Determining the Value of MOC for Radiologists

After Maintenance of Certification (MOC) was formally implemented for radiologists in 2007, the program is back in the spotlight thanks to internists’ public rift with the American Board of Internal Medicine (ABIM).

While the situation in radiology isn’t close to that level of outcry from its members, the discussion is vigorous enough to warrant recent point and counterpoint opinion pieces in the Journal of the American College of Radiology, and heated discussions on radiology online forums. What’s behind the concern and how similar are the radiologists’ complaints to those of their internist colleagues?

Let’s start with a little background. Taking continuing medical education (CME) courses is nothing new, it’s been happening for decades as an informal way to keep up with medical trends. But taking a test every 10 years to renew board certification is more novel, and is part of the MOC program adopted from the American Board of Medical Specialties (ABMS). The question of whether these tests are keeping radiologists current in their skills or just wasting their time and money is one debate. And the formalized quality reporting aspect is something also questioned as being duplicative of what’s done in the workplace, or irrelevant to some physicians.

“The concept of MOC started in 2000 when the ABMS and ACGME were considering how to demonstrate compliance to the public, with an ongoing discussion of what maintenance of certification means,” said Milton J. Guiberteau, MD, professor of diagnostic radiology at Baylor College of Medicine and president of the American Board of Radiology (ABR). “The overwhelming number of physicians and radiologists believe that physicians know best how to hold each other responsible for certain maintenance of skills and knowledge for the benefit and safety of patients.” Rather than relying on external regulators, the ABR and other specialty boards had the ABMS take the lead.

The ABR implemented its MOC program in 2007, with subsequent changes, including the move to Continuous Certification in 2012. MOC applies to all with time limited board certification, though those with lifetime certification can opt in (some have to opt in based on employment or hospital affiliation requirements). For all specialties, the ABMS program requires maintenance of certification based on four standards: professional standing, lifelong learning and self-assessment, cognitive expertise, and practice quality improvement (PQI). How the specialty boards test and evaluate physicians in this four part framework is up to them.

One reason the ABR isn’t getting the same flack from its members as the ABIR, said Guiberteau, is that the ABR lagged behind implementation to see what other boards were doing, to determine what would work best for radiology. “We took a measured approach in introducing this,” he said. While he feels the radiology MOC ultimately turned out well, slowly introducing the program and making constant changes was frustrating for physicians.

What Don’t Radiologists Like About MOC?
There are three things that many radiologists don’t like about MOC, said Saurabh Jha, MBBS, assistant professor of radiology at the Hospital of the University of Pennsylvania. The first is that radiologist board certification went from time unlimited to 10 years (though some were grandfathered in to time unlimited certification). Second, instead of using CME as a voluntary but still practiced life-long education, “codifying CME became part of the MOC,” he said.  Third, there’s an exam every 10 years. ”Now they have to pass essentially a more difficult or relevant version of what fellows and residents pass, to demonstrate that they’re current with a certain body of knowledge.”

In terms of CME, Guiberteau doesn’t see a problem with codifying it. CME is something most states require, he said. “The examination is one where we get pushback.” And he’s seen complaints as well about PQI, “even after over a decade of education and inculcation of the requirements for training programs and practicing physicians, it’s still not understood by a contingent of radiologists.” These are the two areas the ABR is focusing on to make them more in tune with practicing radiologists, so that they resonate with skills and activities they’re already using in their practice.

As for the radiology exam, there are different valid positions on it, said Jha. He sees the MOC test not as improving his knowledge, but as a social contract. “From a patient perspective, I don’t think people would be dying left, right, and center if we didn’t take the test. If it makes people trust, that’s good. That’s what you want. Mistrust has its own cost. I can see how it could be viewed very differently, as burdensome.”[[{"type":"media","view_mode":"media_crop","fid":"38842","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_5875115713371","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3895","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 200px; width: 200px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"©Alekksall/Shutterstock.com","typeof":"foaf:Image"}}]]

Jha said he’s heard a diverse range of responses for how radiologists are preparing for the exam. “Some have said they just turned up, others said they spent weeks preparing for it,” he said. Jha plans to prepare. “I’m not going to take chances.” As a volunteer, he took a sample test to verify question consistency and said he applauded the ABR for taking a lot of effort to make sure there’s consistency and granularity. Passing rates are good, he said. “It’s a reflection of the nature of the exam.” That said, it’s hard to test things in imaging that are cutting edge and evidence-based, because the facts change very quickly. Doctors practicing with new technology in a cutting edge area “consider MOC a waste of time,” he said. “But there are some things in imaging that are time tested and won’t change.”

Another reason physicians aren’t happy with MOC in a broader context is “the way it’s been sold, that it’s improvement in quality without which you’d get an epidemic of errors and malpractice. There’s no evidence of that,” Jha said. On its website, the ABMS does claim that “despite some variation in the activities, they are all built upon evidence-based guidelines, national clinical and quality standards, and specialty best practices.” It also publishes an Evidence Library to support their claim that MOC and board certification is “anchored in evidence-based guidelines” and best practice research.

What Might the ABR Change in MOC?
“We understand there are a number of people who really feel overwhelmed by having to do this, because it’s new,” said Guiberteau. “We’re doing our best to make it palatable in terms of practicality for the diplomates. We’re in the process or revising some of our requirements.”

In terms of PQI, in the next few months the ABR will launch an expanded menu of options to qualify for that section, said Guiberteau. “We’ve greatly expanded the options because we understand that PQI projects do not fit properly and appropriately in some practice settings, particularly in small practices,” he said. “We’ve expanded those options to things that radiologists may already be involved with in their hospitals. As we know, quality improvement is not just something that the ABR or ABMS invented, it’s everywhere. If you’re already doing it in one program, why do it again differently for ABR? We don’t feel you should be, as long as it’s ongoing and you’re performing it in your practice. We feel it will give some relief.”

They’re also looking at expanding testing locations to more than just Chicago and Tucson. Guiberteau said they had difficulty at Pearson testing centers because the testing data sets were so large that it caused problems with loading or crashing. They’re looking to see if they can distribute the exams locally or even allow physicians to take the tests at their home or offices. They’re also checking with other specialty boards to look for alternative testing scenarios.

What’s Different Between the ABIR and ABM?
Fortunately the situation in radiology is not the same as internal medicine. “The ABR is very different than the ABIM, which has gotten off their rockers,” Jha said. They conducted too many patient surveys, increased rates and conducted tests with a high failure rate. “Are people getting more stupid with time or is it a flawed instrument?” Jha said.

Unlike complaints heard from internal medicine physicians, radiologists are not being asked things outside their practice parameters. “The radiology test is more fine-tuned to relevance,” Jha said. The ABR allows physicians to choose the testing subject modules, said Guiberteau, such as GI, nuclear medicine, and ultrasound. “We don’t test people in areas in which they don’t practice,” he said. “That’s a difference between our program and the ABIM program, which requires everyone to take the same exam.”

One good thing the ABR did was make practice quality improvement an ongoing physician effort, not a test. The ABIM got that wrong, making requirements onerous and irrelevant, Jha said. “The ABR made the physician quality reporting very relevant, and there’s a broad range of things that count as PQI that one can do,” Jha said.

The ABIM took their regulations too far, which can happen to specialty boards that don’t work with their constituents, said Jha. “Any principle taken to the extreme becomes nonsense. With anything, when you start getting on board with a high horse, you’re going to polarize, particularly when dealing with hardworking people like physicians,” Jha said.

Other Certification Options
While Jha thinks there needs to be some kind of maintenance of certification, the bigger question is what that should look like. “We need some sort of self-regulation,” he said. “Periodically we should submit ourselves to peer review. The external feedback from other physicians has been key. People don’t really appreciate this. We would not have gotten where we are in medicine if not for the constant professional feedback. Most physicians do tell other physicians when they’re going wrong or have gone wrong. There is a sense of professional pride.”

The internists were unhappy enough with the current situation that some created the National Board of Physicians and Surgeons, which has received more than 2,000 applicants so far, said Paul Teirstein, MD, president of NBPAS and chief of cardiology at Scripps Clinic. The NBPAS doesn’t provide initial board certification, but is a newly created alternative to continued certification in many specialties, including radiology.

“What they’ve done is simplified [maintenance of] certification,” said Jha. You need a certain number of CME hours and a valid medical license number. “I think it will take off.”

For the NBPAS to succeed, it will be fought at a state level, said Jha, but he thinks it will be accepted. And once one board is accepted, why not other boards, much like Moody’s and S&P are different rating agencies “Once you make the argument that you can go beyond your board, why stop at two? Why not 10? There’s no logical reason why you shouldn’t have another board.”

Success will depend on how many doctors get certified through alternative means. Once there’s a critical mass at a certain hospital or health care system, they’ll have no choice but to accept it. The argument against this type of certification is that it doesn’t measure physicians enough, which leads back to the question of whether maintenance of certification has value.

Instead of looking at what the NBPAS is doing, the ABR is trying to make a program “that best demonstrates the ongoing obligations of professional continuing development in health care that we can offer,” said Guiberteau. “We really are more concerned with refining our own program to the satisfaction of most diplomats, than worrying about the NBPAS.”