In 2015, the American Board of Internal Medicine (ABIM) issued a statement in response to numerous criticisms from diplomates and specialty societies, including the American Society of Hematology (ASH), about the ABIM Maintenance of Certification (MOC) program. Since then, ABIM, specialty societies, diplomates, and other stakeholders have been involved in multiple discussions regarding the challenges of the current MOC process and the design of a new process for maintaining certification.
In response to these discussions, ABIM has taken steps to address stakeholders’ concerns, including engaging with the stakeholder community; freezing MOC fees; placing the MOC requirement of engaging in a quality improvement project on hiatus; engaging in a review of the MOC examination blueprint to improve its relevance to test-takers; initiating a study of an “open book” examination; and releasing the ABIM Assessment 2020 Task Force’s report, which called on ABIM to move away from an every 10-year examination system to one with shorter, more frequent, but lower-stakes assessments of medical knowledge.
ASH has been and remains critical of certain ABIM policies and procedures. However, the Society is encouraged that multiple interactions among ABIM, ASH, and the ABIM Hematology Board have occurred and believes creating a dialogue around the future of MOC is a positive step for these organizations.
ASH Clinical News invited Marc S. Zumberg, MD, chair of the ASH MOC Working Group, and Michael E. Williams, MD, ScM, chair of the ABIM Hematology Board, to share details about this dialogue and the future of MOC for hematologists.
Dr. Zumberg: On behalf of ASH, I’d like to start by saying how happy we are to be developing a dialogue with the ABIM and the ABIM Hematology Board to help restructure MOC for hematologists.
Dr. Williams: Absolutely, and as chair of the ABIM Hematology Board, I can tell you that we are as excited about this collaboration with ASH. On the ABIM side, our goal is to continue to improve the certification and MOC process and assessment of knowledge, which we view as critical components of a board certification that tells patients that a physician is meeting a standard of performance and capability.
We can both agree that ASH and ABIM have a shared interest in ensuring that hematologists are well-informed, up-to-date, and engaging in continuous learning. This is particularly vital in a field as dynamic as hematology, where we are seeing rapid progress in diagnostics, therapeutics, and disease monitoring.
Dr. Zumberg: I must say, for some period of time, ASH and other medical specialty societies felt separate from the board certification and maintenance process; it seemed that ABIM made the MOC product and the societies just had to accept it. Creating a dialogue is one mechanism to change this dynamic. In a short amount of time, we have worked together, which I don’t believe had happened in the past.
One of our main efforts has been to open the channels of communication between ASH, other societies, and ABIM. We frequently email each other about certification issues, and, on a society-wide level, we have had multiple conference calls to discuss these issues. This was also something we embraced at the 2015 ASH Annual Meeting, where ABIM and ASH leaders met to talk through some of the certification and MOC concerns of diplomates.
The goal of open communication is to have a channel through which the concerns of hematologists can be heard and have the opportunity to influence ABIM policies and procedures to address those concerns.
Dr. Williams: While there were limited interactions between ABIM and ASH in the past, the focus of those interactions shifted a year ago when we had the first of a series of meetings between ABIM leadership and ASH leadership, culminating in an important and helpful meeting at the 2015 ASH Annual Meeting.
We’ve also welcomed ASH representatives to the twice-yearly ABIM Hematology Board meetings in Philadelphia, to offer the ASH perspective and to drive collaboration. Obviously, that had an impact on trainees and the physician–scientist workforce – a key demographic of ASH’s membership.
Dr. Zumberg: Right, and these meetings are certainly a step forward for us working together. For ASH and our members, our main concern is to have an MOC process that is meaningful, affordable, convenient, and – most importantly – reflective of what diplomates should do in everyday clinical care. We want an MOC exam that adds to diplomates’ knowledge and, ultimately, helps us better serve our patients.
ASH, like many other medical specialty societies, has been anticipating changes to the MOC exam that would address the concerns of test-takers. We heard from many of our diplomates that the MOC exam – in its current, every-10-years state – is very high-stress. It requires a lot of preparation and, some would argue, is not that valuable. Hematologists, like most internists, like CME. As such, many diplomates were calling for a lower-stakes exam, or more frequent exams at shorter intervals. Ideally, the new exam also would include a feedback mechanism; if you answered questions incorrectly, you could be directed to resources that would help increase your knowledge. Alternatively, if you did well, then perhaps you did not have to take a recertification exam.
Other common concerns we heard were about the inconvenience of taking the exam at a Pearson testing center, the cost of the MOC program (and not knowing where that money goes), and the opportunities to earn MOC points.
ABIM requires that physicians earn a certain number of MOC points, but these were previously limited to few activities. Many argued that clinicians are already participating in activities to expand our knowledge base, such as CME at our workplaces, that should earn MOC points. Now, thankfully, there are many different avenues through which diplomates can earn points toward MOC. I recently attended a meeting to review and critique questions for ASH’s Hematology In-service Examination; I earned 10 MOC points for this activity.
Of course, one of the most pertinent concerns was that the MOC exam is not reflective of the day-to-day practice of most hematologists. In addition, in today’s world, the way physicians access information and practice medicine has changed. With the internet and smartphones, information is available at their fingerprints; the real-world isn’t a closed-book situation, as reflected by the MOC examinations.
Dr. Williams: ABIM has heard and is addressing those concerns with the recently announced modifications to the MOC program. All the potential changes you laid out are under active consideration. Our goal is that, by January 2018, we will have the first alternative MOC approach in place, which will include:
- shorter, more frequent assessments
- alternative MOC assessment formats to choose from
- remote proctoring, allowing the use of an individual’s home or office computer
Also, physicians who perform well on shorter assessments would test-out of the longer-form, 10-year assessment. This means that as long as physicians who consistently opt to take shorter assessments and achieve a defined level of performance, they will not need to take the 10-year exam again to remain certified. (For more about what these changes will mean for you, see the SIDEBAR.)
We’ve been trying to reach that point for a couple of years now, but we will need a bit more patience from our diplomates. Our goal with the revised program is to have a meaningful certifying and MOC system. We did not just want diplomates to report Continuing Medical Education (CME) credits without an assessment component; it’s essential that the board certification have real meaning to the public and the profession.
Dr. Zumberg: Diplomates – not just from ASH – are angst-ridden about what the exam has represented and what they were getting out of it. The changes that ABIM is exploring, if implemented correctly, could be welcome steps to making MOC more user-friendly and meaningful.
The future of Part 4 of the MOC program, focused on medical practice improvement, is still unclear. It has been suspended, but will it be gone for good? As ABIM embarks on changes to the MOC program, people may be nervous about where it is headed. We are welcoming of change, but both ASH and hematologists want to be involved in the process.
Dr. Williams: Another element we are keeping in mind is the scope of the knowledge base that will be included in the MOC assessments.
A number of hematologists are focused in one specific area of our field – whether that’s malignant hematology or stem cell transplantation or hemostasis and thrombosis. Clinicians who specialize in primarily one area may ask, “Why should I have to study the entire field when that’s not part of my professional activities?” We at ABIM hear that, and we at the ABIM Hematology Board will be eager to have ASH insight on this aspect as the MOC process evolves.
Dr. Zumberg: The significance of this topic became even clearer to me when I was at the question-review meeting. When it came to the specialized malignant hematology topics, I realized that I was not as nearly as well-versed in those areas as I am in coagulation and non-malignant hematology. However, in my practice, I do not treat those diseases.
Personally, I think we all should have some fundamental knowledge of all aspects of hematology, but I don’t think we should be expected to know or to be tested on the detailed aspects of the areas of sub-specialization where we no longer practice. When patients see me, they want to know that I am up-to-date on non-malignant hematology, not necessarily conditions that I no longer treat.
I think everyone would agree that physicians do need to maintain knowledge and professionalism.
Dr. Williams: What ABIM is in the process of doing now, across all of internal medicine and all the sub-specialties, is revisiting the certification and MOC assessment blueprints and seeking input from external sources; this includes not just those of us who sit on the ABIM Hematology Board, for instance, but also hematologists in various clinical and research settings. We want to learn what is important to our diplomates and that is going to inform the structure of future MOC assessments.
The blueprint is the template upon which, traditionally, the high-stakes exam has been built. It specifies the areas to be included in the exam and how much emphasis will be placed on those areas. For example, following the blueprint, certification exams would include a limited number of questions about rare diseases but a larger number of questions about more common diseases.
The hematology blueprint is open and available for review. (See SIDEBAR for information about accessing the blueprint). At ABIM, we appreciate how ASH has shared this opportunity with their members. The more feedback we get and the more people who respond, the better the template will reflect current practice. This is the diplomates’ chance to tell us what they do and what they need from an MOC assessment.
Dr. Zumberg: When I filled out the survey, I had the opportunity to indicate which conditions I treat often and which conditions I rarely see but are very important to know how to manage, versus conditions that are so rare that they might not require testing. Assuming we get enough of our membership to participate, future exams will hopefully be more relevant to what hematologists do in day-to-day practice.
If I could make one plea, I would stress how important it is that all practicing ASH members participate in the blueprint survey. This is our chance to help shape the content of our future MOC assessments. This is our chance to make sure future MOC examinations test common and important topics.
In the future, the goals of discussions between ASH and ABIM will be to continue to represent the needs of hematologists and our diplomates with the ABIM to produce an MOC product that is ideal for physicians and our patients.
Dr. Williams: On behalf of the Hematology Board members, I can say that we are all very encouraged by the opportunity to work with ASH. After all, board members are ASH members and many have held or currently hold leadership positions in ASH. There is a close alliance of purpose between our two organizations. We are committed to do the very best we can to get the board certification process and MOC to work for our diplomates. I’m looking forward to continued collaboration.
What Do the MOC Changes Mean for Me?
For diplomates whose certification is expiring before 2018 who would like to be reported as certified and participating, the following must be completed:
- Enroll in MOC
- Every 2 years: at least one MOC activity
- Every 5 years: 100 MOC points
- Every 10 years: Pass the MOC exam
Login at abim.org to check your MOC status report for specific next steps.
Share Your Thoughts About the Hematology Exam Blueprint
The ABIM Certification and Maintenance of Certification exam blueprints are available at abim.org/about/exam-information/exam-blueprints.aspx. The ABIM is asking for all hematologists to fill out the survey about the exam blueprints. The ABIM needs to receive another 300 responses to make sure the survey is representative of the hematology community before they can consider making changes to the spring 2017 MOC examination.
To participate, sign in to the ABIM home page at abim.org/online and select “Hematology” under “Rate Blueprint Topics with Blueprint Review Tool.” If you forgot your ABIM six digit ID or password, there are links on the sign in page that will help you quickly retrieve your login information.
ASH has endorsed the blueprint survey as it is one way ABIM is working to make the MOC program more relevant to hematologists. If you do not believe the current content of the ABIM MOC is pertinent to your daily practice, participation in this survey is the best way to bring about change.
Before supporting the ABIM’s request to encourage you to participate in this survey, ASH accepted ABIM’s invitation to have an ASH representative present during future discussions of the blueprint results in response to ASH’s request to understand the data and how it would be used. ASH representatives will be working with ABIM to provide perspective on how to interpret and act on the survey results. By providing your input, you will help ensure a better MOC process for you and your fellow hematologists.