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ABAI News

Volume 5, Issue 1

President's Message: Stephen I. Wasserman, MD

The Accountability, Evidence and Assurance of the MOC Process

by Stephen I. Wasserman, MD

One of the most frequently asked questions I receive is “what is the evidence that Maintenance of Certification (MOC) is needed and is effective.” Coincidentally a supplement to the Journal of Continuing Education in the Health Professions was published late last year that addresses these questions in depth. Two articles in this publication are of particular interest to those of you who wish to take a “deep dive” into the question of evidence. I will try however to summarize the findings presented in this supplement which is the best compilation of the literature on this topic.

First, I believe it is essential to approach this question from the point of view of Medicine as a profession and with an understanding of the requisite responsibilities of this view. Cruess, et al. Med Teach. 2004;16:74-76 have defined a profession as:

1. An occupation whose core element is based on mastery of complex knowledge and skill
2. Founded on service to others
3. Governed by codes of ethics
4. Committed to competence, integrity, morality, altruism and promotion of public good.

They add that these principles form the basis of a contract between physicians and society which grant a great deal of self-governance to the medical profession, but we remain accountable to those we serve and to society.

Given this compact and accountability, is there evidence that something needs to be done to provide society with assurance that this covenant is being honored, and that the components of MOC are appropriate to that task? Are the four parts of MOC: Professional Standing, Self-Assessment, Cognitive Expertise and Practice Assessment/Quality Improvement appropriate to this goal? Hawkins, et al. J Contin Ed Health Prof. 2013;33(Suppl 1):S7–S19) addresses this question in depth. It is known that performance deficits are critical factors in medical errors, that physicians are aware of deficiencies in their colleagues, patients do not receive much of the care recognized as needed for their particular health issues, that skills and knowledge do decline with time after training (especially due to lack of acquisition of new information), and that adverse license/malpractice actions increase with time in practice.

How then to enable physicians to identify areas of opportunity for improvement and to assist them in that improvement. Peer and patient surveys address aspects of communication which is known to be an important aspect of medical practice and an area shown by many studies to be an opportunity for improvement. Data indicate that assessment in this domain can be associated with improvement that is meaningful to patient satisfaction and quality of life.

Part II of MOC (Lifelong Learning and Self-Assessment) covers activities that are widely accepted by physicians as an essential tenet of medical practice. One important aspect of such learning is that to be most effective it requires an external objective assessment to provide individual physicians a road map of areas that would benefit from extra attention. It has been shown that physicians are not good at accurately self-identifying areas of strength or of weakness (Davis DA, et al. JAMA. 2006;296(9):1094–1102), thus feedback from some objective assessment is essential. At present this is provided by the MOC Part III secure examination, but other less high stakes opportunities could be envisioned such as a non-failable examination like the in-training examination provided to Allergy-Immunology fellows. When educational efforts are directed to objectively identified learning opportunities, it has been shown that physician’s knowledge and performance improve.

In addition to helping to focus learning on those areas most in need, the secure examination is a valid instrument in identifying the knowledge and diagnostic reasoning of physicians; and, as noted above these skills have been shown to erode with time out of training and their assessment therefore is not only appropriate but essential. Overall MOC scores and pass vs. fail categories do identify important aspects of a physicians' skill set. Thus, as reviewed by Hawkins, scores on the ABIM MOC secure examination correlate with increased exposure to education and training, with decreased disciplinary actions, and with increased practice complexity. In addition, better care of patients with diabetes, hypertension and in screening practices have been associated with better performance on the MOC examination.

Finally, Part IV of MOC provides a platform for physicians to examine their own care in defined areas using their own data to uncover potential gaps in performance. Such activities provided by ABIM, termed Practice Improvement Modules (PIMs) have been shown to facilitate improvement in care. It is clear however that improvements in data capture and better mechanisms to capture the activity of teams and systems that effect care are essential.

In a separate paper, Lipner, et al. J Cont Ed Health Prof. 2013;33(Suppl 1):S20–S35, summarize the large number of studies dealing with the evidence-base underpinning certification and MOC. While there is more evidence in the literature dealing with initial certification there is an accumulating set of observations that support the conclusion that both certification and MOC identify aspects of physicians that are important to quality health care and to patients. It is clear that the certifying boards, ABAI included, need to do more to evaluate the strengths and weaknesses of each aspect of MOC. In this regard, constructive and candid feedback from diplomates is essential. You will be receiving a survey shortly from ABAI and I hope you will use that opportunity to help us help you by making MOC the most effective tool possible.

Please share your thoughts with me on this topic at abai@abai.org or swasserman@ucsd.edu.

Notes From the Chair

by Scott H. Sicherer, MD

It is a privilege and honor to serve as the 2014 Chair of the Board of Directors of the ABAI. Years before my becoming involved as a director, I had given little thought to the responsibilities of the board and assumed directors were primarily responsible for creating the very challenging examinations that had me leaving the test feeling discouraged. In fact, your directors are tirelessly involved in a myriad of activities that help promote the mission of the ABAI, which is to improve the quality of medical care for our patients by the development and utilization of professional and educational standards for the initial certification and Maintenance of Certification (MOC) for our specialty.

Therefore, aside from creating tests, our directors, as well as the ABAI staff including President Stephen Wasserman, interact with diplomates in various venues to provide information about the certification and MOC process, with our parent boards in pediatrics and internal medicine, and with the Residency Review Committee, the American Board of Medical Specialties, the Accreditation Council for Graduate Medical Education, and myriad other groups that play a role in ensuring quality standards. To explore expansion of MOC products, the directors also discuss common goals with our professional societies and organizations that create these products. Additionally, the board is responsible for addressing concerns such as appropriate representation of certification, ethical and professional conduct, and financial stewardship.

The board is comprised of 16 individuals serving six-year terms with an equal number of internists and pediatricians. The ABAI seeks directors with experience in a variety of practice settings. Nomination to the board is made by the ABAI and sponsoring organizations, including the American Medical Association, the Clinical Immunology Society, the American Academy of Pediatrics, and our two professional organizations. Being a director allows one to serve our specialty in a very impactful way so make your interest in being nominated known!

And now a word about the tests. The directors indeed develop the questions used for our Recent Advances module as well as the secure examinations. With regard to the secure examinations, these tests are hard! But they are challenging for a reason. We are generally used to doing very well on tests and expect, perhaps, to get nearly every question correct to prove mastery. However, modern certifying examinations are based on a philosophy of “criterion referenced testing.” Briefly, the psychometric process is designed to identify those with the knowledge of a competent practitioner in the specialty. The test is therefore not graded on a curve and, theoretically, everyone taking the exam could “pass.” However, the statistical background to this type of testing requires an examination with very challenging questions. Therefore, it is not uncommon to leave the test feeling that it was incredibly difficult. Since 2006, the pass rate for the recertifying examination has been about 98% (range, 94-100%). Of course, these comments should not discourage you from studying and keeping up with the literature! The directors also periodically evaluate the examination “blueprint” to ensure that the content is current and meaningful.

As indicated above, the board is dedicated to improving the MOC process. The directors participate in MOC and, at least two years after completing our term, re-engage with taking the secure examination. Therefore, we understand what you are being asked to do for MOC and appreciate that the process is relatively new and sometimes daunting. One current initiative is to survey diplomates to learn more about your views of the process and to provide us with valuable feedback. Keep an eye out for e-mails in the last week of July with a link to the survey and please respond. We will provide you with information about results over the subsequent months.

In addition to completing the upcoming survey, feel free to contact me or the staff with any questions or concerns. The ABAI is supported not only by the directors and president, but also by six amazing people who keep the process running (http://www.abai.org/Staff.asp).

We are here to help. Feel free to contact us with any questions or concerns.

ABAI Welcomes Class of '19 Directors

The ABAI Board of Directors met in Boston, MA, in November of 2013 for their annual meeting. At the meeting, the ABAI welcomed two new directors to serve on their BOD through 2019.

Lawrence C. Borish, MD, a graduate of Boston University School of Medicine is Professor of Medicine and Microbiology at the University of Virginia School of Medicine, Charlottesville, VA. He completed his residency in Internal Medicine at New England Deaconess Hospital and his fellowship training under the direction of Drs. Ross Rocklin and Lanny Rosenwasser at Tufts University – New England Medical Center. He also works in the Asthma and Allergic Diseases Center, the University of Virginia Cancer Center and the Carter Immunology Center. He is an Associate Editor for the American Journal of Rhinology and Allergy and serves on the editorial board of the Journal of Allergy and Clinical Immunology. His career accolades include: the 2002 ACAAI John McGovern Lectureship, 2003 Pfizer Visiting Professor Award (St. Louis University), 2004 ACAAI Betty Wray Lectureship, and a Best Doctor in America^® in Allergy & Immunology by Best Doctors, Inc. (2005-present.) Dr. Borish brings expertise and interests in chronic sinusitis, aspirin-exacerbated respiratory disease, chronic urticaria, immune deficiencies and asthma to his post at ABAI.

Jay M. Portnoy, MD, is Chief, Section of Allergy, Asthma & Immunology and professor of pediatrics at The Children’s Mercy Hospital, Kansas City, MO. He is a graduate of the University of Missouri-Columbia School of Medicine. Dr. Portnoy completed his pediatric residency at the Children’s Mercy Hospital and his Allergy/Immunology Fellowship at the University of Michigan School of Medicine. He is widely published in the field and has served on numerous editorial boards which currently include Regional Editor for the World Allergy Organization Journal and Editorial Board member for Current Allergy Practice. Dr. Portnoy is past President of the American College of Allergy, Asthma & Immunology (ACAAI) where he has also worked as chair and member of many committees over the years including the CME, publications, aerobiology, allied health, and professional education committees. He was awarded Educator of the Year at Children’s Mercy Hospital in 2007 and past recipient of the ACAAI’s Distinguished Fellow Award and Distinguished Service Award. Dr. Portnoy offers specific interests in aerobiology and environment to his directorship at ABAI.

ABAI Honors Drs. Fasano and Peebles for their Dedicated Service

At their Annual Board of Directors (BOD) Meeting held in Boston, MA, in November 2013, the ABAI celebrated the service of two directors who concluded their six-year terms. Mary Beth Fasano, MD, and R. Stokes Peebles, MD, served on ABAI's BOD from 2008-2013 in a variety of roles that ranged from item writing and exam construction to shaping Maintenance of Certification (MOC) and establishing standards for conjoint board credentials and residency review requirements.

Dr. Fasano, of the University of Iowa was Chair of the ABAI Board of Directors in 2012. In addition to being an MOC Exam Co-Chair (2010-11), she was a member of the Nominating, Ethics and Professionalism, Finance and Audit, Personnel, and Conjoint Credentials Committees.

Dr. Peebles, of Vanderbilt University was ABAI Chair in 2011 and Certification Exam Co-Chair in 2011-12. He served as a member of the Nominating, Ethics and Professionalism, Finance and Audit, Personnel, and Conjoint Credentials Committees.

AAAAI Chronic Urticaria PIM now available to ABAI Diplomates

ABAI has approved the Chronic Urticaria Practice Improvement Module developed by the American Academy of Allergy, Asthma and Immunology (AAAAI) and the American Academy of Dermatology (AAD). This free module is based on the latest evidence on the diagnosis and management of urticaria. The allergist/immunologist can identify areas for improvement of care for these patients and use a set of online patient simulations to practice implementing these new clinical skills. Click here for additional information.

Annual Meeting of the ABAI
Board of Directors

Dr. Nelson appointed to ABIM Council

ABAI Director, Col. Michael R. Nelson, MD, PhD, is a 2013-14 member of the ABIM Council.

ABAI Director Colonel Michael R. Nelson, MD, PhD, was appointed to the American Board of Internal Medicine's “ABIM Council,” serving as ABAI's Liaison to the ABIM for 2013-2014.

Dr. Nelson, a U.S Army Medical Corps Colonel is Director for Education Training and Research at Walter Reed National Military Medical Center, Bethesda, MD. He was named to the ABAI Board of Directors in 2011 where he currently serves as treasurer, exam co-chair, and blueprint committee chair.

The ABIM Council serves to “ensure the quality, relevance and effectiveness of ABIM's programs for certification and Maintenance of Certification for all physicians across the specialties and subspecialties of internal medicine.” In his role as Liaison, Dr. Nelson participates in the biannual meetings and teleconferences of the ABIM Council as ABAI's “voice at the table” during the discussions and deliberations surrounding certification and MOC program issues, policy development/integration and specialty board standards addressed by the Council. He also shares best practices and lessons learned from the ABIM with the ABAI Board of Directors.

FAQs — CME Credits

What types of CME credits are accepted for ABAI MOC?

ABAI accepts AMA PRA Category 1^TM Credit(s) in Allergy/Immunology-related activities. The relevance of the activity is determined by the title printed on the certificate. CME activities outside the field of Allergy/Immunology will be reviewed by ABAI and approved on a case-by-case basis. Activities such as a course on wilderness medicine, for instance, will likely not be approved.

How do I submit proof of my CME credits?

Some activities are reported directly to ABAI, including all AAAAI activities and any modules completed as part of MOC requirements. Otherwise, ABAI requests that copies of CME credit certificates are submitted electronically via the Web Portal or email. They can also be faxed or mailed to the office. Each certificate must clearly state the title of the activity, sponsoring organization, number of credits awarded, and date the activity was completed.

Will ABAI actually check all of my CME credits?

ABAI will audit the CME credits of approximately 10% of its Diplomates annually.

If I don't get 25 CME credits one year but have 50 the next year, will the credits be averaged?

The ABAI requires 25 CME credits per year in keeping with the character of a continuous learning process. If a Diplomate does not meet the CME requirement each year, they will be listed as "Not Meeting MOC Requirements" until such time that the requirement is completed. Diplomates should contact the office with any extenuating circumstances if the annual CME requirement cannot be completed.

American Board of Allergy and Immunology
A conjoint Board of the American Board of Internal Medicine and the American Board of Pediatrics, Inc.^TM
A Member Board of the American Board of Medical Specialties
1835 Market Street, Suite 1210, Philadelphia, PA 19103
Fax 215-592-9411 - Telephone 1-866-264-5568
Email abai@abai.org