Alphabet soup: ABAI, ABMS, and MOC vs EBM, VBM, and IRB

In a recent editorial in the Annals, 2 members of the American Board of Allergy and Immunology (ABAI) stated their case for physician participation in maintenance of certification (MOC).1 They wrote, “There are growing expectations by those outside the medical profession for professional ac- countability and transparency. Focusing solely on the physician side of the physician-patient equation in opposing the MOC process risks the perception that these opinions (opposing MOC) are self-serving.”

Physicians function in an evidence-based medicine (EBM) environment. Alleged failure to adequately adhere to evidence -based best practices is a fundamental justification for MOC cited by James and Corbett along with others.2 EBM “is an approach to clinical care based on the claim that the appropriateness of clinical interventions should be justified by the existence of high-quality evidence for the effectiveness of the intervention rather than on other grounds, such as the authority of the clinician, tradition, or politically motivated policy.”3

This has evolved into a values-based medicine approach (VBM), incorporating the patient’s values and preferences into the decision-making process. Parker writes, “The final layer, the apex of the pyramid, is the integration of values and costs, using cost-utility analysis, to arrive at VBM itself.”3

Physician associations have adopted the principles of EBM and related concepts with enthusiasm.4,5 The 2010 update of the anaphylaxis practice parameter grades the strength of every recommendation based on the quality of the evidence, with 6 different categories of increasing evidence strength, citing 311 references in support of its recommendations.6

In contrast to the robust data used to justify and characterize task force recommendations, “Currently, no outcomes data exist to prove that the ABAI MOC programs improve allergy/immunology care.”1 Still, supporters of MOC contend, “There is an accumulating body of evidence that the public and patients already believe that physicians and the profession already do what MOC is designed to do.”1

Evidence for this is limited at best. On its Web page on physician certification, the American Medical Association says only, “Many boards require recertification at periodic intervals.”7 The ABAI board members’ article1 cites just 2 references in support of that fundamental claim. The first primarily addresses initial board certification, not MOC. It has 5 references, none of which directly report measured patient attitudes. It refers to an unpublished Gallup poll, performed at the behest of the American Board of Internal Medicine (ABIM), but the actual questions asked and results are not provided.8 The second paper contends, “The public has begun to expect physicians to participate in an ongoing assessment program,”9 but no reference is provided for that assertion. It is unlikely that “the public” understands, let alone specifically wants MOC as it is currently promulgated.

Holmboe et al2 examined practice behavior by 3,602 primary care physicians initially certified by the ABIM between 1990 and 1995 who took the internal medicine MOC examination. Although they found statistically significant differences in the percentage of patients receiving 4 of 6 studied routine screening measures between the lowest- and highest- quartile MOC test performers, behavior differences were modest, fewer than 10 percentage points for any single ac- tivity and 5 or fewer percentage points for 4 of the 6 evaluated performance measures.

The ABIM charges $1,810 for a specialist to enroll in MOC through completion of the examination process.10 The ABAI charges $2,850 to take the examination, plus a total of $1,500 in annual fees during the 10-year recertification cycle, as well as further unlisted charges for additional modules.11 This does not include other direct expenses, such as travel to the examination site and time lost from work. No estimate is provided of the number of hours anticipated to be required by physicians and their office staffs, including the hours spent not just in study but also in completion of the paperwork that is part of the certification process and surveying patients and other practitioners as part of required modules—as well as completion of assessments of colleagues when they do MOC.

Understanding the time and cost for completing each component of MOC is essential to rational evaluation of its worth in any evidence-based system. By law, federal government agencies must explain the reason for each form required and “estimate the burden in terms of time and money that the form will impose . . .”12

Physicians have others also placing demands on their educational and practice time. Hospitals, institutional review boards (IRBs), state medical boards, insurance carriers, and pharmacy benefit managers all demand their share. All of these efforts have good reasons behind them, but time in one activity is time taken from another.

The ABAI has not provided figures, but only 1% of physicians certified by the ABIM with time-unlimited certification have enrolled in MOC. Most physicians do not believe it is sufficiently worthwhile.13

Still, it has been proposed that successful attestation of continued board certification and/or participation in MOC will be used by regulatory agencies, hospitals, and payers as a requirement for practice.1

In response to the growth and aging of the American population, as well as changing demographics among physicians, there has been increasing concern about a looming physician and specialist shortage.14 A recent detailed analysis by the American Association of Medical Colleges suggests a national shortage of nearly 125,000 physicians in 2025.15

It is reasonable to postulate that some physicians will fail to pass or retire rather than participate in a process that may have little bearing on their specific practice activities and that has been rejected by substantial numbers of physicians, especially those with time-unlimited certification who have a choice.16 Many physicians narrow their scope of practice over time, making general specialty and subspecialty examinations more time consuming to prepare for and less relevant to what they do on a daily basis.

The potential impact of earlier retirement has not been examined by proponents of universal MOC. Are patients better off with a timely visit to a well-regarded and experienced specialist who has not participated in MOC or a generalist, emergency department, physician extender, or phar- macist because no physician is available?

Physician critics of the MOC process have made accusations of self-serving behavior on the part of certifying boards,17 the converse of observations by members of certifying boards critical of those resistant to MOC.1 although physicians have reason to be concerned about the growth of one more bureaucracy seeking a share of the health care dollar, such charges and countercharges contribute little to optimal process.

Most physicians are committed to providing quality care to their patients, while maintaining their necessary skills during the life of their practice. Few if any, and certainly not the 99% opting out of recertification, are opposed to continuing edu- cation and acquiring new knowledge. That is what attracts many to a career in medicine. It is the current MOC process not continuing education that is at issue.

Under well-established precepts, experimental studies must be approved by an independent IRB and subjects have the option of rejecting participation.18 The MOC process is still an experiment with undefined costs and unproven ben- efits. Until those can be measured and justified by sound evidence, it is premature to require universal application or compel voluntary participation. Just as we teach our trainees to adhere to EBM and VBM, so should physician-guided organizations such as the ABIM, ABAI, and American Board of Medical Specialties practice it themselves.

JOHN R. COHN, MD

Chief Adult Allergy Section

Thomas Jefferson University and Hospitals

Philadelphia, Pennsylvania

john.cohn@jefferson.edu

ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY

REFERENCES

1 James JM, Corbett M. The American Board of Allergy and Immunology maintenance of certification program: “To do or not to do? That is the question”. Ann Allergy Asthma Immunol. 2010;105:485– 488.

2 Holmboe ES, Wang Y, Meehan TP, et al. Association between mainte- nance of certification examination scores and quality of care for Medi- care beneficiaries. Arch Intern Med. 2008;168:1396 –1403.

3 Parker M. Evidence-based to value-based medicine. ACP Journal Club. 2006;144:A10.

4 Shekelle PG, Woolf SH, Eccles M, Grimshaw J. Developing guidelines. BMJ. 1999;318:593–596.

5 Guyatt GH, Oxman AD, Vist GE, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336:924 –926.

6 Lieberman P, Nicklas RA, Oppenheimer J, et al. The diagnosis and management of anaphylaxis practice parameter: 2010 update. J Allergy Clin Immunol. 2010;126:477–480.

7 American Medical Association. Medical Specialty Board Certification. http://www.ama-assn.org/aps/physcred.html#specialty. Accessed November 12, 2010.

8 Brennan TA, Horwitz RI, Duffy FD, et al. Status in the quality movement: the role of physician specialty board certification. JAMA. 2004;292:1038 –1043.

9 Shaw K, Cassel CK, Black C, et al. Shared medical regulation in a time of increasing calls for accountability and transparency: comparison of recertification in the United States, Canada, and the United Kingdom. JAMA. 2009;302:2008 –2014.

10 American Board of Internal Medicine. Cost to Enroll. http:// www.abim.org/moc/policies.aspx#enrollCost. Accessed November 12, 2010.

11 American Board of Allergy and Immunology. Schedule of Fees 2010. https://www.abai.org/calendar.asp#fees. Accessed November 12, 2010.

12 Wikipedia. Paperwork Reduction Act. http://en.wikipedia.org/wiki/ Paperwork_Reduction_Act. Accessed November 12, 2010.

13 Levinson W, King TE. Enroll in the MOC program as currently configured. N Engl J Med. 2010;362:949–950.

14 Cooper RA. There’s a shortage of specialists: is anyone listening? Acad Med. 2002;77:761–766.

15 Center for Workforce Studies. The Complexities of Physician Supply and Demand: Projections Through 2025. Washington, DC: American Asso- ciation of Medical Colleges; 2008:1–90. https://services.aamc.org/ publications/index.cfm?fuseaction Product.displayForm&prd_id 244&prv_id 299. Accessed November 12, 2010.

16 Goldman L, Goroll AH, Kessler B. Do not enroll in the MOC program. N Engl J Med. 2010;362:950–952.

17 Kritek PA, Drazen. American Board of Internal Medicine maintenance of certification program—polling results. N Engl J Med. 2010;362:e54.

18 US Food and Drug Administration. A Guide to Informed Consent: Information Sheet. http://www.fda.gov/RegulatoryInformation/ Guidances/ucm126431.htm. Accessed November 14, 2010.

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