Maintenance of certification: Confession of a grandfather

In 2008, I chose to complete Maintenance of Certification (MOC) in medical oncology, 25 years after I initially took the American Board of Internal Medicine (ABIM) Medical Oncology Certification Examination. If you are an ABIM “grandfather” like me, you are probably thinking, “Surely this was a monumental waste of time.” And you are not alone. In a recent New England Journal of Medicine Web poll,1 two thirds of respondents said they didn't think grandfathers should recertify. As a member of the ABIM Board of Directors, I am frequently asked to defend the MOC process, its expense, and its relevance to my practice. And, because most oncologists engage in regular continuing medical education (CME), read medical journals, and attend the annual ASCO meeting or other important scientific and CME programs, colleagues simply ask, “Why bother?” So why did I recertify? The truth is, I had to. As a member of the ABIM Board of Directors, I am required to participate in MOC as a condition of my service. Like many of you who were board certified before 1990, I had pretty much ignored the ABIM MOC program; after all, I was “board certified for life.” Moreover, I was doing plenty of meaningful activities to maintain my expertise in medical oncology. I hold a faculty position at a top-ranked medical school; I teach medical students, residents, and fellows on a regular basis; I am engaged in clinical research; I write numerous scientific, peer-reviewed articles; and I edit textbooks of medicine and oncology. I wondered, “How is MOC going to benefit me?” and, more to the point, “Who has the time?” Every minute spent working on MOC is a minute not spent with patients. In short, I thought MOC would add nothing of substance to my knowledge base or my professionalism. Of course, I was wrong! Once enrolled and engaged in MOC, I quickly realized that my efforts to keep up with developments in oncology were not as effective as I had imagined. This should not have been a surprise, as research indicates a physician's knowledge deteriorates over time.2 It turns out that traditional CME is not particularly effective in preventing this decline, nor does clinical experience per se reduce the rate of diagnostic errors that are all too prevalent. And like most physicians, my ability to accurately assess my own knowledge and clinical skills without appropriate measurement and feedback proved inadequate.3 This is where MOC differs from traditional CME. MOC helps address these concerns, as it is much more than just an updating and burnishing of one's knowledge. So what is MOC? MOC engages physicians in lifelong learning and competency in a specialty and/or subspecialty by requiring ongoing measurement of six core competencies adopted by the American Board of Medical Specialties (ABMS) and the Accreditation Council for Graduate Medical Education in 1999. Measurement of these competencies happens in a variety of ways, some of which vary according to the specialty. This is carried out by all ABMS member boards (including ABIM) using a four-part process: Enrolling in maintenance of certification at www.abim.org. Earning 100 points in self-evaluation of medical knowledge and practice performance. You are required to earn a minimum of 20 points of medical knowledge and 20 points of practice performance. The remaining 60 points may be from either. The points you earn can be applied to all certifications you are maintaining. (By the way, you don't need to maintain your internal medicine certificate, if you are maintaining your medical oncology!) Scheduling, taking, and passing the secure ABIM Medical Oncology Maintenance of Certification Examination. Being licensed and in good standing. Both ABIM and ASCO offer products that help physicians meet the requirement for self-evaluation of medical knowledge and practice performance. ABIM makes available for each subspecialty knowledge self-assessment modules, and ASCO also provides self-evaluation products that can earn MOC credit. To meet my practice performance requirement, I did an ABIM Practice Improvement Module (PIM). PIMs are Web-based tools that guide physicians through a review of their own patient data and support the development and implementation of a quality improvement plan for their practice. ABIM proffers a variety of PIMs to choose from, ranging from cancer screening to communications. For my PIM requirement, I used ASCO's Quality Oncology Practice Initiative (QOPI) to complete a self-directed PIM. QOPI provided a wealth of physician-determined metrics of quality: “Is the official pathology report in your medical record confirming the patients' specific diagnosis?” “Are you providing tamoxifen to a premenopausal woman who has ER-positive breast cancer?” By answering these and other questions for my own practice, I was able to identify some gaps. For example, I chose to assess how often informed consent forms actually made it into the electronic medical records (EMRs). In my institution, paper consent forms are supposed to be scanned into the EMR. In fact, we found that only 60% of the forms were actually scanned into the EMR. This led us to examine our processes, develop and implement an improvement plan, and then reassess the process several months later. I was gratified to see a marked improvement in the percentage of informed consent forms in the EMR. Completing this PIM also got me to thinking about how I might implement more quality improvement projects in my practice. Nearly 75% of physicians report that they changed their practice as a result of completing an ABIM PIM.4 As I wrapped up the MOC process, I took the dreaded secure exam. The last time I took such an exam, number two pencils had just been invented, and paper was being mass produced for the first time! Maybe that is a bit of an exaggeration, but the test today is far more sophisticated; it is given on this thing called a computer. Mentally exhausted, I nonetheless left the testing center with a sense of accomplishment and pride—yes, pride. Participation in MOC made me feel good about myself. It renewed my enthusiasm for learning and, in a roundabout way, led to my current position as Chairman of Medicine. Who knows what participation in MOC can do for you and, more important, what it will do for your patients?