Daniel E. Weiner
L. Ebony Boulware
Eduardo Lacson Jr
Bruce M. Robinson
Policy Forum highlights aspects of nephrology relating to payment and social policy, legislation, regulation, demographics, politics, and ethics, contextualizing these issues as they relate to the lives and practices of members of the kidney community, including providers, payers, and patients.
These are trying times for physicians in the United States. Our health care system is in a state of rapid change. In news reports, on social media, and in break rooms, conversations are similar: physicians feel burned out due to a confluence of issues affecting our profession. These include spending more time on documentation in electronic health records and on various other uncompensated tasks, navigating payer requirements in patient care, managing quality measures, and adapting to an evolving physician-patient relationship in the age of Google and WebMD. Despite this, we yearn for “life-long learning” while fighting against forces that continue to divide our time and attention. How do nephrologists work together to achieve this goal and, more importantly, ensure that physicians are staying current?
The American Board of Internal Medicine (ABIM) has traditionally set the benchmark for both the initial certification process and the ongoing Maintenance of Certification (MOC). There seems to be little dispute that the initial certification process that residents and fellows typically complete soon after their residency or fellowship training is successful. Initial certification has the trust of the physician community and the public. It is the MOC arm of the program that has drawn a very mixed reaction from physicians. Rather than dwelling on issues of the past that have already been discussed at great length, this editorial describes MOC’s evolution from my vantage point as both a practicing nephrologist and a member of the ABIM Nephrology Specialty Board and suggests a way forward. I believe that ABIM’s recent and ongoing transformation of the MOC process is a sincere attempt at achieving a “middle ground” that most can find acceptable. Realistically, achieving a perfect balance that completely appeases everyone will likely not be possible.
My journey as a member of ABIM governance began 2 years ago, after serving on the American Society of Nephrology (ASN) Practicing Nephrology Advisory Group for 3 years. I was humbled that ASN provided me with a leadership opportunity fresh out of training. As a member of the Practicing Nephrology Advisory Group, I found it impossible to ignore that practicing nephrologists serving on the group were in frustrated disagreement with several aspects of MOC. Like many of them, I was also vocal about the MOC process; my opinion about ABIM at the time was primarily based on negative press coverage and social media posts.
Like many of you, I am a busy physician. I work more than 20 days a month seeing patients, often coming in the middle of the night to dialyze them due to missed sessions, and running from hospital to clinic to dialysis center, then back to the hospital. In addition to my private practice, I am involved in cohosting a medical radio show for the community (Doctalklive.com
), serve as Chair of Medicine for the local community hospital, participate on multiple hospital and specialty society committees, and teach nephrology trainees the importance of leadership and business skills (NBLUniv.com
). Given my full professional and personal life, why would I walk into the maelstrom of MOC at ABIM? When I speak to nephrology fellows about leadership, I mention that when a challenging, and potentially unpopular, leadership opportunity comes their way, accepting it head on will be a true test of their leadership skills. This was a key reason I joined the ABIM Nephrology Specialty Board 2 years ago at the start of the transformation process.
There I was, an Asian millennial in private practice who graduated from a foreign medical school, sitting on the board. I may not be someone you expect to see on the governing body of an organization like ABIM. Some of the groups opposed to ABIM regularly imply that it is made up of “old white men.” Nothing could be further from the truth. Today, 42% of ABIM governance members are women, and the governance as a whole represents a wide variety of demographics. I am also not alone as a practicing physician on ABIM governance; >90% of ABIM’s governing physicians provide direct patient care and nearly half spend most of their time doing so.
Many of you may wonder why I have not embraced a Continuing Medical Education (CME)-only approach, along with an alternate board providing certificates based on CME hours. Don’t get me wrong—this approach would definitely allow me more personal time. However, sometimes the easy thing to do is not the best thing to do. Under a CME-only approach, all that I would have to do is submit proof of earning some number of CME credits to maintain my Internal Medicine certificate even though I have not practiced general internal medicine for a decade and all my CME was nephrology oriented. More importantly, I think we all recognize that CME comes in all shapes and sizes. I sit on a hospital quality council and sign off on credentialing, and CME-only does not sit well with me. I think the ideal situation lies somewhere between one extreme, CME-only, and the other extreme of ABIM’s position 3 years ago, before it began a series of significant changes.
I am often asked by physicians to provide evidence demonstrating that MOC is effective. Here is some of what we know. ABIM board-certified physicians who score high on the Internal Medicine MOC examination are ∼17% more likely to adhere to guidelines for their diabetic patients.
- Holmboe E.S.
- Wang Y.
- Meehan T.P.
- Ho S.Y.
- Starkey K.S.
- Lipner R.S.
Association between maintenance of certification examination scores and quality of care for Medicare beneficiaries.
General internists who pass an Internal Medicine MOC examination within 10 years of their initial certification are more than 2 times less likely to receive a state medical board disciplinary action.
- McDonald F.S.
- Duhigg L.M.
- Arnold G.K.
- Hafer R.M.
- Lipner R.S.
The American Board of Internal Medicine Maintenance of Certification Examination and state medical board disciplinary actions: a population cohort study.
MOC potentially improves value of care; per-patient expenditures are $167 less for Medicare beneficiaries whose primary care physician is a general internist who completed MOC recertification as compared with those who did not recertify, with no significant difference in quality as assessed by ambulatory care–sensitive hospitalizations.
- Gray B.M.
- Vandergrift J.L.
- Johnston M.M.
- et al.
Association between imposition of a Maintenance of Certification requirement and ambulatory care-sensitive hospitalizations and health care costs.
And women who had not received recommended mammography screenings were 8.5% more likely to get these screenings when seen by an internist who is required to maintain certification.
- Gray B.M.
- Vandergrift J.L.
- Lipner R.S.
Association between the American Board of Internal Medicine's General Internist's Maintenance of Certification requirement and mammography screening for Medicare beneficiaries.
A recent study shows that physicians who maintained their certification for 20 years perform better on HEDIS (Healthcare Effectiveness Data and Information Set) performance measures, including diabetes care, mammography screening, and heart disease care, compared with similar physicians who did not maintain their certification.
- Gray B.M.
- Vandergrift J.L.
- Landon B.
- Reschovsky J.
- Lipner R.S.
Associations between American Board of Internal Medicine Maintenance of Certification status and performance on a set of healthcare effectiveness data and information set process measures.
These are not trivial numbers in the context of the entire population that internists and subspecialists serve. However, I could not agree more that the internal medicine community needs to make it a priority to continue conducting research demonstrating the value of maintaining certification.
ABIM has learned from its recent challenges. It has briskly transformed into a much more open, collaborative, and transparent organization. ABIM governance has worked hand in hand with thousands of physicians who provided input on how to make MOC more reflective of how we practice medicine. Nephrologists have played a key role in contributing to these conversations through surveys, focus groups at ASN Kidney Week for the last 2 years, ABIM’s Community Insights Network, and the ABIM Engage community forum. Amid this transformation, ABIM has openly shared details about everything from its decision-making process to finances. ABIM achieved the highest transparency rating on GuideStar, a website focused on not-for-profit fiscal reporting, for the amount of financial information it shares publicly.
To be further transparent, I receive a taxable stipend of $333 per month for my work with ABIM (averaging 15 hours per month in total). Those of us serving on the ABIM Nephrology Specialty Board could earn much more allocating these hours to our practices, but we serve because we are convinced that our mission is needed now more than ever. We must lead in governing and regulating our specialty.
ABIM’s commitment to community engagement and a co-creation approach ensures that new programs are built based on peer input and in consultation with medical specialty societies, with whom ABIM regularly meets. With the input of nephrologists on the relative frequency and importance of medical conditions represented by the content in MOC assessments, an updated Nephrology MOC examination blueprint was created and launched; a similar process is in place for all specialties. More physicians are also being invited to participate in the standard-setting process for ABIM’s examinations. Based on community input, ABIM is adding an “open book” component to the 2- and 10-year MOC assessments. ABIM has not required completion of a Part IV requirement (the old Practice Improvement Modules [PIMs]) since 2015, although physicians who choose to do so can receive credit for a variety of quality improvement activities. ABIM, in collaboration with the Accreditation Council for CME (ACCME), offers a CME-for-MOC option that continues to grow in popularity. In June, ABIM launched the 2-year Knowledge Check-in in Internal Medicine and Nephrology, an assessment option that was developed through physician engagement. These shorter assessments can be taken at home or in the office, and I will be among the test takers trying it out this year. It takes a great deal of commitment and a sense of urgency to accomplish so much in such little time.
I encourage you to reflect on what a world without MOC would look like. When answering that question for yourself, step away from thinking about your own clinical skills. Many of us are or will become medical directors of a dialysis unit, quality leaders at a hospital, credentialing committee chairs, or even more likely, co-manage patients with physicians we do not choose and whose decisions affect our outcomes and liability. Do not forget that we will all be patients one day. How do we best ensure that all patients are cared for safely? In the end, staying current in our medical knowledge is our commitment to our patients. And the assessments that are part of MOC allow us to know—and show others—that we have kept that commitment.
The recent changes in the ABIM MOC process are an initial step. There is a lot more to do to make MOC efficient, effective, and beneficial for all participants. We have more doors to open in making MOC even better, especially given the rapid pace of change in health care today. Will there be another way in the future to assess which physicians are staying current? Absolutely. I believe that physicians can be extremely innovative, and with the help of the entire community, ABIM can continue to transform with your ideas. This is our challenge, how we prepare to deliver care and how we credential fellow nephrologists. We can either sit on the sidelines and criticize or roll up our sleeves and participate to collectively improve the process. I choose the latter.
Published online: August 27, 2018
Complete author and article information provided before references.
Financial Disclosure: Dr Nangia currently serves on the ABIM Nephrology Board, for which he receives a modest monthly stipend.
Peer Review: Received February 28, 2018, in response to an invitation from the journal. Evaluated by 2 external peer reviewers, with direct editorial input from the Feature Editor and a Deputy Editor. Accepted in revised form June 30, 2018.
© 2018 by the National Kidney Foundation, Inc.