Looking forward – August 2017

David B. Hoyt

David B. Hoyt, MD, FACS

The Maintenance of Certification (MOC) requirements established by the American Board of Medical Specialties (ABMS) and its member boards, such as the American Board of Surgery (ABS), have been in place for approximately 12 years. Since then, MOC has been the source of considerable controversy and conflict.

The American College of Surgeons (ACS) leadership and our colleagues at the ABS, other boards, and other medical associations understand that the existing MOC process is burdensome for many practicing clinicians and are taking steps to address these concerns. Some individuals feel that these efforts have proven ineffective and are now calling upon state legislatures to take action. I believe that this approach is foolhardy and that the profession itself is best positioned to resolve these issues.

Standards and controversy

Over the years, the ABS requirements for MOC have called for diplomates to submit information on the following every three years:

  • Professional standing as evidenced by a full and unrestricted medical license and hospital or surgery center privileges
  • A total of 90 hours of Category 1 Continuing Medical Education (CME) credits relevant to the physician’s practices over a three-year cycle, with at least 60 of the 90 credit hours including self-assessment
  • Practice assessment demonstrated through participation in a local, regional, or national outcomes registry or quality assessment program

In addition, diplomates must successfully complete a recertification examination every 10 years. This high-stakes recertification exam is the source of much of the debate, with some surgeons and other physicians arguing that it does little to measure whether a clinician is able to provide quality care.

In a memorandum sent July 7 to all diplomates from ABS chair Mary E. Klingensmith, MD, FACS, and ABS executive director Frank R. Lewis, MD, FACS, the ABS announced that MOC reporting requirements for the first three components will change immediately to reporting only every five years instead of three, and self-assessment CME will be reduced by 50 percent. In 2018, diplomates will be offered alternatives to the 10-year exam.

The ACS has a long history of advocating for and setting standards relating to quality patient care, and a key qualification for Fellowship in the College is certification from an ABMS surgical specialty board, an American Osteopathic Surgical Specialty Board, or the Royal College of Surgeons of Canada. The College’s Statements on Principles reaffirm that Fellows should engage in many of the activities outlined in the MOC requirements. Specifically, the College expects Fellows to commit to lifelong learning through self-study, formal CME, and periodic assessment of their clinical practices.

The College maintains that board certification and MOC are valid means of verifying that surgeons have the educational background and competencies needed to provide quality care. This verification process is integral to ensuring that health care professionals have the rare privilege of self-regulation.

Legislative route

Some physicians have sought legislative remedies for their complaints about the MOC process. In April 2016, Oklahoma enacted legislation that prohibits failure to comply with MOC mandates as a reason to exclude a physician from hospital staff appointment or from insurance company panels. Other states have since followed suit. Perhaps the most sweeping legislation has been introduced in Texas, where state Senate bill S.B. 1148 would restrict the ability of the medical profession to set professional standards and would implement a state registration system for any entity that provides MOC to physicians.

The leaders of the major medical and surgical organizations agree that legislation like the Texas bill interferes with the profession’s ability to govern itself. Going the legislative route will serve only to erode our ability to self-regulate and will open the door to greater government interference than we already are experiencing. State and federal governments lack the knowledge or expertise to determine whether a physician is adequately prepared and credentialed to provide quality care.

Addressing your concerns

We are much better off settling our differences within the house of medicine than doing this on a piecemeal basis in all 50 states. The boards, medical and surgical associations, the Council of Medical Specialty Societies, hospitals, payors, and medical educators are working together to develop thoughtful alternatives to the current MOC requirements. In addition to replacing the high-stakes 10-year exam with more frequent but lower-stakes outcome assessments and changing reporting requirements, other possible modifications include offering new opportunities for surgeons to learn how to perform complex operations, providing “just in time” learning tools, and disseminating critical new knowledge alerts. New assessment programs will focus on high-value, practice-relevant learning, and diplomates will be solicited to help design the new program.

According to Jo Buyske, MD, FACS, who will assume the role of ABS executive director when Dr. Lewis retires later this year, “The ABS is committed to changing its policies regarding lifelong learning and certification in the interests of better serving both our diplomates and the public. Our goal is to have the best combination of practice-pertinent, timely, and valuable assessment tools to assure our patients that board-certified surgeons are knowledgeable and up-to-date. We plan to work with the diplomates and with the College and other societies in what will be an ongoing project of quality and service improvement.”

Every surgeon’s responsibility

A major premise of the recently released ACS Optimal Resources for Surgical Quality and Safety manual is that surgeons should engage in lifelong learning and continuous quality improvement activities—that they should analyze their outcomes to identify areas of improvement in their practices. The College maintains that these are important responsibilities for all surgeons to fulfill, regardless of what predetermined requirements the boards or any other entity may impose.

We are practicing in an era that holds surgeons to a greater level of accountability and transparency. Patients expect us to be competent professionals and assume that we hold ourselves to high standards of excellence. Today’s surgeon and the surgeon of the future need to lead safe, reliable teams that integrate surgical and nonsurgical skills as part of systems of care. Evidence-based practice, public reporting of outcomes data, and continuous professional development will be integral activities for all surgical practices.

Surgeons have a responsibility to maintain top-level skills and leading-edge knowledge. In addition to continually attaining didactic knowledge, we have a unique need to acquire new skills and technical competencies, and we must demonstrate to patients and other stakeholders that we are capable of providing optimal care.

Going forward, we will need to redefine professionalism with an emphasis on collaboration over autonomy, evidence over authority, measurement over assertion, transparency over control, and the public good over our self-interests. By working together, I believe we can come to agreement on how to achieve these goals without government intervention and the loss of our ability to self-regulate.

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