Has ABIM Gone Too Far?

Marc J. Kahn, MD, MBA
Peterman-Prosser Professor of Medicine in the Section of Hematology/Medical Oncology at Tulane University School of Medicine

Recently, the American Board of Internal Medicine (ABIM) announced plans to implement new Maintenance of Certification (MOC) requirements, including requiring physicians to complete some MOC activity every two years and accrue 100 MOC points every five years. If they fail to do so, physicians will be reported as “Not Meeting MOC Requirements.”

Unsurprisingly, these new MOC requirements have been met with much controversy, as evidenced by an anti-MOC petition started in March 2014 that is currently signed by more than 18,000 physicians. In response to the petition and concerns voiced by several medical societies, ABIM leadership has announced changes it will be undertaking in the future, including increased flexibility on deadlines and providing more feedback regarding test scores.

So, are the new requirements a necessary change, or are they too strict? In this edition of “Drawing First Blood,” ASH Clinical News has invited Marc J. Kahn, MD,MBA, and Michael E. Williams, MD, ScM, to debate this topic, with Dr. Williams arguing for their value, and Dr. Kahn arguing that they are unnecessary. 

Disclaimer: The following positions were assigned to the participants and do not necessarily reflect their opinions or what they do in daily practice.  

Michael E. Williams, MD: Before we discuss the value of the current changes, I think it’s worth summarizing what led ABIM to institute these changes to the MOC process. Prior to 1990, individuals who were seeking board certification in internal medicine or one of the specialties would complete their training, sit for the board certification exam, and – if they passed – receive lifetime certification. Starting in 1990, in an effort to be better aligned with other specialties within the American Board of Medical Specialties (of which ABIM is a member), ABIM began issuing time-limited certificates. Board certification was valid for 10 years, at which point doctors had to retake the exam to maintain certification. [Editor’s note: ABIM now requires that individuals accumulate 100 MOC points over five years; previously, the 100 MOC points could be accumulated over 10 years.]

With the recent changes, ABIM’s aim is to keep pace with the fast-moving field of medicine, consistent with the Institute of Medicine’s statement that in a profession with a “continually expanding knowledge base” a mechanism is needed to ensure that practitioners remain up-to-date with best practices. I think this is especially true for hematology. There is also a need for feedback to improve practice, patient outcomes, and the delivery of care.

Marc J. Kahn, MD: I certainly agree with the rationale behind the changes, but I disagree with the assumption that changes to MOC will impact patient outcomes. To me, ABIM has not done an adequate job of proving that relationship. For example, if you search PubMed for “ABIM recertification” and “outcomes,” you’ll see two papers. In my opinion, that’s woefully inadequate data to support the type of changes that have occurred. So, I am going to fault ABIM for not having the appropriate data, and suggest that ABIM make funds available to unaffiliated individuals to do this type of research to avoid any conflict of interest. 

Dr. Williams: That criticism is certainly one that the ABIM has heard, and I don’t disagree that there needs to be more robust and independently-generated data showing that completing the MOC process actually does subsequently improve patient care and outcomes. Everyone, I think, can agree that we need continuous, lifelong learning and we need to be proactive in our efforts to improve patient care. But we need to show that MOC helps get you to that end; we need to reinforce the existing evidence of MOC benefit and continue to improve the MOC process.

Dr. Kahn: Another concern I have is the lack of financial transparency. I realize that ABIM has provided access to their 990s forms [a report on financial activity that federally tax-exempt organizations file with the IRS] via GuideStar, but that is not what we want. We want to see pro forma financial statements so we know how much money is being generated by the MOC process, and what is being done with that money. There is a lot of concern that MOC is, for lack of a better term, a “cash cow” for ABIM. Physicians are spending a lot of money for something that, again, may not provide us with the right benefit. 

Also, as you know, subspecialty societies like ASH develop and sell their own MOC products to members, whereas ABIM uses our fee money to generate similar products for free. It really seems that ABIM has set up an unlevel playing field, whereby they are competing with subspecialty societies for MOC process and items – I think that’s inherently unfair. 

Dr. Williams: The request for additional transparency is understandable. Physicians want to know specifically what is being done with the MOC fees and how those fees will be used to continually improve the MOC process. ABIM has added a Revenues and Expenses section to its website to provide information on how MOC fees are spent. And, to address concerns about the competition between subspecialty and ABIM products, ABIM is now looking at is changing the MOC fee structure to allow for “opting out” of a proportion of the fees if you would prefer to use an outside resource.

I think it’s very important to recognize that ABIM has always valued the interactions with professional societies. Within the recently reorganized ABIM governance, there is a newly configured Hematology Specialty Board, which I chair, and which includes many of the nominees that ABIM solicited from ASH. ASH Vice President Charles Abrams, MD, who is a former ABIM Hematology Exam Committee member and chair, and Scott Gitlin, MD, who is a member of the ASH Awards Committee and former Chair of the ASH Committee on Training, are each on this board. I previously chaired the ASH Education Committee and have also served in ASH educational programs. Thus, there is a very high level of insight and appreciation for what ASH contributes to our profession, and we will continue to incorporate that expertise into MOC.

In terms of fees for MOC: if you are recertifying in just hematology, the cost is $256 per year; recertifying in internal medicine and hematology costs $353; recertifying in both hematology and medical oncology costs $384. If you choose to recertify in all three, the annual cost would be $512.

ABIM does not require physicians to maintain internal medicine or medical oncology in addition to their hematology certification – it is a personal choice for each physician. In fact, according to the research that is generated for the Hematology Specialty Board’s review, 46 percent of hematologists do choose to maintain their certification in internal medicine. If a physician does choose to maintain multiple certifications, the MOC points earned for one certification apply to all additional certifications, so physicians only have to earn 100 MOC points in total every five years. The only additional requirement is passing the secure MOC exam in each certification area every 10 years. It is also important to note that the first attempt at each MOC exam earns 20 MOC points. 

Dr. Kahn: So, it seems that the current fee structure actually carries a disincentive for hematologists to maintain oncology and/or internal medicine certification – that just doesn’t make sense to me. Wouldn’t the ABIM want to encourage its constituents to remain certified in boards that they have held? 

Dr. Williams: Personally, I think that the actual cost per year for maintaining more than one board certification is modest – while recognizing that a diplomate recertifying and retaking the exams may incur other expenses, such as review courses or self-assessment products. It is an investment of both time and money, and the issue of cost is in front of the ABIM Board of Directors and the Council for ongoing discussion. 

Dr. Kahn: And, as constituents, we want to make sure that what we are paying for is worth it. I have taken the recertification exam twice now – in hematology, oncology, and internal medicine – and each time, I receive a pass/fail notice with little other feedback. If ABIM is really interested in improvement, I would think test-takers should receive a more detailed report. 

Dr. Williams: That’s a great point, Marc. In fact, starting next year, individuals will receive an enhanced report for initial certification and recertification exam results. Those reports will include much more detail about the examinee’s performance in individual areas. 

Dr. Kahn: That’s good to know. Regarding the test-taking process, I have to ask whether you think a sit-down exam is really appropriate for an adult learner. Are there perhaps better, more efficient ways to gauge a practitioner’s performance that reflect how we practice medicine? Medicine is no longer an individual sport, it’s a team sport. If I have a question, I am not obligated to find the answer myself; I can ask a colleague who is an expert. 

Dr. Williams: The form of the exam has changed significantly since ABIM was founded in 1936 and will continue to evolve according to how we practice medicine. The resources we have available now have really altered the ways we tap into information for clinical decision-making.

To that end, ABIM is considering new test and question formats for the certification and MOC exams, including “open-book” or “open-resource” components. As you said, this is more consistent with the way we actually respond to clinical problems or diagnostic issues. With certain specialty exams, for instance, we have already started testing questions with more than one correct answer because – as you know – there isn’t always a single-best answer in practice. We are piloting new testing formats, but we also need to ensure that test results remain statistically valid and are able to discriminate between highly and less-qualified test takers. 

Dr. Kahn: Mike, I am encouraged by the changes that you described are underway, but I would strongly encourage ABIM to continue listening to its constituents, to have forums where these issues can be discussed, and to strive for greater transparency in their decision-making. 

Dr. Williams: ABIM definitely agrees that there is room for improvement. The challenge the MOC process seeks to address is identifying the best ways to assess the results of those efforts and to fold them back into practice improvement and continuous learning.

The Hematology Specialty Board reviews data collected about multiple-board recertification and diplomate feedback every year, and over the last four to five years the numbers have been reassuring: of more than 800 hematologists who have participated in the MOC program, 85% stated that the process was valuable to them, and more than 80% agreed that participation made them a better physician. I have to say that I found my own MOC and exam experience very helpful, much of which I have now carried through my practice for the last several years.

Getting it right is a work in progress, and continual improvement is the goal. We will certainly be working with ASH toward that end. 


Changing Landscape of MOC

For more than 10 years, ASH has been active in challenging the ABIM on MOC, while also working to create products that would help our members meet MOC requirements. With the announcement of the recent changes to ABIM’s MOC program, we have ramped up our efforts to make sure our members’ voices are heard.

With the implementation of the 2014 iteration of MOC, the ABIM has heard from many diplomates. The ABIM has also heard from the internal medicine and subspecialty societies – both on behalf of their members and specifically regarding ABIM policies and processes that govern the creation of MOC products.

The concerns, which have not changed substantially in the 13 years since ASH President Beverly Mitchell first voiced ASH’s reservations in 2001, include the lack of evidence about the importance and value of MOC. If anything, the myriad changes to the program over the past 13 years has increased the doubts about the efficacy of the MOC program.

In March 2014, the American College of Physicians (ACP) convened a meeting of internal medicine and subspecialty societies. The ACP then presented the ABIM with a letter, co-signed by ASH, outlining concerns and recommendations discussed during that meeting, including:

  • Proving the benefit of MOC
  • Increasing financial transparency
  • Streamlining the approval process for societies’ Part II products

ABIM has responded quickly to professional societies’ concerns and announced welcomed program changes at a recent meeting. ASH hopes that when these changes are rolled out to diplomates they will find some measure of relief in meeting MOC requirements.

MOC issues will continue to be a hotly debated issue, and ASH will continue to advocate on behalf of our ABIM-certified members through multiple channels. We urge members to stop by ABIM’s booth at the 2014 ASH Annual Meeting Exhibit Hall for more information about this developing topic. Additionally, if ASH members would like to submit their complaints or recommendations to ABIM, please use [email protected].

Editor’s note: After this interview took place, ABIM announced that additional changes would be released shortly. ACN will report on these when they are released.