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In reply—American Board of Internal Medicine and the Maintenance of Transparency

      We thank Dr Hayes for his feedback about the changes to the American Board of Internal Medicine (ABIM) maintenance of certification (MOC) process. Dr Hayes contends that the recent changes to the ABIM’s certification status reporting format “provide patients with inadequate information about the recertification status of their physicians”; however, these changes are intended to do the opposite. By paring down the amount of information publicly reported about ABIM diplomates, we believe the certification status reporting on our website is now clearer and more understandable to the public and other stakeholders. Although we applaud physicians who have voluntarily recertified in the past, our new reporting focuses on recency—whether physicians are currently and continuously engaged in activities to stay up-to-date.
      The new reporting format is also designed to enhance clarity regarding the certification status of physicians with multiple certifications. The ABIM encourages diplomates to maintain only the certifications that are relevant to their practice. However, before the recent reporting changes, the way certification status was reported could appear misleading to patients. For example, if a cardiologist decided to maintain only his cardiovascular disease certification because his internal medicine certification was not relevant to his current practice, he would be listed under the old reporting format on the ABIM’s website as “Not Certified” in internal medicine. With the new reporting format, this diplomate would be listed as “Certified” in cardiovascular disease, and internal medicine would be listed only with the date of initial certification, without designating lapsed certifications as “Not Certified.” The only physicians who are reported as “Not Certified” under the new reporting format are those who no longer have any valid certifications. Diplomates can access their complete certification history by logging in to their account on the ABIM website.
      Dr Hayes asks why the ABIM did not address the “grandfather” issue sooner. Incidentally, the ABIM Board of Directors decided to discontinue issuing “lifetime” certifications in 1968, but they concluded at the time that the ABIM did not yet have the capacity to develop a comprehensive recertification program. When the ABIM rolled out recertification and began issuing time-limited certifications in the late 1980s, they made the decision to honor certifications that had been issued without expiration dates, thus creating the grandfathers. The ABIM has sought ways to engage grandfathers in the MOC process for many years. The new MOC requirements do not take away the certification of physicians with lifetime certifications, but the ABIM now reports whether all physicians, including grandfathers, are “Meeting MOC Requirements” on a continuous basis. Since the new program launched on January 1, 2014, more than 8000 grandfathers have chosen to enroll in MOC.
      The ABIM believes it is critical that its leadership be held to the same or higher standard for MOC participation as its diplomates. All physicians in service to the ABIM—including staff, directors, councilors, and members of ABIM committees—are required to adhere to the ABIM’s MOC Policy for Physicians Serving ABIM.

      American Board of Internal Medicine. MOC Policy for Physicians Serving ABIM. http://www.abim.org/moc-policy-for-physician-serving-abim.aspx. Accessed April 11, 2014.

      This policy includes the requirement that internists/subspecialists who have valid-indefinitely certification (grandfathers) must take and pass an MOC secure examination within the first 3 years of service (or within 3 years of the date this updated policy was enacted in 2013) if they have not passed an ABIM secure examination within 10 years before starting ABIM service. The policy also requires that all internists/subspecialists serving the ABIM, including grandfathers, must continuously meet MOC requirements throughout their ABIM service.
      The principles behind MOC are, in fact, based on evidence. Studies have shown that a physician’s overconfidence
      • Meyer A.N.
      • Payne V.L.
      • Meeks D.W.
      • Rao R.
      • Singh H.
      Physicians’ diagnostic accuracy, confidence, and resource requests: a vignette study.
      inhibits his or her diagnostic accuracy. A physician’s ability to independently and accurately self-assess is poor,
      • Davis D.A.
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      “I'll never play professional football” and other fallacies of self-assessment.
      and more clinical experience does not necessarily lead to better outcomes of care.
      • Choudhry N.K.
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      Systematic review: the relationship between clinical experience and quality of health care.
      Studies have also found that fewer than 30% of physicians examine their own performance data and try to improve.
      • Audet A.M.
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      • Shamasdin J.
      • Schoenbaum S.C.
      Measure, learn, and improve: physicians' involvement in quality improvement.
      The MOC program structure tries to address these concerns with a sound theoretical rationale via the Accreditation Council for Graduate Medical Education’s 6 competencies framework. There is also a respectable body of scientific evidence regarding MOC’s relationship to patient outcomes, physician performance, and validity of the assessment or educational methods utilized in the program and its learning or improvement potential.
      • Hawkins R.E.
      • Lipner R.S.
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      American Board of Medical Specialties maintenance of certification: theory and evidence regarding the current framework.
      • Lipner R.S.
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      Specialty board certification in the United States: issues and evidence.
      The ABIM is a physician-led, nonprofit, independent evaluation organization with the mission of enhancing the quality of health care by certifying internists and subspecialists who have the knowledge, skills, and attitudes essential for excellent patient care. Ensuring that our MOC program contributes to improved health care delivery is as important to us as it is to our diplomates. We recognize that there is currently a limited evidence base regarding the impact of MOC on patient outcomes. Thus, over the next several years, we will continue to evaluate our MOC program and its recent changes. The results of this evaluation will help us to further enhance the value of MOC to both physicians and the patients they serve.
      Although this reply may not address all of Dr Hayes’ concerns, we have a continuing and robust research program regarding MOC and welcome outside, well-designed research as well. Through a new initiative called Assessment 2020, the ABIM is also actively reaching out to physicians and the broader community to help define what competencies physicians will need as the field of medicine continues to evolve. For more information and to participate in this conversation, we encourage readers to visit the Assessment 2020 website.

      American Board of Internal Medicine. Assessment 2020. http://assessment2020.abim.org. Accessed April 11, 2014.

      We appreciate Dr Hayes’ feedback, which is precisely the kind of engagement and input that helps our process continue to get better.

      References

      1. American Board of Internal Medicine. MOC Policy for Physicians Serving ABIM. http://www.abim.org/moc-policy-for-physician-serving-abim.aspx. Accessed April 11, 2014.

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      Linked Article

      • American Board of Internal Medicine and the Maintenance of Transparency
        Mayo Clinic ProceedingsVol. 89Issue 7
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          In the May 2013 issue of Mayo Clinic Proceedings, a compelling editorial by the American Board of Internal Medicine (ABIM) leadership entitled “Physician Responsibility and Certifying Examinations” outlined a continual need for integrity and a high standard of ethical behavior.1 Using the search function on the ABIM website for the terms transparency or transparent, these terms are used at least 14 times in reference to various topics.2 However, in remodeling their maintenance of certification (MOC) program and its expectations, the ABIM has taken a large step backward in its efforts to make board certification status more transparent to members, patients, hospitals, and care organizations.
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