Is Internal Medicine MOC necessary?

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Category : Medical Rants

Maintenance of certification is, in my opinion, a good idea. While I had significant concerns about the structure that the ABIM was using, the idea that we have an obligation to maintain our knowledge.

I believe that the only legitimate argument is in the definition of how one documents maintenance.

The ABIM had two major problems to address. The first issue that they are working vigorously to improve is the criteria for MOC. I have written often about how I would document maintenance. I hope the performance improvement concept is taken out of MOC because we are subject to too many performance report cards already. While our interactions with patients are very important, I dislike the patient survey concept. Perhaps part of our knowledge points should include patient concepts, but I would rather leave that idea to licensing boards, hospital staffs and practice leaders.

In the current environment, including safety modules makes sense. We all have a responsibility to maintain and improve our knowledge of common safety issues.

Unlike some critics, I would like to see a more specific core curriculum, primarily based on very important new concepts (treatments, diagnostic strategies, etc.) that my peers believe I should definitely know. We should have a variety of ways to learn those concepts (given the variety of learning styles). I favor an open book test that documents that I have learned exactly those concepts. This test should have a very reasonable pass rate.

I favor this over non-specific continuing medical education. As an academic hospitalist, I have responsibility to learn both outpatient internal medicine and inpatient internal medicine. Readers know that I love renal disease and acid-base electrolyte problems. I am not as facile with rheumatology or endocrine. Should I be able to ignore those parts of internal medicine? Should I not have a responsibility to understand psychiatric drugs and the side effects that patients will have on presentation?

I do have faith in the ABIM Board. They have taken a bold step and are trying to improve their processes.

The second problem that many worry about is the ABIM finances. I hope the ABIM will address their finances with even greater transparency.

I am much more concerned about getting the first issue correct at this time. And that is my opinion. I know that many internists agree with this formulation, while others will disagree.

So let’s agree to disagree on the best way to document MOC. I will not focus on the finances, but will continue to encourage the ABIM to respond to the internal medicine community.

I truly believe that we are well represented on the ABIM board by thoughtful, ethical physicians, many of whom I know. They deserve our support as they work to fix the problems they inherited and address the mandates from ABMS.

Comments (12)

Dr. Centor –

I can see you still won’t let go of MOC. So be it and I respect that you are entitled to your opinion.

I would ask several other important considerations, however. First if the issue of trust. When we work as physicians with our colleagues we must trust they are doing everything in their power on behalf of the patient. Likewise, when we have people placed in positions of unparalleled authority, such as regulators who have the power to remove a person’s ability to practice their trade via loss of credentials, suing them because they leak hidden answers to a test, or being included on insurance panels or receiving bonuses from the US government for participation in their program, physicians MUST trust those people, especially when they are non-practicing physicians. Separating financial transgressions from content improvements to MOC when financial trust has been squandered as it has by the ABIM leadership, makes any credibility for other programs logically impossible to support, in my opinion, irrespective of whether these folks are as nice as you say. I have no doubt Dr. Richard Baron is a nice guy – after all, he really seems to be trying to right a wrong, especially since he and his colleagues got caught with their hand in practicing physicians’ financial cookie jar – but this does not relieve him and his board from responsibly addressing many serious financial dealings of the ABIM and their Foundation which I and others have uncovered. In fact, their continued failure to release ALL of their auditied financial statements to the main stream media voluntarily speaks volumes, especially when request for those documents required a call to the PA governor’s press secretary. Non-profits have an obligation to make their financial dealings transparent to the public lest they lose their non-profit status.

I would offer an alternative to MOC that has much more credibility at assuring physicians are staying current. #1) acceptance of CME as has been done for over 60 years before 1990 and #2) continued evidence of clinical activity as demonstrated by a significant number of Medicare payments for services rendered. With the release of Medicare payments of every US physician in 2014 from fiscal year 2012, anyone can quickly determine if a person is actively seeing patients. Patients are our best teachers after all, especially when one considers the consequences if poor patient care is rendered. Recall that the Medicare data is public information and does not require thousands of dollars to access. Want someone experienced in a procedure? Check their Medicare payment data. Interestingly when I correlated ABIM authors to this database, the median income of those authors in 2014 was $0, suggesting they have no clue what it takes to practice medicine.

So please, don’t EVER separate the financial benefit to the ABIM and their Foundation from the MOC program. It is disingenuous and possibly foolhardy. Stop viewing MOC as the only option available to assess competency to manage patients. Consider other measures, like the Medicare payment data and CME, that could be used in lieu of MOC. MOC, you see, has been irrevocably corrupted by the ABIM, and will never recover UNLESS there is financial accountability.

Dr. Centor,

In an email to me regarding the ABIM and the ABIM Foundation financial behavior, Dr. Baron stated in the email that the ABIM has never had any inappropriate financial behavior. (I can send you the email from Rich Baron if you would like to read it yourself)

Is that so?

Myself and folks like Dr. Fisher, Dr. Cutler and legions of other hard working clinicians take great issue with a group of aloof administrator physicians spending vast amounts of money on themselves via Mercedes Limo Service, Condos, and “retreats” to the Four Seasons. Is it appropriate to pool the fees from graduating housestaff and hard working clinicians so they can reward themselves with nauseatingly gaudy creature comforts?

How can an organization designed and run by non-clinicians tell the rest of us to “Choose Wisely” and to embrace cost efficiency/austerity while making themselves multi-millionaires off the sweat equity of the everyday clinician and graduating housesat? Would you trust such an organization?

Dr. Fisher’s point is very, very well taken. More so since the ABIM and the ABIM Foundation are both registered “non-profit” organizations. In essence, the American Taxpayer is subsidizing their operational status and their capital budget when in fact the ABIM is totally, hugely, and utterly profitable. That hypocrisy has never been fully addressed by Dr. Baron or any other ABIM representative.

Can you trust an clinical regulatory organization that is utterly devoid of any contemporary clinicians? Dr. Cutler pointed out that Dr. Zeke Emanuel is “not certified” by the ABIM continues to be “not certified” and yet remains as a leader for ABIM Assessment 2020. According to the 2012 Medicare database, Dr. Krumholz has no patient E/M contacts and read a handful of echos. Yet he is another leader of ABIM Assessment 2020.

Isn’t the lack of inclusion of active, high volume clinicians into the structure of the ABIM and the ABIM Foundation patently wrong? And yet you trust and “hope” this clubby cadre of “ethical” non-clinical physicians will magically do the right thing when it is clear they been doing it wrong for almost a decade. The irony of this oxymoronic situation is troubling and sickening.

Even more ironic and more sickening is the ABIM’s driving point- that their mission is somehow a product of pure altruism and promoting honesty and integrity to its Diplomates. If that were to be true, the ABIM leaders should immediately vow to take an oath of fiscal modesty and financial mediocrity.

Do you think the ABIM leaders would ever take a significant pay cut and promise never to abuse the money from an impoverished senior resident on Mercedes limo service? When you look at your residents at Morning Report ,can you honestly and whole heartedly tell all these young folks that your friends at the ABIM are doing them right?

Do you think the ABIM has the courage to set aside their own financial interests and to show leadership when they are apt to state their financial misbehavior were inherited? How cowardly is the ABIM to place all the blame on Christine Cassel?

Would you have to courage to ask the ABIM and the ABIM Foundation to take such an oath of modesty and fiscal/financial mediocrity? Or is your sense of cronyism clouding your judgment?

In the end, we have a growing schism between those who are placing their bets on a sclerotic ABIM whose leadership has failed its Diplomates and those who welcome change, competition and Darwinian evolutionary forces in Medicine. The loss of trust and faith in the ABIM cannot be ignored by their leaders and the proof in the pudding will be when the Diplomates who are sick and tired of the ABIM selling them out will defund this organization and turn to more responsible organizations willing to document their lifelong learning without pricing in a condo, a limo, a retreat to the Four Season, and massive salaries for themselves.

At low tide, everyone will find out who is swimming naked.

Dr C, Although I fully respect your view point and also agree that the test makes me read and refresh which I think is important, I agree with Dr Wes and likes in the overall big picture. Why should a test cost in the range of 1400-2000 dollars? What is the need for that kind of profit for a non profit? Why can’t we have accountable cme from respectable organizations ( sccm, accp, ats in my situation) qualify for MOC? If you want to beef up rheumatology, you can go attend ACR or rheumatology specific sessions at acp/ sgim?

Dr. Centor: Our neighbors to the north only do cme. After passing initial certification just out of residency, Canadian doctors (non-surgeons) are only required to participate in 400 hours of cme in a 5 year period to remain Fellows of the Royal College of Physicians of Canada. I’ve heard that most of Europe is this way too.
Let’s not reinvent the wheel squandering our time and $ on MOC that just functions to support the coffers and whims of another bureacracy.

I think you need to let go of MOC. There is no reason for ACP to support ABIM’s quest to impose MOC. MOC is burdensome, and does not address the needs of practicing physicians. “So let’s agree to disagree on the best way to document MOC…” yes by not even having it as a requirement to remain board certified. If anything at all is even contemplated, non-specific CME, since I as a practicing physician will seek information as I need it, such as UpToDate. Unfortunately, the ACP has done a bad job of advocating physicians and the physician-patient relationship with its fascination with the ACA, so I am not very hopeful that the ACP will do anything but want to remain at the table with the big boys.

I think most physicians believe that continuing education or maintenance of knowledge base is necessary to be a competent physician, let alone a good one.

Would you provide some more insight why you think it has to be regulated under MOC rather than lobbying for CME reform (if you believe it necessary)?

Those who make a living off the MOC system will defend it forever.

“It is difficult to get a man to understand something, when his salary depends on his not understanding it.”

“those who hold the pursestrings hold the power”

Asking the ABIM to change is pointless. Leaving the system or forcing change from the outside is the only way.

As an academic hospitalist you may feel you need to keep up with all aspects of internal medicine. However, a physician who does only outpatient office medicine does not necessarily need to be an expert in the management of ventilators, septic shock or other aspects of ICU medicine. A career flight surgeon or military physician will have different learning needs than one taking care of a practice dominated by elderly medicare patients. A VA physician will not be taking care of young adolescents. I know of two physicians who do almost exclusively sleep medicine. There are differences in practices and learning needs. Indeed, I suspect that what you need to know to take care of a patient with an acute STEMI in an academic center with full time cardiology backup is a lot different than what a physician in a rural hospital 100 miles from a cardiologist needs to know.

Having said that, if there is MOC the core curriculum should be defined and the test should be reviewed or even developed by physicians with a lot of practice experience, and should be formatted to mimic how physicians actually practice. I am not so concerned that my physician can remember the minutia of an uncommon condition as that he or she can recognize the condition and knows what resources to use to care for the condition. If a person takes the test they should at least receive the courtesy of knowing what questions they were wrong about. Personally when I go through the questions on the MKSAP book, I find the discussion on the answers as illuminating as the text on many issues. Finally, we should be assured there is some intrinsic value to the whole enterprise of MOC (as opposed to CME). Currently there is no such data.

I think it will be very difficult for the average practicing internist to fully separate the financial issues of the current ABIM from the issue of MOC. I might be wrong, but my opinion, shared by many, of the recent ABIM officers is that they are by and large executives who have made a very lucrative living, based on their medical or academic credentials, of sitting on boards and committees, pushing increasingly burdensome regulations on physicians (by this I mean doctors who actually take care of patients) until they have finally put on the “straw that broke the camel’s back”. They do not seem to be as interested in truly furthering the education of physicians or enhancing patient care as they do to feathering their own nests. Full credibility will come when all the current members resign or are replaced, hopefully with physicians rather than physician-executives, their reimbursement packages are restricted to a reasonable amount, the abim becomes fully transparent, and the whole exercise becomes one in which physicians see practical value.

Dr. Centor. We agree to disagree. It is time to defund the ABIM and any organization that facilitates them. This should include the ACP. Step one is for all internists to stop enrolling in MOC. The ACP should set up a legal fund to help any internist who loses his or her job as a result of this. If the ACP does not do this, then step two is to stop being a member of the ACP. Despite what appear to be good intentions on your part, I think you have underestimated the anger and frustration on the part of practicing physicians. We do not feel represented by the national groups that are supposed to represent us. Don’t tread on me.

Question 1

If you agree with many of us that a yearly payroll (not total budget, just salaries/benefits!) of $30,000,000 is unfathomably excessive for the ABIM/ABIM foundation then on what basis can you choose to ignore it?

Question 2

You “truly believe that we are well represented on the ABIM board by thoughtful, ethical physicians.” Being on the board of any organization is a serious matter – and not a CV-builder – and should be treated as such. Any member of the ABIM board who has not fought stringently against a payroll of $30,000,000/year is complicit unless he or she has been actively deceived by the management. The only other explanations are apathy or incompetence.

So there are only four potential positions for yes-voting ABIM board members to take: 1) “Such a payroll is defensible and justified and here’s why.” 2) “I was misled by the presentations made by management.” 3) “I did not care enough or pay enough attention.” 4) “I do not understand numbers, etc.”

Which positions do these thoughtful board members take – 1,2,3, or 4?

The ABIM suffer from ‘existential schizophrenia’. The Pope said this about his curia, and we can say the same about many of our ‘physician-leaders’: ‘It’s the sickness of those who live a double life, fruit of hypocrisy that is typical of mediocre and progressive spiritual emptiness that academic degrees cannot fill. It’s a sickness that often affects those who, abandoning pastoral service, limit themselves to bureaucratic work, losing contact with reality and concrete people.’

Excellent comments. Now Action. 1 Change hospital med staff bylaws to end MOC requirements. As advocated by AMA (Nov 2014, bullet 4 of 7) and 14 medical societies, plus JCAHO recommendations. No licensure or medical credentialing should depend upon membership in any single medical society or group. That includes MOC. 2 If not done already, get your state medical society to OPPOSE MOC. See our Mass Med Soc Resolution of 12 6 2014 for a template and references, on ChangeBoardRecert and AAPS sites. 3 Stop Interstate Medical Licensure Compact and all Federation State Medical Boards activities marketing MOC among eligibility requirements. Guilding, unconstitutional. For Utah and Wyoming, it is too late. Physicians in those states won’t get interstate licenses unless MOC recertified. Physicians and state boards in those states lost rights to due process and abilities to challenge the large, national, federal Commission ruling over them. Get your state society to oppose the Jan 2015 Interstate Med Licensure Compact and all such entities linking physician credentials to MOC.

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