BOSTON -- "Are there shared values we have in what we expect from internists and subspecialists?" was the question posed to physicians by internal medicine leaders during a town hall-style session to discuss maintenance of certification (MOC) requirements.
Representing the American Board of Internal Medicine (ABIM) at the session of the American College of Physicians (ACP) annual meeting were President and CEO , and , chair-elect of the ABIM board of directors.
But comments by audience members sometimes veered away from the specific question as physicians expressed frustration and confusion over the MOC process.
"I feel like the board has wanted to be punitive," said one physician. "If any board member wants to take my job in a small town where I have to run the ICU because there are no specialists for 600 miles ... we're recruiting."
ABIM-ACP Partnership
Before opening the floor, Baron reiterated the ABIM's apology and announcement issue earlier this year and its longstanding partnership with the ACP. "We decided an apology -- along with meaningful action -- was necessary," he said. "Feedback from [the] ACP played a key role in decisions announced Feb. 3."
At that time, the ABIM made several changes. They included suspending practice assessment, patient voice, and patient safety requirements through at least January 2017; freezing fees at or below 2014 levels; and describing physicians as "participating in MOC" instead of "meeting MOC requirements."
The organization also plans to update the MOC exam "to make it more reflective of what physicians in practice are doing," Baron said. "We want your help to create a better MOC."
The ABIM has partnered with with 3,000 members of the ACP "to take a look at the blueprint that drives the assembly of the exam," he said. Those members will then comment on the relevance of testing points.
The exam changes will be incorporated in the fall of this year.
By the end of 2015, there will also be "new and more flexible ways for physicians to earn MOC points by completing new types of ACCME [American Council for Continuing Medical Education]-approved activities," Baron said.
The ABIM will give at least a year's notice for any additional changes to the program, he added.
Switch in Exam Focus Needed
But for physicians scheduled to recertify this year, uncertainty still exists. One audience member described feeling as though she were in "quicksand -- things are changing from under us ... we're left not knowing what we're doing with very short notice." Baron responded that the ABIM will publish a blueprint for the exam several months before it is given.
Several physicians commented on the relevance of topics tested on the exam and urged a change in focus from rote memorization to critical thinking skills. "None of the answers are 'consult an oncologist' or 'consult a gastroenterologist,'" said one audience member to applause.
Another physician recalled a question from his exam: What is the major cause of pulmonary hypertension worldwide? Answer: "How many cases have you seen of it?" he said.
"I think that's off the exam," Baron conceded.
One physician who worked in an urban Veterans Administration hospital advocated getting rid of the recertification exam entirely, stating that it "doesn't reflect what people do in practice." If it is required, more evidence of its effectiveness should be provided, he added.
Money Questions
Another audience member asked leaders to respond to claims made in two articles published in Newsweek by reporter Kurt Eichenwald about the ABIM's financial practices. "If you want a reputable status, you have to address this," she said.
"Both of those articles are categorically wrong," Baron responded. "We don't manipulate exam pass rates," he said in reference to the .
"We are not financially unstable. We are not on the threat of bankruptcy," he said in reference to the . "We are fully transparent about our finances," and the ABIM has an , he added.
Another audience member asked if physicians on the ABIM board were paid. "We receive an honorarium," Braddock answered. The oversight organization should not have a paid board, the audience member responded. It should rely on volunteers instead.
One physician asked if the ABIM has made any push to require MOC for reimbursement or state licensure. "None," Baron responded. Completion of MOC is not a requirement for reimbursement by the Centers for Medicare and Medicaid Services, he added.
More Options for Part IV
Relevance and applicability continued to be a theme for performance in practice projects.
More flexibility is needed for those who don't have a traditional primary care practice base, said one audience member who had worked in urgent care. Internists doing occupational medicine, urgent care, or student health do not have patients that are established for years. Without a stable of patients, "we can't send them surveys," he said. Not fulfilling Part IV isn't an option. "I need to be board certified or else I'm out of a job."
The best types of modules are the easily done ones that aren't overly onerous, added a geriatrician.
Credit for participating in nationally recognized quality improvement projects such as developing a patient-centered medical home would "remove a big burden," said another audience member. That work would satisfy pediatric board requirements as well, she added.
The ABIM board is composed mainly of physicians who practice and value the breadth that comes with lived experience, Braddock said, and the program will evolve to take that into account. "It got away from us over the years," he said.
At a separate MOC session aimed at early career physicians, Baron fielded a question from an audience member asking if the ABIM saw the recently established alternative recertifying organization, the National Board of Physicians and Surgeons (NBPAS), as a threat.
"There have always been alternative boards," Baron said. "The ABIM is focused on the quality of our credential" and that the credential "adds the most value that it can."