A roundtable discussion on the ins and outs of Maintenance of Certification
Recently, AAOS Now editorial board member Frank B. Kelly, MD, held a roundtable discussion to dispel some common misconceptions about the American Board of Orthopaedic Surgery (ABOS) Maintenance of Certification™ (MOC) process. Participants inclued Shepard R. Hurwitz, MD, ABOS executive director; James R. Kasser, MD, ABOS past president; David F. Martin, MD, ABOS president; Thomas Parker Vail, MD, chair of the ABOS MOC Committee; and Stephen M. McCollam, MD, a community-based orthopaedist and member of the Board of Councilors (BOC).
Dr. Kelly: From talking to colleagues, I’ve found that many have misconceptions and misunderstandings about the ABOS MOC program. I’d like to clarify some of these issues and concerns, beginning with what MOC is, and how it was developed.
Dr. Hurwitz: MOC is a process; it’s not simply taking a recertifying exam. That’s the big difference between MOC and the previous recertification requirement.
MOC was developed in response to directives from the American Board of Medical Specialties (ABMS), of which the ABOS is a member. The shift from a single test to the MOC process was to show the public—including patients, payers, hospitals, health systems, and regulators—that certification is not static, but an ongoing process of both knowledge- and skill-based education to improve quality and patient care.
Outside stakeholders see MOC as a quality improvement process. The main buy-in has been from the public sector, from groups such as the Centers for Medicare & Medicaid Services. The private sector—private payers, hospitals, the Joint Commission, and other groups—are beginning to use MOC participation as a marker that an individual physician or surgeon has taken it upon himself or herself to maintain a knowledge base and a skill set and to keep current with practice changes, including changes in health delivery and systems.
Dr. Kelly: So, MOC is not an initiative of the ABOS, but a response to a mandate from the ABMS?
Dr. Hurwitz: Correct. The mandate was to change recertification to a process that had certain elements of what is now called “maintenance of certification.” It’s important to note that this was not a one-sided process created by the ABOS without input from the fellowship of the Academy. MOC was developed by orthopaedic surgeons for orthopaedic surgeons. The Joint AAOS/ABOS Task Force on MOC was created as soon as the ABMS announced that recertification would be changing.
Dr. Kelly: How do each of the four basic components—professional standing, life-long learning, cognitive expertise, and performance in practice (Fig. 1)—apply to MOC?
Dr. Vail: The first component—evidence of professional standing—is demonstrated by having an unrestricted state medical license and unrestricted surgical privileges (if the physician is still performing surgery), and by undergoing some type of peer review that demonstrates professionalism and behavior in one’s community.
The life-long learning component involves the attainment of 120 AMA PRA Category 1 CME credits™ during each of two 3-year cycles.
Evidence of cognitive expertise is demonstrated through a secure computer examination or a practice-based oral examination.
The performance in practice component provides orthopaedic surgeons with a way to evaluate the quality of their own practice using familiar metrics. It is self-reflective, and should demonstrate self-improvement.
Dr. Hurwitz: The first component—evidence of professional standing—is common to all 24 ABMS specialty boards. It doesn’t require that orthopaedic surgeons do anything extra; they just need to have a state medical license, be credentialed at facilities to perform surgery or procedures, and demonstrate certain characteristics to be members of local medical societies and state medical societies. This is the one component in which diplomates are being given credit for what they are already doing.
As for the CME requirements, at least 20 of the required 120 credits must come from scored and recorded self-assessment examinations; that is, the diplomate takes the exam, records his or her responses, and then obtains feedback on the correct answers after recording the score. A list of ABOS-approved self-assessment products is available on the ABOS website.
Dr. Martin: The 10-year MOC cycle begins with evidence of professional standing—holding a license and having admitting privileges. The second MOC component—evidence of life-long learning—comes into play twice—during the first 3 years, and again between year 3 and year 6. In each of these cycles, the orthopaedic surgeon must earn 120 CME credit hours, including 20 hours of scored-and-recorded self-assessment.
Then, between year 6 and year 10 come the third and fourth parts of MOC, evidence of cognitive expertise and evaluation of performance in practice. The cognitive expertise portion involves a secure examination. The ABMS and the ABOS believe that some evidence of cognitive expertise demonstrated by a secure examination is important for us to be able to certify that the diplomate is maintaining the necessary competencies to provide quality patient care.
Diplomates can choose to take a computer exam consisting of multiple choice questions in general orthopaedics, or they may select an oral exam based on their practice. We also have profiled exams, 60 percent of which are based on the specialty of adult reconstruction or spine surgery. Between year 8 and year 10, a diplomate has up to three opportunities (one per year) to pass one of the recertifying exams to remain certified. These computer-based written examinations are offered in testing locations around the country.
Dr. Kelly: How does the Subspecialty Certificate in Surgery of the Hand (formerly CAQ Hand) fit into this?
Dr. Martin: Both hand surgeons and orthopaedic sports medicine specialists have the opportunity to become subspecialty certified, which involves a separate examination from the original certification examination. After becoming subspecialty certified, diplomates can take an examination that will renew both the original orthopaedic surgery general certification and the subspecialty certification in either hand surgery or sports medicine.
Dr. Kelly: The proof of cognitive expertise component has been discussed for a number of years at the BOC level. What feedback have members of the BOC had about MOC?
Dr. McCollam: The response to taking these exams in the local community, as opposed to having to fly to AAOS headquarters, has been consistently positive. But I think the average orthopaedic surgeon still has concerns about the test itself and how to prepare for it. Even though the Academy and the ABOS have communicated and collaborated significantly over the years regarding MOC, members often experience a disconnect between the material that is taught by educators and what the ABOS actually tests on. Addressing this issue in a constructive fashion would be very helpful.
Dr. Kelly: Any response to that issue from our ABOS representatives?
Dr. Kasser: I can understand the concerns about the content of the exam and the disconnect. The content is a review of what should be known by practicing orthopaedic surgeons to practice excellent and safe orthopaedic surgery; it does not necessarily cover all of the latest advances.
Exam questions are prepared by a team of question writers who are aided by the National Board of Medical Examiners. Then, practicing orthopaedic surgeons who are representative of the entire orthopaedic community analyze the questions and make decisions about how the exam should be graded.
We’ve made an effort to ensure that the general exam and the general questions that appear on all the exams do not overemphasize a specialty or basic science. I think that the general questions are representative of what knowledge is required to practice.
Dr. Kelly: How would you prepare for the cognitive exam?
Dr. Kasser: I would recommend completing a general review of orthopaedic practice, either through a review course or a basic textbook. The focus should be on basic orthopaedic information, not the most up-to-date information from the latest journal.
MOC requires each diplomate to submit a case list prior to sitting for the examination. That case list is part of the fourth component of MOC—performance in practice—and is required prior to sitting for the exam.
Dr. Kelly: Can an orthopaedist who is no longer performing surgery still go through the MOC process and take the secure examination?
Dr. Hurwitz: Any orthopaedic surgeon who has ever been or who is currently certified can go through MOC and maintain his or her certification.
Dr. Martin: An orthopaedist who no longer performs surgery would have to take the computer-based written examination—the oral examination is not an option. As for the case list, an orthopaedist who is not currently performing surgery can submit a case list consisting of initial office visits. If the orthopaedic surgeon in question were not seeing patients, a peer review process, tailored to that individual’s particular situation, would be required. A case list would not be required.
Dr. Kelly: Does that case list requirement include a maximum of a certain number of cases or must it include all cases during a 3-month period?
Dr. Martin: If it’s for the computer-based written pathway, it’s a 3-month case list, or a maximum of 75 consecutive cases. Every case does not have to be included. For the oral examination pathway, however, a complete 6-month case list is required.
Dr. Kelly: What about the fourth component of MOC, performance in practice. How is that measured?
Dr. Kasser: The ABMS mandate to measure performance in practice has three components—an analysis of a portion of one’s practice, a comparison to national benchmarks, and a subsequent analysis after the orthopaedist completes an educational activity.
The performance in practice requirements can be satisfied in many ways. Currently, the ABOS measures performance in practice based on the case list and the responses to the peer review questionnaire that goes out to the orthopaedic community and the hospital where the orthopaedist works. Another way to measure performance is practice is through tools such as databases or practice improvement modules, known as PIMs.
Dr. Kelly: How would databases be used in satisfying the performance in practice requirement? Would it be through a hospital joint registry, for example?
Dr. Kasser: Eventually, yes. The ABOS would like to give orthopaedists credit for all of their efforts to improve performance in practice, but the mechanisms for doing that aren’t in place yet. We’re looking for ways to measure performance in practice better and leverage the performance in practice efforts that orthopaedic surgeons are already undertaking.
Dr. Kelly: Now, on to the new concept of practice improvement modules, which the ABOS has been developing for the last couple of years.
Dr. Vail: PIMs will allow the orthopaedist to measure some part of his or her clinical activity, assess that clinical activity, and participate in some process of education related to that activity. So, if an orthopaedist were assessing bunion care using a measure from the American Orthopaedic Foot and Ankle Society, he or she might then participate in some sort of CME activity related to treatment of bunions that would involve a practice improvement plan followed by a re-evaluation.
PIMs might include evaluation of nonsurgical management, evaluation of a surgical procedure, or, as Dr. Kasser mentioned, registry participation. Our goal is to work with specialty societies and other groups that have the expertise to enable surgeons to get credit for using these measures in their practice and evaluating their practice.
Dr. Kelly: So, the bottom line is that PIMs are still in development. They have not replaced the submission of a case list. Dr. McCollam, what have you heard from other members of the BOC and from community-based orthopedists about PIMs?
Dr. McCollam: Some people are still a little confused about the concept. As I understand it, a PIM would be a voluntary way to satisfy the performance-in-practice portion of MOC. You could also opt not to use a PIM and could stick with case list submission and other pathways that are available now.
Dr. Vail: That’s correct. The PIM might be a good fit for some orthopaedic surgeons, while others may choose to continue to submit case lists or do other activities.
Dr. Kelly: Are PIMs available now, or are they still under development?
Dr. Hurwitz: One module is ready and will be available soon. It’s a carpal tunnel assessment and treatment PIM that was developed by a group from the hand societies. It was modeled on a PIM that was created and has been used by the section on hand surgery in the Board of Plastic Surgery for the past 4 years. It will be on the ABOS website and will provide full credit for self-assessment in one of the two MOC reporting cycles.
Dr. Kelly: If a time-limited certificate holder wanted to start the MOC process, would he or she have to register with the ABOS?
Dr. Martin: For the past 3 years, orthopaedic surgeons with time-limited certificates have automatically been enrolled in the MOC process. Farther out than the past 3 years, we would like orthopaedic surgeons with time-limited certificates to register on the ABOS website. They will then be listed as participating in the MOC process, which may become important to them as hospitals, state, and other organizations look at the MOC process and at those physicians who are participating.
Dr. Kelly: What’s the best way for diplomates to find out about the MOC deadlines that apply to them and to track their CME and self-assessment credits?
Dr. Hurwitz: The ABOS will help anyone register and track his or her status, deadlines, and timelines. Simply call the ABOS office in Chapel Hill, N.C., at 919-929-7103, or email me at email@example.com
Diplomates can go to the ABOS website to get a timeline of what activities are due and the deadlines for those activities.
In a few months, when the new ABOS website is introduced, individuals will be able to maintain personal learning portfolios to track their progress in meeting MOC requirements. By June 2013, diplomates will not only be able to see their status but will also be prompted about what requirements need to be met next.
For those diplomates who have missed a critical deadline and are no longer certified, there will be a full outline of how to re-enter certification via the MOC pathway.
Dr. Kelly: Recently it has been rumored that diplomates who have lifetime certificates may need to go through the MOC process to stay certified. Is this true?
Dr. Kasser: Lifetime certificate holders are the approximate 14,000 diplomates who were certified before 1986. They are not required to participate in MOC and will retain their certification whether or not they choose to do so.
Many lifetime certificate holders, however, may find it necessary to participate in the MOC process due to individual patient requests and requirements by insurers or state licensure departments. The ABOS will provide a way for lifetime certificate holders to participate in MOC, if they so choose. If they’re in a state or environment where it’s not necessary, there’s no reason they have to participate.
Dr. Martin: Lifetime certificate holders who want to participate in MOC should contact the ABOS office, sign up, and create an account at no charge.
Dr. Hurwitz: We would like lifetime certificate holders to consider the ABOS as a resource for meeting local requirements. If new regulations arise related to hospital accreditation, we’re willing to help. We want to get people on board with the process as soon as possible.
Dr. Kelly: The MOC process has been criticized as being time-consuming and expensive, and for taking time away from one’s practice. Is it really worth the effort and the expense?
Dr. Hurwitz: Yes, participating in MOC is more work and expense than doing nothing, but one of the ways that we can show a concerted, conscientious effort to provide quality care is to participate in MOC. It shows a dedication to providing good care, communicating effectively with patients, and safeguarding and improving safety and outcomes.
Dr. Vail: We as orthopaedic surgeons want to be the ones who determine what a competent orthopaedic surgeon is, and we need to take the lead in that area. We don’t want to abdicate that to any other group. I think orthopaedic surgeons are in the best position to determine what is quality in orthopaedics.
Dr. Kelly: Do you think MOC helps community-based orthopaedists and their patients?
Dr. McCollam: Despite the grumbling, most orthopaedists will admit that MOC helps them stay abreast of the latest information. If my state of Georgia required either a general medical exam or participation in MOC to maintain licensure, I would opt for the ABOS MOC process.
Dr. Kasser: Some people wonder whether MOC actually improves practice and has any demonstrable effect on the quality of orthopaedic care. We’re trying to do something that’s very manageable for the orthopaedic surgeon, is not too intrusive, and still has a significant effect, which I think is all true of MOC.
Dr. Kelly: Dr. Martin, as president of ABOS, do you have any final thoughts or comments on the value of the program?
Dr. Martin: As a profession, orthopaedic surgeons should take the responsibility to demonstrate to our patients that we are maintaining our competency. MOC enables us to do that by involving activities in which many of us already participate. Surgeons who go through this process will, as Dr. McCollam mentioned, be willing to say that it has a positive effect.
Dr. Hurwitz: The ABOS is really a dedicated group of orthopaedic surgeons trying to do the right thing for the entire field of orthopaedic surgery. We welcome input from everyone.
Learn more about MOC at the AAOS Annual Meeting
Stop by the MOC information booth to speak with ABOS staff and board members about the MOC program during the 2012 AAOS Annual Meeting in San Francisco. You will be able to check your certificate expiration date and learn what your MOC requirements are.
The MOC booth will be in the Lower Level, North Hall of the Moscone Center. The booth is open from 8 a.m. to 5 p.m., Tuesday through Friday, Feb. 7 – 10.