Straight Talk | By Patrick T. O’Gara, MD

Two recent perspective pieces published in the New England Journal of Medicine highlight two sides of the ongoing debate over the American Board of Internal Medicine’s (ABIM’s) Maintenance of Certification (MOC) process.

From the perspective of the American Board of Medical Specialties (ABMS), the MOC process has played, and continues to play, a critical role in improving physicians’ performance and patient outcomes in a rigorous and unbiased way. Those involved in developing the newest MOC standards emphasize that the updates were the result of a 2-year review that indicated a clear need to refine the process to better meet the needs of physicians who are facing significant changes in their educational and practice environments. The time-worn model of passive continuing medical education is changing in favor of newer techniques solidly based on adult education theory that demonstrate improved learning and behavior change. Mira B. Irons, MD, and Lois M. Nora, MD, JD, MBA, representatives of ABMS, note in NEJM that “high standards of specialty certification are important to health care,” and encourage the medical community to work with ABIM to continue to evolve its certification systems to ensure that the standards set “continue to be highly valued in the future.”

Balancing Concerns And Obligations

Many physicians have raised valid questions about the relevance, utility, and associated financial and opportunity costs involved in meeting the new ABIM requirements. In addition, many ACC members have clearly expressed their frustration and dissatisfaction with the process and have proposed alternative approaches. Paul S. Teirstein, MD, echoes many of these sentiments in his NEJM piece and notes that “many physicians are waking up to the fact that our profession is increasingly controlled by people not directly involved in patient care who have lost contact with the realities of day-to-day clinical practice.” He suggests that “perhaps it’s time for practicing physicians to take back the leadership of medicine.”

This is a storm that arises at the junction of two strong societal frontal systems, and it swirls around a fundamental tenet: society grants to members of the medical profession enormous privileges, including enhanced status, respect, economic advantages, and, most critically, self-governance. In return, the public expects professional behavior from physicians, including strong measures of altruism, professional competence, scientific knowledge, integrity, and accountability. On one side of the bar, the ABMS and its 24 member boards, including the ABIM, are working to demonstrate to society in a modern and credible way that these obligations are being met by practicing physicians. On the opposing side, Dr. Teirstein expresses the increasing concerns of many practicing physicians who question the validity of the ABIM process and take exception to the imposition of regulations and expectations whose relevance has been called into question.

The Role of the ACC

The ACC finds itself in the eye of this storm. On one hand, there is no arguing the need to continuously maintain the public’s trust by transparently demonstrating ongoing competence as guided by the principles of high value patient care. The College prides itself in being a learning organization that places significant value on lifelong learning and professional development. With 25,799 cardiovascular disease diplomates on the ABIM rolls—of which 74% are enrolled in MOC—part of the College’s responsibility is to ensure that members have the tools and resources they need to meet new requirements, but also to ensure that processes that don’t work are modified.

In a member survey conducted last year, 68% of respondents recommended that ACC work with ABIM to revise the requirements. There was also a strong request for ACC to make more MOC modules available and more easily accessible. The College continues to make significant headway in both areas: online medical knowledge (Part II) MOC modules are provided at no charge, and there have been continued enhancements to the MOC Hub on ACC.org, as well as ongoing discussions taking place between ABIM and the ACC and other specialty society leaders. The ABIM has been receptive to the feedback and is willing to, or already has, modified certain aspects of the new requirements. In a recent Leadership Page published Jan. 12 in JACC, ACC Executive Vice President for Science, Quality and Education William Oetgen and I presented a detailed table outlining the College’s requests to ABIM and their efforts to address these requests to date.

These efforts, however, in no way minimize the fact that 90% of ACC members are opposed to the MOC changes, with approximately one-third advocating for a new certification path altogether. There is clear and understandable frustration with the pace of changes to the process. The College does not take these concerns lightly. It has been working both independently and as part of a larger group of specialty societies whose members are also impacted by the MOC changes to advocate not just for discussions, but real and timely changes. Additional meetings with ABIM leadership will be held this month. In the absence of meaningful change, the College will give thoughtful consideration and review to other credible accreditation options.

Weathering the Storm

When the MOC changes were revealed early last year, the Board of Trustees committed the College to a three-pronged strategy focused on 1) serving as a source of information about the changes for members; 2) providing tools and resources to help members more easily meet the new requirements; and 3) advocating on behalf of members for changes to the MOC process. One year later, we are still fully committed to this strategy. We are listening, we are hearing, and we are representing you and understand the need for timely progress!

The MOC storm will pass, and when it does, the landscape will have changed. It is our hope that there will be a legacy of increased attention to the concerns and realities of practicing physicians and that there will be an even stronger compact of medicine with society. Integrity and accountability will be reinforced, and physicians will continue to enjoy the precious benefit and privilege of self-regulation.

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Patrick T. O’Gara, MD, FACC, is the outgoing ACC president and director of clinical cardiology at Brigham and Women’s Hospital.

Keywords: ACC Publications, CardioSource WorldNews

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