To be a member of the board that is not a full time clinician I would propose requiring the other members be required to take a “Clinician Relevant Activity Program”. This will be a week long program, required every two years during which time non full time clinicians could join me or another busy clinician for the week. Knowing that when a practicing MD takes time away from practice, he or she likely earns no money for his or her time away, I would expect that the salaried ABIM members donate this week’s salary to a charity of his or her choice. This will be educational and offer CME, and I offer the following advanced agenda (will be changed frequently and without notice):

Monday through Friday
0400- wake up, stretch, read a bit
0430- go run 5-6 miles knowing that physical health is important to yourself and the importance of being a good example for patients
0600-0800- Inpatient rounds (census 6-10 patients, hospital conveniently across street from clinic)
0800-1200 morning clinic except on days when at a committee meeting (As Chief of Medicine the medical executive, physician wellness, quality, cardiac and critical care committees are my current voluntary committees)
1200-1300- repeat rounds on sick inpatients or see patients missed on early rounds, inhale food in physician dining room. Exception is Tuesday, which is section journal club.
1300-1530- back to the clinic (unless nursing home rounds or teaching students and residents)
1530-1630- back to hospital for further inpatient work,
1630-1900- the real fun (requires caffeine or candy prior)- deal with EHR inefficiencies, phone calls, documentation. This segment lasts 60-90 minutes longer than it did 5 years ago
1900-2200- time for kids and spouse, community events

Sat and Sunday- if on call expect 28 hours of clinical activity. If not, then only need three hours to finish last week’s activities.


Saint Bernard of Clairvaux is credited with saying “The road to hell is paved with good intentions”. It is time for the ABIM to stop laying down more pavement on the autobahn.

Refs
1- Baron RJ, Johnson D. The American Board of Internal Medicine: Evolving Professional Self-regualtion. Ann Intern Med 2014;161:221-223 doi 10.7326/M13-2478

2- Rhon DI. Boyles RB, Cleland JA. One-Year Outcome of Subacromial Corticosteroid Injection Compared with Manual Physical Therapy for the Management of the Unilateral Shoulder Impingement Syndrome. Ann Intern Med 2014;161:161-169 doi:10.7326/M13-2199

3- Centor RM, Fleming DA, Moyer DV. Maintenance of Certification: Beauty is in the Eyes of the Beholder. Ann Intern Med 2014;161:226-227, doi:107326/M14-1014


Timothy C Kleinschmidt MD FACP
Duluth MN

Snake oil from the Healers?
Posted on August 29, 2014
James R. Gould, MD, FACP
Oncology Associates of W. Kentucky, Paducah, Kentucky
Conflict of Interest: None Declared
To the Authors:

I read with interest your comments on professional self regulation(1).

However, I am still unaware of data which correlates maintenance of certification (MOC) with improved quality on the part of any physician or physician group. Likewise, I am unaware of any data supporting the use of beta blockers to control urinary tract infections. Or the use of ciprofloxacin for successful control of hypertension.

I find it quite remarkable that the medical educators who lean so heavily on evidence-based practice continue to promote a process whose outcome is unproven: maintenance of certification! Unknowingly, medical leadership has adopted the ‘familiarity heuristic’ to solve the “fact gap” problem. That is, the use of a familiar process (studying and test-taking) to solve a problem (information gap) though the outcome (improved quality) is not demonstrated to exist.

As physicians, we are expected to seek the information we need when performing our tasks. And, we are expected to develop a work-life balance which allows us to wear many hats. Unfortunately, the expectations of the few who generate the “standards” may not be applicable to all.

The goal of continuing education and MOC is to assure that a provider’s facts are current. None of us can assure that facts stuffed into one’s brain during exam prep will remembered or be translated into outstanding patient care. What patients and providers alike wish for is the doc who we can trust, identify with, and depend on to nurture those under care: The patient’s advocate. These qualities cannot be legislated.

The intent of medical leadership is appropriate and is well-intentioned. However, caveat emptor.

Perhaps the time is right to admit that the remedy does not fit the ill. Perhaps it is time to admit that we’ve all learned a lesson and can look another direction. Perhaps MOC should be reserved for those who feel the need. And perhaps, CME post-testing should be applied more rigorously to assure attention to detail.



1. Baron RJ, Johnson D. The American Board of Internal Medicine: Evolving Professional Self-Regulation. Ann Intern Med. 2014:161:221-223. Doi: 10.7326/M13-2478.
Regarding Professional Self Regulations
Posted on October 2, 2014
Warren W. Furey, MD, MACP
Northwestern University
Conflict of Interest: None Declared

Baron and Johnson’s recent statement regarding the ABIM and Centor’s presentation of the many concerns expressed by American College of Physician members prompt this reflection. It was 1966 and I was Chief Resident at Northwestern the VA Research Hospital under Dr. Craig Borden. Dr. Borden was the then Chair of the Oral Board of ABIM and a wonderful scholar, clinician, and teacher. I was part of setting up patients for Board Candidates to examine and felt privileged to meet some stars from the country’s leading schools as examiners. Getting my boards in medicine was very important to me. I passed the written board and then flew to Seattle for the oral board a few months later. One patient had been told not to tell us what she had, and she really wouldn’t tell us anything. Dr. Jack Meyers my examiner tried to get history he knew from her and no deal. He asked me what I’d say if he told me the patient has a chronic infectious disease. “Don’t tell me she has tuberculosis, “No but in the same family,” and I said “Oh no, Leprosy” – “Correct – from the Philippines married an Army guy.”

My other patient was a delight and as I was finishing, she pointed to her left radial artery and said “did you find this” – and I said I had and she said, “thank goodness the last boy didn’t and he really got scolded.” My experience took me to my hotel bar where I had a beer with two used car salesmen from Billings, Montana and then called my Northwestern University Medical School 1960 classmate and 1961 wife to tell her my experience. I started to tell her my story and all I got said was “from the Philippines” and she said “Oh Warren they have a lot of Leprosy in the Philippines.” Convinced I had failed, I headed back to the bar and thanks be to God, good education, training, and poise I passed. I was Board Certified in Internal Medicine and I was so very pleased and proud. I felt the same way when I became a Fellow in the American College of Physicians. Pleased and proud to be so recognized.

Baron and Johnson in their review of key milestones in ABIM history did not mention three important dates in my history. –In 1974 and again in 1980 I voluntary-wise recertified in Internal Medicine—I have a certificate from 1974 and 1980 on my office wall and in 1987, I again took a voluntary exam and this time, a Certificate of “Advanced Achievement in Internal Medicine.” –I loved and respected the ABIM and the American College of Physicians.

Took first ever board in infectious disease and passed it with only training being Infectious Disease consults under Richard Parker during chief residency and attending Infectious Disease conferences at Northwestern, the University of Virginia, and the University of Minnesota. Was one of just a very few people in the country certified in Infectious Disease. Again, a feeling of satisfaction—Practiced Internal Medicine and Infectious Disease and along came Geriatrics and I passed that too. Didn’t recertify in Geriatrics in 1997 because I was American College of Physician Governor and too much on my plate.
Was chief of Infectious Disease for 40+ years and Chair of Medicine at a Community Hospital for 20 years. Did all 16 MKSAPs, most for score, read every page, answered all questions. Attended annual ACP meetings, attended weekly Grand Rounds, Tumor Boards, Morning reports at the community hospital and the Firm Conference every week at Northwestern University—My practice shifted; no surprise after many years to Geriatrics and Palliative Care—decided it would be great at age 79 to see if could recertify in Geriatrics and maybe get Palliative Care Boards. Till now, I was a big ABIM fan. My son and daughter just recertified in Internal Medicine and it was very stressful. Recertification is so important to them personally and to their employment. They both passed.

My experience with MOC was an invitation to sign up for 10 years, and all I can say is that in 10 years I am as likely to be receiving Palliative Care and Hospice as to be practicing it. I love being a physician and caring for people, my patients, my friends. I know being a good physician means we are forever students. I get a kick out of telling med students I’m P.G.Y. 54. I look forward to MKSAP 17 and I feel hurt that what I have done and am doing isn’t recognized as M.O.C. The major M.O.C. I am currently in need of is to appoint, as Faith Fitzgerald suggests, “watchers” who will tell me if it time to go out to pasture. Til then I will proudly go on the lesser list – “Certified but not meeting requirements” – and tell anyone interested how I got here.

Author's Response
Posted on October 10, 2014
Richard J. Baron, MD, David H. Johnson, MD
ABIM, UT Southwestern
Conflict of Interest: None Declared
Given the ongoing debate about the value of Maintenance of Certification (MOC), we are not surprised that our article generated a number of comments. We very much value these constructive comments as we work to enhance the MOC program. Readers may not be aware that ABIM recently announced plans to make changes to MOC based on similar valuable feedback received from a number of specialty societies and diplomates over the past few months. The planned changes, as well as other potential modifications still under discussion, are outlined in a letter to the internal medicine community dated July 10, 2014 and posted on the ABIM website: https://www.abim.org/pdf/press-releases/July28IMLetter.pdf.
Dr. Volpintesta raised the point that Board certification was never intended to be mandatory. We agree and regret that our article may have implied otherwise. Indeed, board certification and MOC have always been voluntary. In fact, we believe the voluntary nature of these peer developed credentials adds to their value. That said we also recognize that the reality for many physicians is that Board certification and/or MOC may not be experienced as voluntary because they have been adopted by many hospitals, health systems and insurers as part of their requirements for credentialing. In seeking an objective sign that physicians are well trained and keeping up, they have gravitated toward certification and/or MOC likely because it is a peer-developed credential. In light of this reality we recognize that ABIM must always strive to ensure that MOC is meaningful, evidence-based and fair – a responsibility we take very seriously. Parenthetically, there is also a common misconception that ABIM seeks to make MOC a required component of other forms of physician credentialing, such as Maintenance of Licensure (MOL). ABIM does not support using MOC as a requirement for MOL. We do believe that physicians who choose to engage in MOC should be exempted from any additional requirements for licensure renewal. In order to reduce redundancy for these physicians, we want MOC to count as an option – not a requirement – for satisfying other physician credentialing processes.
Dr. Kleinschmidt emphasized the need to include the perspectives of “practicing physicians” in ABIM’s decision-making. We agree. The new governance structure we described in the article is intended to explicitly affirm this commitment. Though ABIM’s founding documents do require that at least half of the Directors be at the rank of full professor in a U.S.-accredited medical school, we have over the years reliably included practicing clinicians in our governance, and this recent governance change merely codifies those efforts. With the many burdens practicing physicians face in this unprecedented time, we believe it is vital that those physicians have an active role in shaping the future of MOC.
With respect to Dr. Weiss’s comment, it was not our intention to reprint the questions from the original 1936 ABIM exam in a way that made them hard to read. Rather, our intent was to illustrate how medical knowledge and practice expectations change over time. For example, one of the questions on the 1936 exam was, “Discuss the general principles and sources of error involved in the Wassermann reaction.” This antibody test for syphilis was essential knowledge for internists in 1936, and while internists today may know the answer to the question, this once-common test is no longer relevant to modern practice. The point of sharing the 1936 exam was not to claim the test was more or less difficult than now, nor to presume a level of knowledge or lack thereof among our fellow internists; it was merely to demonstrate that the definition of what it means to be a good physician has changed and will continue to change over time – and that Board certification and MOC will need to change accordingly.
We believe strongly in the principles behind MOC but also agree that the process can improve. Since its inception ABIM has been a standard setting organization committed to ongoing summative and formative assessment of physicians over the course of their career. To that end the Board remains dedicated to working with specialty societies and others to continuously improve and enhance the MOC program. We welcome constructive feedback from all members of the internal medicine community as we labor to refine Board certification and MOC to maximize their relevance and value to physicians and patients.
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The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.

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