The American Board of Surgery Maintenance of Certification Program: The first 10 years

The American Board of Surgery (ABS) Maintenance of Certification (MOC) Program has now been in place for 10 years. This article looks back at the basis and rationale for establishing the MOC program, explains the current requirements, and discusses possible future directions for the program.

The beginning

Following the release of the Flexner Report on medical education in 1910, medical leaders in the U.S. realized that more needed to be done to ensure qualified physicians were providing care to patients. Board certification officially began in 1916 with the incorporation of the American Board of Ophthalmology, initiating a movement to establish a defined standard for the knowledge and skills of physicians in a discrete area of medicine.

In 1937, the ABS was founded by the leading surgical organizations of the time, including the American Surgical Association and the American College of Surgeons (ACS). The leaders of these organizations realized that surgery had evolved into a full-time specialty and recognized the need to differentiate between formally trained surgeons and physicians in general practice. This concept was developed with the intention of both protecting the public and improving the specialty. The Advisory Board for Medical Specialties was formed in 1933 as the umbrella organization for all certifying boards, becoming the American Board of Medical Specialties (ABMS) in 1970. Today, certification by an ABMS member board is recognized as the standard for allopathic physicians who practice in the U.S.

As set forth in its mission statement, “The American Board of Surgery serves the public and the specialty of surgery by providing leadership in surgical education and practice, by promoting excellence through rigorous evaluation and examination, and by promoting the highest standards for professionalism, lifelong learning, and the continuous certification of surgeons in practice.”1 The purposes of the ABS are highlighted in the sidebar on this page.

Purposes of the ABS

To conduct examinations of acceptable candidates who seek certification or maintenance of certification by the board

To issue certificates to all candidates meeting the board’s requirements and satisfactorily completing its prescribed examinations

To improve and broaden the opportunities for the graduate education and training of surgeons

Source: American Board of Surgery. About us.
Available at: www.absurgery.org/default.jsp?abouthome. Accessed May 7, 2015.

Initial certification

ABS certification is based upon a process of education, evaluation, and assessment. Accredited training, broad operative experience, and high ethical standards have always been core requirements of ABS certification. As specialties in addition to general surgery have been established within the ABS, certification processes have been developed using these requirements as a framework. These specialties include pediatric surgery, vascular surgery, hand surgery, surgical critical care, and complex general surgical oncology. Today, through its board of directors, component boards, and advisory councils, the ABS includes representation from 39 different surgical societies, as well as three members elected at large and one public member. Settings standards for board certification is a privilege of self-regulation that the American public has bestowed on the medical and surgical professions.

Recertification takes hold

In its first three decades, ABS certification, once achieved, was valid for a surgeon’s entire professional career. In the 1970s, however, the ABS Board of Directors recognized that surgical practice was evolving rapidly and determined that it was important for diplomates to demonstrate to the public that they were remaining current with changes in medical knowledge and patient care. The ABS became the second medical board to require its diplomates to recertify by passing an examination once every 10 years. This change took effect in January 1976. Initially, ABS diplomates were required to take a proctored written examination administered at regional sites. Since 2005, these examinations have been given in a computerized format and are offered at hundreds of testing centers across the country, thus eliminating a potential day of travel and associated expenses for many surgeons. To gain admittance to the recertification exam, diplomates needed to have a full and unrestricted medical license, hospital privileges in surgery, and letters of support from the chief of surgery and chair of credentialing at the institutions where they practice.

In further recognition of the need to remain current in practice, in 2000 the ABS adopted a requirement for diplomates to demonstrate that they had completed 100 credit hours (60 Category I and 40 Category II) of continuing medical education (CME) in the two years prior to applying to take the recertification exam. Although this requirement has been modified during the last 15 years, the basic principle for its implementation remains relevant.

Advent of MOC

In 2005, the ABMS introduced standards for MOC, which were the end result of a multi-year planning process based on the six competencies developed jointly by the Accreditation Council for Graduate Medical Education and the ABMS. These competencies were consolidated to form the four parts of MOC: (1) professional standing, (2) lifelong learning and self-assessment, (3) cognitive expertise, and (4) evaluation of performance in practice.

At that time, many ABMS boards did not have any requirement for recertification or were in the very early stages of development. With the establishment of MOC, ABMS member boards acknowledged that board certification needed to become a more continuous process. Ongoing training and professional development were seen as key in addressing the gap between the rapid pace of advances in medicine and the more than 15 years on average it took for these important advances in care to be incorporated into practice.2

The ABMS MOC effort was initially led by former ACS Regent and Past-Interim Director of the College, David L. Nahrwold, MD, FACS, a general surgeon and ABS diplomate. Dr. Nahrwold recognized that for board certification to remain relevant and for medicine to continue to enjoy the privilege of self-regulation, the certification process had to evolve beyond initial certification, or even once-in-10-years recertification. Boards and their diplomates had to demonstrate to the public and their colleagues an enduring commitment to maintaining the standards of the profession, participating in lifelong education, possessing medical knowledge relevant to their specialty, and improving practice performance.

All surgeons who certified or recertified after July 2005 became enrolled in the ABS MOC Program. At present, 95 percent of ABS diplomates with time-limited certificates are enrolled in ABS MOC. Once enrolled, MOC applies to all certificates a surgeon may hold.

Current requirements

While the ABMS established general standards for MOC that all ABMS member boards must meet, each board is responsible for developing its own MOC requirements within the ABMS framework. The current requirements of the ABS MOC Program are outlined in the table on page 18. In crafting these requirements, the ABS Board of Directors has sought to provide enough flexibility that surgeons can meet them in a way best suited to their individual practice environment.

The ABS MOC Program requirements are organized in identical three-year reporting cycles, running from January 1 to December 31. Toward the end of each three-year cycle, diplomates are required to submit information through the ABS website regarding how they are meeting MOC requirements. This information must be submitted by March 1 (two months after the end of the cycle). Diplomates also must pass a secure MOC exam every 10 years; however, the exam may be taken up to three years before certificate expiration.

ABS MOC requirements

Every three years, ABS diplomates submit information on:

Professional standing
Full and unrestricted medical license; hospital or surgical center privileges; contact information for chief of surgery and chair of credentialing where most work is performed.

CME activity
90 hours of Category I CME relevant to your practice over a three-year cycle, with at least 60 of the 90 credit hours including self-assessment (written or electronic question-and-answer exercise). A score of 75% or higher must be achieved on the self-assessment activity; however, no minimum number of questions is required and repeated attempts are allowed. In addition, the ABS will waive 60 hours of CME with self-assessment for passing a certifying or MOC exam given by the ABS or another ABMS board.

Practice assessment
Participation in a local, regional, or national outcomes registry or quality assessment program. Surgeons are asked to describe how they are meeting this requirement; no data is collected.

Every 10 years, diplomates must successfully complete:

MOC examination in the specialty
Surgeons are eligible to apply for an MOC exam starting three years before their certificate’s expiration. A full exam application is required, including a 12-month operative log (case numbers only), reference forms, and CME documentation. Diplomates must be in compliance with MOC to apply.

For surgeons who hold multiple ABS certificates, this requirement is the only one that must be met for each certificate. Once the exam is passed, the surgeon receives a new certificate with an expiration date 10 years from the previous certificate’s expiration.

Relevance of ABS MOC

Surgeons practice in a variety of settings, each with its own characteristics. The ABS MOC Program is designed to be practice-relevant, allowing each surgeon to satisfy the requirements by completing CME and participating in a practice assessment activity in a way that best applies to his or her unique situation. Specific CME activities required by state medical licensing boards are considered practice-related and also may be used toward the CME requirement.

If a surgeon’s hospital participates in the ACS National Surgical Quality Improvement Program, Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program, Trauma Quality Improvement Program, or other registries that track patient outcomes, this activity will satisfy the practice assessment requirement. Participation in a state surgical collaborative, such as the Surgical Clinical Outcomes Assessment Program in Washington State or the Michigan Surgical Quality Collaborative, also meets this requirement. The ACS Surgeon Specific Registry is another option for fulfilling this mandate.

Other surgeons may comply with the practice assessment requirement through their institution by enrolling in the Multi-Specialty Portfolio Approval Program sponsored by the ABMS or by participating in a local hospital-based quality improvement activity. In addition, some diplomates have developed performance assessment activities within their own practices by focusing on a specific area of practice, defining measures and goals, tracking outcomes, making changes, and then reassessing to gauge improvement. Regardless of which pathway is chosen, the diplomate must only attest to his or her participation. The board does not collect, review, or otherwise scrutinize an individual’s specific results.

The ABS recognizes that practice improvement is a multifaceted process. Simply showing up for a CME course or entering cases into a registry is unlikely to improve care on its own. Rather, surgeons should use self-assessment opportunities to demonstrate that new knowledge or skills have been acquired, and practice assessment activities to view and analyze their individual results. More importantly, these results should be used to develop an action plan for improvement. There is good evidence that active participation in a national or state registry can improve quality of care, often through the identification of best practices.3,4

Future of ABS MOC

ABS MOC is a surgeon-defined national standard that formally documents many of the activities surgeons already do to stay current in their field. Participating in the ABS MOC Program demonstrates a surgeon’s commitment to remain up to date in his or her specialty and to strive for improved outcomes and patient care.

Just like changes in medical practice, MOC will evolve over time to reflect new standards and best practices. The measurement tools available will undoubtedly improve in the coming years. The ABS Board of Directors is focused on making ABS MOC a more useful and meaningful process for surgeons without adding to the administrative burden surgeons already face.

ABS leaders are looking at innovative programs under development at other ABMS boards and organizations involved in quality improvement. However, we know that any requirements we establish will affect approximately 30,000 surgeons across the U.S. who practice in a wide range of practice environments. We are listening to feedback from our diplomates and affiliated societies and will take it into account as we continue to develop ABS MOC, while at the same time staying mindful of our duty to the public and our privilege of self-regulation.

Participation in ABS MOC demonstrates to both patients and peers that you are making a dedicated effort to improve the care you provide. As we move into the next decade of MOC, the ABS appreciates your involvement and welcomes your input. Suggestions, comments, and questions may be sent to moc@absurgery.org.


References

  1. The American Board of Surgery. ABS Newsletter. Report from the chair. 2014. Available at: www.absurgery.org/default.jsp?newsletter. Accessed May 7, 2015.
  2. Fuchs VR, Milstein A. The $640 billion question—why does cost-effective care diffuse so slowly? N Engl J Med. 2011;364(21):1985-1987.
  3. Cohen ME, Liu Y, Ko CY, Hall BL. Improved surgical outcomes for ACS NSQIP hospitals over time: Evaluation of hospital cohorts with up to 8 years of participation. Ann Surg. 2015 Feb 26. [Epub ahead of print].
  4. Hakkarainen TW, Steele SR, Bastaworous A, et al. Nonsteroidal anti-inflammatory drugs and the risk for anastomotic failure: A report from Washington State’s Surgical Care and Outcomes Assessment Program (SCOAP). JAMA Surg. 2015;150(3):223-228.

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