Published 8/1/2016
Gerald R. Williams Jr, MD

Making Sense of Maintenance of Certification

Since 1986, maintenance of certification (MOC) has been a major issue for orthopaedic surgeons. It was then that the American Board of Medical Specialties (ABMS)—the governing board for medical specialties such as orthopaedics—introduced the MOC concept. As a result, the American Board of Orthopaedic Surgery (ABOS)—one of the ABMS member boards—began developing a unique certification pathway for orthopaedic surgeons.

The ABOS was established in 1934 specifically to oversee orthopaedic certification. Directors of the ABOS come from the American Orthopaedic Association (AOA), the AAOS, and the section of orthopaedic surgery of the American Medical Association (AMA), as well as one public member. Directors of the ABOS are elected by closed ballot from slates proposed by the AMA Council on Medical Education, the AOA, and the AAOS. The Academy's nominees to the ABOS are vetted and proposed by the same Nominating Committee that selects the slate for AAOS leadership.

What is MOC?
Each of the 24 medical specialties under the ABMS has different requirements for MOC. However, all medical specialties must measure the same six competencies (practice-based learning and improvement; patient care and procedural skills; systems-based practice; medical knowledge; interpersonal and communication skills, and professionalism) within the same four-part framework (professionalism and professional standing; lifelong learning and self-assessment; assessment of knowledge, judgment, and skills; and improvement in medical practice).

For orthopaedic surgeons, MOC is a 10-year cycle. It involves earning at least 120 AMA PRA Category 1 CME Credits in the first 3-year period and a total of at least 240 credits before taking the secure cognitive examination. Applicants must submit proof of having obtained at least 20 credits from scored and recorded self-assessment examinations (SAE) as part of the total 120 CME credits required for the first 3-year period and a total of at least 40 SAEs as part of the 240. This will ensure that the diplomate's status on the ABOS website is shown as "Participating in MOC: YES."

Once the required CME and SAE have been approved, an orthopaedic surgeon is able to apply to sit for a recertification examination starting in year 7 of the 10-year cycle. The application includes the names of individuals who will serve as professional peer reviewers. Orthopaedic surgeons are able to take either a computer-based examination or an oral examination based on 12 of their own cases. For those in active practice, submission of a case list is also required, either 3 months for the computer-based examination or 6 months for the oral examination. The final requirement is payment of the application and examination fees.

These requirements are designed to meet the four-part framework for MOC. Professionalism requires an unrestricted state medical license; it is also evaluated through the credentialing and peer-review process. Beginning next year (2017), orthopaedic surgeons will also have to attest their commitment to the ABOS's professionalism guidelines.

The CME and SAE requirements show lifelong learning and self-assessment, while the case review shows improvement in practice. New practice improvement activities—such as Practice Improvement Modules (PIMs), registry participation, quality improvement programs, and certain educational volunteer activities—can also qualify for SAE credit as they become available and approved by the ABOS.

For every 3-year cycle beginning in 2017 and after, diplomates will be required to complete and attest their participation in a patient safety activity. Participation in a patient safety activity at a hospital or health system will be allowed as well as ABOS-approved patient safety activities created by professional organizations.

The AAOS/ABOS relationship
For several years, the ABOS and the AAOS have staffed a combined task force on MOC. Current AAOS members of the task force include Lisa K. Cannada, MD, co-chair; Evan L. Flatow, MD, who also chairs the Council on Education; Kevin G. Shea, MD; Paul Tornetta III, MD; and Montri D. Wongworawat, MD. In addition, several members of the AAOS staff, including Chief Education Officer Ellen Moore and CEO Karen L. Hackett, FACHE, CAE, participate in meetings.

Task force members from ABOS include Terrance D. Peabody, MD, co-chair; Stephen A. Albanese, MD; John M. Flynn, MD; Gregory A. Mencio, MD; Thomas P. Vail, MD; and David F. Martin, MD, currently serving as Interim Executive Director of the ABOS. Two ABOS staff members also support the task force, which meets on a regular basis.

This task force has been meeting for more than a decade and has made strong progress discussing proposed changes to MOC and evaluating those changes as they have been implemented. The task force has the following charges:

  • Communicate developments in the MOC process to the respective boards and the membership of AAOS
  • Assess and identify the current and future MOC needs of AAOS fellows for the purposes of MOC planning
  • Clarify options for parts II and IV of MOC and communicate those requirements
  • Establish measurable criteria by which the program's effectiveness will be evaluated from the perspective of the AAOS, ABOS, and orthopaedic surgeons
  • Remain focused on making CME and MOC process simple
  • Assess changes to MOC (such as practice improvement/registries, peer review cases)
  • Develop and execute communications plans for MOC changes; explore future MOC enhancements under consideration
  • Leverage our mutual investments in technology to support the MOC process for members and diplomates

New developments in MOC
As J. Lawrence Marsh, MD, and Douglas W. Lundy, MD, explain in their article in this issue ("Recertification Examinations That Fit Your Practice"), changes to the high-stakes examination that are required as part of the MOC cycle will soon be implemented. For years, hand surgeons and sports medicine surgeons with specialty-specific certificates have been able to take a more practice-focused examination. Over the next 2 years, that opportunity will be extended to several other orthopaedic specialties. The table on page 8 shows the changes that will occur and the timeline for implementation.

Not only will the focus of the questions change to be more practice-specific, but the number of questions will be reduced as well. In practice-specific exams, questions about general orthopaedics will be dropped. Additionally, the requirement that the case list be notarized has been eliminated.

In part, these changes are being made because the ABOS and the AAOS listen to members. In the past, the Board of Councilors (BOC) and the Board of Specialty Societies (BOS) have raised concerns. The AAOS, through the joint task force, has brought those concerns before the ABOS—and has worked with the ABOS to address them.

The changes will have an impact on the educational offerings of the AAOS, which is why Dr. Flatow, as chair of the Council on Education, and Ms. Moore, as chief education officer, are part of the task force. In the coming months, as these changes are implemented, you will also see relevant changes in AAOS courses, exam preparation courses, and SAE offerings.

Simplifying your MOC tracking
The AAOS and ABOS work together to help diplomates track and transfer CME credits based on individual activity. When a diplomate participates in any AAOS activity that qualifies for CME, credit can be claimed using the AAOS Learning Portfolio. When it is time to inform and upload credits to ABOS, diplomates can import their AAOS credentialed CME from the AAOS to the ABOS. This is currently available from the ABOS website.
The AAOS and ABOS are working together to enhance this capability and will begin allowing non-AAOS CMEs to be transferred as well. Diplomates will be able to track all of their MOC CME activities in the AAOS Learning Portfolio and also use it to send their credits and related details to ABOS. These enhancements are currently being developed and are expected to become available in the fall.

Like it or not…
In today's healthcare environment, with its emphasis on providing value to patients, some form of MOC will undoubtedly be required. Each medical specialty has been charged with developing a program for physicians within that specialty. As a result, the requirements set by the ABOS differ from those established by the American Board of Internal Medicine (ABIM) or the American College of Surgery (ACS). However, each program must address the same competencies within the same framework (professionalism and professional standing; lifelong learning and self-assessment; assessment of knowledge, judgment, and skills; and improvement in medical practice).

Not all physicians are happy with MOC. The American College of Cardiology (ACC), whose members must meet ABIM MOC requirements, has even investigated alternative options to ABIM certification. The ACC is exploring an alternative pathway to MOC; to see what they are doing, click here.

Orthopaedists, through the BOC and BOS, have also expressed dissatisfaction with the MOC process, calling it "irrelevant, onerous, and expensive." Many believe the ABOS has been unresponsive to their concerns. In response to advisory opinions passed by the BOC and BOS, representatives from the ABOS addressed the AAOS Board of Directors meeting in June, explaining their position.

Although the current process can definitely be improved, I am heartened by the recent steps taken by the ABOS to simplify the process, to improve communications with diplomates, and to introduce practice-specific exams. Encouraging life-long learning to ensure competent orthopaedic surgeons and to address public and patient safety is a laudable goal.

The AAOS plans to continue our dialogue on your behalf with the ABOS through the joint task force, and we will continue to work with the ABOS to simplify and ensure accurate transmission of CME and SAE credits across the websites.

We are also researching the pros and cons of establishing alternate pathways for MOC, and this subject will be the topic of a strategic discussion at the September Board meeting. We will continue to keep you informed regarding all MOC-related activities and initiatives.