Letters
3. Kayser RG, Ornato JP, Peberdy MA; American Heart Association National Registry of Cardiopulmonary Resuscitation. Cardiac arrest in the emergency department: a report from the National Registry of Cardiopulmonary Resuscitation. Resuscitation. 2008;78(2):151-160. 4. Kudenchuk PJ, Cobb LA, Copass MK, et al. Amiodarone for resuscitation after out-of-hospital cardiac arrest due to ventricular fibrillation. N Engl J Med. 1999; 341(12):871-878. 5. Lin S, Callaway CW, Shah PS, et al. Adrenaline for out-of-hospital cardiac arrest resuscitation: a systematic review and meta-analysis of randomized controlled trials. Resuscitation. 2014;85(6):732-740.
Despite Wang and Kupas’ positive assessment of the skills and interventions deployed in a paramedic-based system, we believe our data call into question the institutional and political inertia that supports the current practice of ALS in the absence of scientific evaluation. Improved protocols based on evidence have the potential to save lives in cardiac arrest. Prachi Sanghavi, PhD Anupam B. Jena, MD, PhD Alan M. Zaslavsky, PhD
In Reply We do not agree with Drennan et al that the 20% claim sample we used has a sampling bias. It is a sample randomly assembled by the final digit of Social Security numbers. Wang and Kupas rightly note that Medicare will only reimburse for a single transport, but this will be at the higher service level, that is ALS, as long as a written agreement exists between the responding emergency medical services (EMS) agencies.1 We excluded the relatively few areas identified in interviews with state EMS offices where such agreements may not exist. However, since billing is determined by the existence of an agreement and is unrelated to case characteristics, such random error in classification would attenuate the estimated effects. Several criticisms concerned the lack of detailed measures of patient status, clinical processes, or circumstances of the cardiac arrest that could confound our analyses. The scenarios described by Drennan et al for confounding by indication and similar biases were addressed in our eAppendices 4, 5, and 7.2 The list of rare instances provided by Wang and Kupas that may have generated BLS cases only supports our understanding of essentially random assignment at dispatch. Drennan and colleagues also suggest that the gold standard Utstein variables3 are required for an unbiased analysis, but much of that data would be unavailable even with hospital records. Furthermore, a plausible argument should be made for why these variables would systematically differ between patients receiving ALS and BLS. Mark et al raise issues about 2 sensitivity analyses, calculating that under assumptions moderately favorable to ALS, statistical significance might be lost. However, the analyses we presented were conservative because we omitted adjustments that would have improved the standing of BLS relative to ALS in the Medicare data . More generally, it seems reasonable to have higher expectations for ALS, the predominant and more expensive mode of out-of-hospital care, than that its outcomes might not quite be significantly worse under the most favorable conditions. We recognize that our study was unable to assess specific interventions. For this reason, we emphasized that our objective was to compare ALS with BLS as practiced using key outcomes of survival and neurological functioning. We disagree with the claim by Wang and Kupas that the outcomes of 2 systems can be compared only if we know the specific interventions supplied in each case. The 3 letters in response to our Original Investigation confirmed our assessment of the dearth of scientific evidence supporting superiority of ALS in treating out-of-hospital cardiac arrest.2 None of the cited research was designed to compare ALS with BLS, although some compared different methods of providing ALS interventions.
To the Editor The American Board of Medical Specialties (ABMS) appreciates the research and feedback presented in the study by Cook et al.1 At approximately the same time this study was undertaken, the ABMS was conducting a 2-year review as part of an ongoing quality improvement process and soliciting input about the ABMS Program for Maintenance of Certification (ABMS MOC) from medical professionals, health care organizations, and the public. This review resulted in the 2015 Standards for the ABMS Program for MOC2 approved in January 2014. As the authors acknowledged, the updated standards “address several of the barriers and shortcomings identified in this study.” The updated standards continue to emphasize the importance of discipline- and practice-specific continuing professional development as part of the ABMS certification process.
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(Reprinted) JAMA Internal Medicine August 2015 Volume 175, Number 8
Author Affiliations: Program in Health Policy, Faculty of Arts and Sciences, Harvard University, Cambridge, Massachusetts (Sanghavi); Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts (Jena, Zaslavsky); Massachusetts General Hospital, Boston (Jena); National Bureau of Economic Research, Cambridge, Massachusetts (Jena). Corresponding Author: Prachi Sanghavi, PhD, Harvard University, Program in Health Policy, 1737 Cambridge St, K311, Cambridge, MA 02138 (sanghav @fas.harvard.edu). Conflict of Interest Disclosures: None reported. Funding/Support: Dr Sanghavi was supported by a National Science Foundation Graduate Research Fellowship and by the Agency for Healthcare Research and Quality (1R36HS022798-01). Dr Jena acknowledges support from the Office of the Director, National Institutes of Health (NIH Early Independence Award, 1DP5OD017897-01). Role of the Funder/Sponsor: These funders played no role in the analysis and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Additional Contributions: We thank our coauthor, Joseph P. Newhouse, PhD, for his contributions to this letter. 1. Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual, Chapter 10 - Ambulance Services, Section 10.5 Joint Responses. March 2015. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals /downloads/bp102c10.pdf 2. Sanghavi P, Jena AB, Newhouse JP, Zaslavsky AM. Outcomes after out-of-hospital cardiac arrest treated by basic vs advanced life support. JAMA Intern Med. 2015;175(2):196-204. 3. Jacobs I, Nadkarni V, Bahr J, et al; International Liason Committee on Resusitation. Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and simplification of the Utstein templates for resuscitation registries: a statement for healthcare professionals from a task force of the international liaison committee on resuscitation (American Heart Association, European Resuscitation Council, Australian Resuscitation Council, New Zealand Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa). Resuscitation. 2004;63(3):233-249.
American Board of Internal Medicine and Maintenance of Certification Standards
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Conflict of Interest Disclosures: Dr Nora is a salaried employee of the American Board of Medical Specialties. No other disclosures are reported.
untarily completed (successfully) the MOC process and as an internal medicine residency program director of 15 years and counting, I can say that the results were predictable. Hopefully, this article will serve as a wake-up call to the ABIM from certified physicians. Having heard the public comments of the ABIM chair nearly every year for the past 30 years at Association of Program Directors of Internal Medicine semiannual meetings and having repeatedly voiced alarm to the ABIM at these meetings that the MOC process is impractical and lacks scientific merit, a change in direction by the ABIM would be welcome even though overdue. The guiding principle of the MOC process should focus on the certification, not on the education, of physicians. The process of certification should be scientifically valid and practical. The current MOC process fails on both counts. Rather than focusing on certification, the ABIM version of MOC has diverted to administering and documenting educational, safety, and quality activities. Other than the (re)certification examination itself, there is nothing uniform or standarized or scientifically validated about the remaining components, which are particularly disconcerting to physicians. Documentation of educational activities should be largely unnecessary if the certification examination has been constructed optimally. From the standpoint of practicality, the current MOC is a bridge too far. Given that there are approximately 7500 new internal medicine graduates per year, of whom nearly twothirds enter fellowship training with additional certifications and recertifications,2 the tasks of the ABIM regarding all this documentation cannot be maintained with integrity and accuracy, short of a massive and overly costly infrastructure. I propose again, as did the many voices of program directors 2 decades ago, that MOC should consist of a periodic (every 10 years is reasonable) high-stakes examination in conjunction with maintenance of a valid medical license (which usually requires documentation of educational activities) or, in lieu of a license, documentation of an equivalent number of relevant educational activities.
Additional Information: Dr Nora is the president and chief executive officer of the American Board of Medical Specialties.
George Douglas Everett, MD, MS
They encourage the certifying boards to consider the complex and diverse environments in which physicians practice, as well as to increase the quality, relevance, and meaningfulness of the MOC program with sensitivity to the time and administrative burden associated with participation. The updated standards are reflected in improvements to the MOC program across the boards. Specialty societies and continuing medical education (CME) providers are increasingly creating practice relevant Part II and Part IV MOC activities for which physicians may receive CME credit. New activities developed by certain boards to help physicians remain current in their specialties include reading lists of key articles in the literature and Question of the Week self-assessment activities. Some boards also are investigating innovative methods of external assessment, including remote proctoring, to continue to provide meaningful assessment in more userfriendly ways. The 20 boards that participate in the ABMS Multispecialty Portfolio Approval Program (Portfolio Program) have enabled thousands of physicians, to date, to receive MOC credit for engaging in multidisciplinary, organizational quality improvement projects. Reducing adverse drug events by 76%3 and Clostridium difficile infections by 30%4 are among the improvements that resulted from Portfolio Program projects at 2 of the 45 sponsor organizations. As Cook and colleagues1 noted, MOC “is in an ongoing state of evolution.” The ABMS and its 24 member boards are committed to the continuous improvement of the MOC process and continue to seek and implement feedback provided by all key stakeholders to enhance—and advance—MOC. Lois Margaret Nora, MD, JD, MBA Author Affiliation: American Board of Medical Specialties, Chicago, Illinois. Corresponding Author: Lois Margaret Nora, MD, JD, MBA, American Board of Medical Specialties, 353 N Clark St, Ste 1400, Chicago, IL 60654 ([email protected]).
1. Cook DA, Holmboe ES, Sorensen KJ, Berger RA, Wilkinson JM. Getting maintenance of certification to work: a grounded theory study of physicians’ perceptions. JAMA Intern Med. 2015;175(1):35-42. 2. American Board of Medical Specialties. Standards for the ABMS program for maintenance of certification (MOC) for implementation in January 2015. http: //www.abms.org/media/1109/standards-for-the-abms-program-for-moc-final .pdf. Accessed November 11, 2015. 3. McClead RE Jr, Catt C, Davis JT, et al; Adverse Drug Event Quality Collaborative. An internal quality improvement collaborative significantly reduces hospital-wide medication error related adverse drug events. J Pediatr. 2014;165(6):1222-1229.e1. 4. Pyrek KM. Cleaning intervention cuts C difficile acquisition rates by one-third. Infection Control Today. September 7, 2010. http://www.infectioncontroltoday.com/PrinterFriendly.aspx?id =FD87035E-9082-4D98-B640-1C2573D9E32A#. Accessed November 11, 2015.
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Author Affiliation: Department of Internal Medicine, Florida Hospital, Orlando. Corresponding Author: George Douglas Everett, MD, MS, Department of Internal Medicine, Florida Hospital, 2501 N Orange Ave, Ste 235, Orlando, FL 32804 ([email protected]). Conflict of Interest Disclosures: None reported. 1. Cook DA, Holmboe ES, Sorensen KJ, Berger RA, Wilkinson JM. Getting maintenance of certification to work: a grounded theory study of physicians’ perceptions. JAMA Intern Med. 2015;175(1):35-42. 2. American Board of Internal Medicine. Resident and Fellow Workforce Data. http: //www.abim.org/about/examInfo/data-workforce.aspx. Accessed January 12, 2015.
To the Editor Cook et al1 reported on their focus group study of American Board of Internal Medicine (ABIM)– and American Board of Family Medicine (ABFM)–certified physicians related to the current Maintenance of Certification (MOC) process. As a permanently ABIM-certified physician who has vol-
To the Editor The recent study by Cook et al1 provides valuable insight to inform the ongoing efforts of the American Board of Internal Medicine (ABIM) to enhance Maintenance of Certification (MOC). The authors make important suggestions, which are consistent with feedback we have received from others in the internal medicine community. Since the study’s focus groups were conducted (2011-2012), the ABIM has made several changes to MOC that address some of these concerns,
JAMA Internal Medicine August 2015 Volume 175, Number 8 (Reprinted)
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and additional changes are under way. In February, 2015, the Practice Assessment requirement was suspended for at least 2 years. Physicians can still get MOC credit for doing improvement work, and there are multiple options for those engaged in that work to get credit. The Mayo Clinic, for example, participates in the MOC Portfolio program, in which physicians involved in approved QI efforts at participating institutions can earn MOC credit. The ABIM will also be allowing many more activities to count toward the Medical Knowledge (Part 2) requirement, including most forms of ACCME accredited CME. To address the distinct needs of the 20 subspecialties of internal medicine, the ABIM’s new governance structure includes physician-led specialty boards that will help establish discipline-specific standards and facilitate multidirectional communications with other relevant organizations and the larger physician community in each discipline. The ABIM is working to further reduce redundancy by aligning MOC with other physician reporting processes. Several states now accept MOC participation to satisfy Continuing Medical Education requirements for medical licensure renewal. However, the ABIM does not believe that MOC should be required for maintenance of licensure, but we do believe that physicians who engage in MOC should be exempted from other reporting requirements. We are encouraged by this study and others that indicate physicians believe in the principles behind MOC. As physicians, we all want to stay up to date and provide the best care for our patients. Maintenance of Certification should facilitate these processes, not hinder them. We will continually enhance the MOC program based on the latest research, finding ways to integrate MOC into physicians’ clinical practices and give MOC credit for more of what physicians already do. The ABIM is committed to continuous improvement, and we welcome well-designed research and constructive feedback to help us make MOC more relevant, efficient, and meaningful for physicians and their patients. Richard J. Baron, MD Author Affiliation: American Board of Internal Medicine, Philadelphia, Pennsylvania. Corresponding Author: Richard J. Baron, MD, American Board of Internal Medicine and ABIM Foundation, 510 Walnut St, Philadelphia, PA 19106 (rbaron @abim.org). Conflict of Interest Disclosures: Dr Baron is a salaried employee of the American Board of Internal Medicine and ABIM Foundation. Additional Information: Dr Baron is the president of the ABIM and ABIM Foundation. 1. Cook DA, Holmboe ES, Sorensen KJ, Berger RA, Wilkinson JM. Getting maintenance of certification to work: a grounded theory study of physicians’ perceptions. JAMA Intern Med. 2015;175(1):35-42.
sage—that “physicians view MOC as an unnecessarily complex process that is misaligned with its purposes,” and that physicians, patients, and MOC programs will all benefit as these misalignments are corrected.1 We emphasize in particular our suggestions that MOC create tangible value for physicians, integrate tightly with physicians’ daily work, and build in support for tasks that do not require physicians' expertise and have low learning and/or experiential benefit. We recognize that our model offers only partial answers. We further believe that lasting improvement will require rigorous research into what works (or does not) for MOC, for whom, and in what circumstances.3 It is helpful to distinguish the concept and philosophy of MOC—which the participants in our study generally endorsed1—from the programs of MOC, which have varied widely over time and between specialty boards. Any given program in any field will provide only a partial solution.3 As such, we should not expect that a single program of assessment and professional development can meet every need of all physicians working in the complex US health care system. The scope of MOC is also in dispute. Should MOC programs focus exclusively on assessment and certification? Or should they also actively assist physicians in acquiring the competencies required to keep pace with the transformative changes occurring in health care delivery? As much as we would like to simplify the MOC program to a single written test every 10 years, we do not believe this would provide evidence sufficient to make valid decisions4 about a physician’s performance in core competencies, such as practice-based learning and improvement, systems-based practice, and interpersonal and communication skills—all core skills required to function as a physician in 21st-century health care.5 However, we do believe that programs of assessment need not be onerous, and our suggestions to promote value, integration, and systemic support apply to assessment as much as to training. We believe certification boards should continue to engage the academic research community to assist in the evaluation and evolution of MOC. Past conceptions of professional self-regulation incorporated a rigid separation between regulators and those regulated. Such conceptions are no longer sufficient or effective. We need new models that break down these barriers and create an arena in which physician regulators and physicians in the trenches work in collaboration, along with education experts, patients, and other professionals, to first co-create better programs (innovative and high-value approaches, tools, and systems for meaningful assessment) and then to co-produce physicians whose certification reflects not only competence but a also commitment to ongoing professional development.6 We look forward to continued dialogue around co-created and coproduced research and development in MOC.
In Reply We appreciate the efforts of certification boards to continually improve the maintenance of certification (MOC) process. While the substantial changes implemented in MOC since our study’s data collection1 ended in 2012 have been wellintended, the time, effort, and emotional investments expected of physicians continue to be critical and contentious. The American Board of Internal Medicine’s decision to review and revise its MOC program2 aligns with our key mes-
Eric S. Holmboe, MD David A. Cook, MD, MHPE
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(Reprinted) JAMA Internal Medicine August 2015 Volume 175, Number 8
Author Affiliations: Accreditation Council for Graduate Medical Education, Chicago, Illinois (Holmboe); Mayo Clinic College of Medicine, Rochester, Minnesota (Cook). Corresponding Author: David A. Cook, MD, MHPE, Division of General Internal Medicine, Mayo Clinic College of Medicine, 200 1st St SW, Mayo 17-W, Rochester, MN 55905 ([email protected]).
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Conflict of Interest Disclosures: Dr Holmboe was at the American Board of Internal Medicine during the design, data collection, and most of the qualitative analysis stages of the study. No other disclosures are reported. 1. Cook DA, Holmboe ES, Sorensen KJ, Berger RA, Wilkinson JM. Getting maintenance of certification to work: a grounded theory study of physicians’ perceptions. JAMA Intern Med. 2015;175(1):35-42. 2. Baron R. ABIM announces immediate changes to MOC program. http://www .abim.org/news/abim-announces-immediate-changes-to-moc-program.aspx. Accessed February 25, 2015. 3. Pawson R, Tilley N. Realistic Evaluation. London, England: Sage; 1997.
zation of Care,” published in the August 3, 2015, issue of JAMA Internal Medicine (doi:10.1001/jamainternmed.2015.2047), the Role of the Funder/Sponsor statement was incorrectly reported. The beginning of that statement should have read “The Commonwealth Fund had no role….” This article was corrected online.
Errors in Figure Labels: In the Invited Commentary titled “Vitamin D and Falls— Fitting New Data With Current Guidelines” published online March 23, 2015, and in the May 2015 issue of JAMA Internal Medicine (2015;175(5):712-713. doi:10.1001 /jamainternmed.2015.0248), the labels in the Figure were transposed. This article was corrected online.
4. Cook DA. When I say… validity. Med Educ. 2014;48(10):948-949. 5. Lucey CR. Medical education: part of the problem and part of the solution. JAMA Intern Med. 2013;173(17):1639-1643. 6. Sabadosa KA, Batalden PB. The interdependent roles of patients, families and professionals in cystic fibrosis: a system for the coproduction of healthcare and its improvement. BMJ Qual Saf. 2014;23(suppl 1):i90-i94.
CORRECTION
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Error in Figure and Text: In the Original Investigation titled “Epidemiology of the Homebound Population in the United States,” published online May 26, 2015, in JAMA Internal Medicine,1 there was an error in the Figure. The arrow from the box “Rarely, most times, or sometimes” was incorrectly placed. Also, in the first paragraph of the Discussion section, the third sentence should have read “The homebound population included approximately 400 000 people who were completely homebound and approximately 1.6 million people who rarely went out.” This article was corrected online.
Incorrect Role of Funder/Sponsor Statement: In the Original Investigation titled “Effects of a Medical Home and Shared Savings Intervention on Quality and Utili-
1. Ornstein KA, Leff B, Covinsky KE, et al. Epidemiology of the homebound population in the United States [published online May 26, 2015]. JAMA Intern Med. doi:10.1001/jamainternmed.2015.1849.
JAMA Internal Medicine August 2015 Volume 175, Number 8 (Reprinted)
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3. Kayser RG, Ornato JP, Peberdy MA; American Heart Association National Registry of Cardiopulmonary Resuscitation. Cardiac arrest in the emergency department: a report from the National Registry of Cardiopulmonary Resuscitation. Resuscitation. 2008;78(2):151-160. 4. Kudenchuk PJ, Cobb LA, Copass MK, et al. Amiodarone for resuscitation after out-of-hospital cardiac arrest due to ventricular fibrillation. N Engl J Med. 1999; 341(12):871-878. 5. Lin S, Callaway CW, Shah PS, et al. Adrenaline for out-of-hospital cardiac arrest resuscitation: a systematic review and meta-analysis of randomized controlled trials. Resuscitation. 2014;85(6):732-740.
Despite Wang and Kupas’ positive assessment of the skills and interventions deployed in a paramedic-based system, we believe our data call into question the institutional and political inertia that supports the current practice of ALS in the absence of scientific evaluation. Improved protocols based on evidence have the potential to save lives in cardiac arrest. Prachi Sanghavi, PhD Anupam B. Jena, MD, PhD Alan M. Zaslavsky, PhD
In Reply We do not agree with Drennan et al that the 20% claim sample we used has a sampling bias. It is a sample randomly assembled by the final digit of Social Security numbers. Wang and Kupas rightly note that Medicare will only reimburse for a single transport, but this will be at the higher service level, that is ALS, as long as a written agreement exists between the responding emergency medical services (EMS) agencies.1 We excluded the relatively few areas identified in interviews with state EMS offices where such agreements may not exist. However, since billing is determined by the existence of an agreement and is unrelated to case characteristics, such random error in classification would attenuate the estimated effects. Several criticisms concerned the lack of detailed measures of patient status, clinical processes, or circumstances of the cardiac arrest that could confound our analyses. The scenarios described by Drennan et al for confounding by indication and similar biases were addressed in our eAppendices 4, 5, and 7.2 The list of rare instances provided by Wang and Kupas that may have generated BLS cases only supports our understanding of essentially random assignment at dispatch. Drennan and colleagues also suggest that the gold standard Utstein variables3 are required for an unbiased analysis, but much of that data would be unavailable even with hospital records. Furthermore, a plausible argument should be made for why these variables would systematically differ between patients receiving ALS and BLS. Mark et al raise issues about 2 sensitivity analyses, calculating that under assumptions moderately favorable to ALS, statistical significance might be lost. However, the analyses we presented were conservative because we omitted adjustments that would have improved the standing of BLS relative to ALS in the Medicare data . More generally, it seems reasonable to have higher expectations for ALS, the predominant and more expensive mode of out-of-hospital care, than that its outcomes might not quite be significantly worse under the most favorable conditions. We recognize that our study was unable to assess specific interventions. For this reason, we emphasized that our objective was to compare ALS with BLS as practiced using key outcomes of survival and neurological functioning. We disagree with the claim by Wang and Kupas that the outcomes of 2 systems can be compared only if we know the specific interventions supplied in each case. The 3 letters in response to our Original Investigation confirmed our assessment of the dearth of scientific evidence supporting superiority of ALS in treating out-of-hospital cardiac arrest.2 None of the cited research was designed to compare ALS with BLS, although some compared different methods of providing ALS interventions.
To the Editor The American Board of Medical Specialties (ABMS) appreciates the research and feedback presented in the study by Cook et al.1 At approximately the same time this study was undertaken, the ABMS was conducting a 2-year review as part of an ongoing quality improvement process and soliciting input about the ABMS Program for Maintenance of Certification (ABMS MOC) from medical professionals, health care organizations, and the public. This review resulted in the 2015 Standards for the ABMS Program for MOC2 approved in January 2014. As the authors acknowledged, the updated standards “address several of the barriers and shortcomings identified in this study.” The updated standards continue to emphasize the importance of discipline- and practice-specific continuing professional development as part of the ABMS certification process.
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(Reprinted) JAMA Internal Medicine August 2015 Volume 175, Number 8
Author Affiliations: Program in Health Policy, Faculty of Arts and Sciences, Harvard University, Cambridge, Massachusetts (Sanghavi); Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts (Jena, Zaslavsky); Massachusetts General Hospital, Boston (Jena); National Bureau of Economic Research, Cambridge, Massachusetts (Jena). Corresponding Author: Prachi Sanghavi, PhD, Harvard University, Program in Health Policy, 1737 Cambridge St, K311, Cambridge, MA 02138 (sanghav @fas.harvard.edu). Conflict of Interest Disclosures: None reported. Funding/Support: Dr Sanghavi was supported by a National Science Foundation Graduate Research Fellowship and by the Agency for Healthcare Research and Quality (1R36HS022798-01). Dr Jena acknowledges support from the Office of the Director, National Institutes of Health (NIH Early Independence Award, 1DP5OD017897-01). Role of the Funder/Sponsor: These funders played no role in the analysis and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Additional Contributions: We thank our coauthor, Joseph P. Newhouse, PhD, for his contributions to this letter. 1. Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual, Chapter 10 - Ambulance Services, Section 10.5 Joint Responses. March 2015. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals /downloads/bp102c10.pdf 2. Sanghavi P, Jena AB, Newhouse JP, Zaslavsky AM. Outcomes after out-of-hospital cardiac arrest treated by basic vs advanced life support. JAMA Intern Med. 2015;175(2):196-204. 3. Jacobs I, Nadkarni V, Bahr J, et al; International Liason Committee on Resusitation. Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and simplification of the Utstein templates for resuscitation registries: a statement for healthcare professionals from a task force of the international liaison committee on resuscitation (American Heart Association, European Resuscitation Council, Australian Resuscitation Council, New Zealand Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa). Resuscitation. 2004;63(3):233-249.
American Board of Internal Medicine and Maintenance of Certification Standards
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Conflict of Interest Disclosures: Dr Nora is a salaried employee of the American Board of Medical Specialties. No other disclosures are reported.
untarily completed (successfully) the MOC process and as an internal medicine residency program director of 15 years and counting, I can say that the results were predictable. Hopefully, this article will serve as a wake-up call to the ABIM from certified physicians. Having heard the public comments of the ABIM chair nearly every year for the past 30 years at Association of Program Directors of Internal Medicine semiannual meetings and having repeatedly voiced alarm to the ABIM at these meetings that the MOC process is impractical and lacks scientific merit, a change in direction by the ABIM would be welcome even though overdue. The guiding principle of the MOC process should focus on the certification, not on the education, of physicians. The process of certification should be scientifically valid and practical. The current MOC process fails on both counts. Rather than focusing on certification, the ABIM version of MOC has diverted to administering and documenting educational, safety, and quality activities. Other than the (re)certification examination itself, there is nothing uniform or standarized or scientifically validated about the remaining components, which are particularly disconcerting to physicians. Documentation of educational activities should be largely unnecessary if the certification examination has been constructed optimally. From the standpoint of practicality, the current MOC is a bridge too far. Given that there are approximately 7500 new internal medicine graduates per year, of whom nearly twothirds enter fellowship training with additional certifications and recertifications,2 the tasks of the ABIM regarding all this documentation cannot be maintained with integrity and accuracy, short of a massive and overly costly infrastructure. I propose again, as did the many voices of program directors 2 decades ago, that MOC should consist of a periodic (every 10 years is reasonable) high-stakes examination in conjunction with maintenance of a valid medical license (which usually requires documentation of educational activities) or, in lieu of a license, documentation of an equivalent number of relevant educational activities.
Additional Information: Dr Nora is the president and chief executive officer of the American Board of Medical Specialties.
George Douglas Everett, MD, MS
They encourage the certifying boards to consider the complex and diverse environments in which physicians practice, as well as to increase the quality, relevance, and meaningfulness of the MOC program with sensitivity to the time and administrative burden associated with participation. The updated standards are reflected in improvements to the MOC program across the boards. Specialty societies and continuing medical education (CME) providers are increasingly creating practice relevant Part II and Part IV MOC activities for which physicians may receive CME credit. New activities developed by certain boards to help physicians remain current in their specialties include reading lists of key articles in the literature and Question of the Week self-assessment activities. Some boards also are investigating innovative methods of external assessment, including remote proctoring, to continue to provide meaningful assessment in more userfriendly ways. The 20 boards that participate in the ABMS Multispecialty Portfolio Approval Program (Portfolio Program) have enabled thousands of physicians, to date, to receive MOC credit for engaging in multidisciplinary, organizational quality improvement projects. Reducing adverse drug events by 76%3 and Clostridium difficile infections by 30%4 are among the improvements that resulted from Portfolio Program projects at 2 of the 45 sponsor organizations. As Cook and colleagues1 noted, MOC “is in an ongoing state of evolution.” The ABMS and its 24 member boards are committed to the continuous improvement of the MOC process and continue to seek and implement feedback provided by all key stakeholders to enhance—and advance—MOC. Lois Margaret Nora, MD, JD, MBA Author Affiliation: American Board of Medical Specialties, Chicago, Illinois. Corresponding Author: Lois Margaret Nora, MD, JD, MBA, American Board of Medical Specialties, 353 N Clark St, Ste 1400, Chicago, IL 60654 ([email protected]).
1. Cook DA, Holmboe ES, Sorensen KJ, Berger RA, Wilkinson JM. Getting maintenance of certification to work: a grounded theory study of physicians’ perceptions. JAMA Intern Med. 2015;175(1):35-42. 2. American Board of Medical Specialties. Standards for the ABMS program for maintenance of certification (MOC) for implementation in January 2015. http: //www.abms.org/media/1109/standards-for-the-abms-program-for-moc-final .pdf. Accessed November 11, 2015. 3. McClead RE Jr, Catt C, Davis JT, et al; Adverse Drug Event Quality Collaborative. An internal quality improvement collaborative significantly reduces hospital-wide medication error related adverse drug events. J Pediatr. 2014;165(6):1222-1229.e1. 4. Pyrek KM. Cleaning intervention cuts C difficile acquisition rates by one-third. Infection Control Today. September 7, 2010. http://www.infectioncontroltoday.com/PrinterFriendly.aspx?id =FD87035E-9082-4D98-B640-1C2573D9E32A#. Accessed November 11, 2015.
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Author Affiliation: Department of Internal Medicine, Florida Hospital, Orlando. Corresponding Author: George Douglas Everett, MD, MS, Department of Internal Medicine, Florida Hospital, 2501 N Orange Ave, Ste 235, Orlando, FL 32804 ([email protected]). Conflict of Interest Disclosures: None reported. 1. Cook DA, Holmboe ES, Sorensen KJ, Berger RA, Wilkinson JM. Getting maintenance of certification to work: a grounded theory study of physicians’ perceptions. JAMA Intern Med. 2015;175(1):35-42. 2. American Board of Internal Medicine. Resident and Fellow Workforce Data. http: //www.abim.org/about/examInfo/data-workforce.aspx. Accessed January 12, 2015.
To the Editor Cook et al1 reported on their focus group study of American Board of Internal Medicine (ABIM)– and American Board of Family Medicine (ABFM)–certified physicians related to the current Maintenance of Certification (MOC) process. As a permanently ABIM-certified physician who has vol-
To the Editor The recent study by Cook et al1 provides valuable insight to inform the ongoing efforts of the American Board of Internal Medicine (ABIM) to enhance Maintenance of Certification (MOC). The authors make important suggestions, which are consistent with feedback we have received from others in the internal medicine community. Since the study’s focus groups were conducted (2011-2012), the ABIM has made several changes to MOC that address some of these concerns,
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and additional changes are under way. In February, 2015, the Practice Assessment requirement was suspended for at least 2 years. Physicians can still get MOC credit for doing improvement work, and there are multiple options for those engaged in that work to get credit. The Mayo Clinic, for example, participates in the MOC Portfolio program, in which physicians involved in approved QI efforts at participating institutions can earn MOC credit. The ABIM will also be allowing many more activities to count toward the Medical Knowledge (Part 2) requirement, including most forms of ACCME accredited CME. To address the distinct needs of the 20 subspecialties of internal medicine, the ABIM’s new governance structure includes physician-led specialty boards that will help establish discipline-specific standards and facilitate multidirectional communications with other relevant organizations and the larger physician community in each discipline. The ABIM is working to further reduce redundancy by aligning MOC with other physician reporting processes. Several states now accept MOC participation to satisfy Continuing Medical Education requirements for medical licensure renewal. However, the ABIM does not believe that MOC should be required for maintenance of licensure, but we do believe that physicians who engage in MOC should be exempted from other reporting requirements. We are encouraged by this study and others that indicate physicians believe in the principles behind MOC. As physicians, we all want to stay up to date and provide the best care for our patients. Maintenance of Certification should facilitate these processes, not hinder them. We will continually enhance the MOC program based on the latest research, finding ways to integrate MOC into physicians’ clinical practices and give MOC credit for more of what physicians already do. The ABIM is committed to continuous improvement, and we welcome well-designed research and constructive feedback to help us make MOC more relevant, efficient, and meaningful for physicians and their patients. Richard J. Baron, MD Author Affiliation: American Board of Internal Medicine, Philadelphia, Pennsylvania. Corresponding Author: Richard J. Baron, MD, American Board of Internal Medicine and ABIM Foundation, 510 Walnut St, Philadelphia, PA 19106 (rbaron @abim.org). Conflict of Interest Disclosures: Dr Baron is a salaried employee of the American Board of Internal Medicine and ABIM Foundation. Additional Information: Dr Baron is the president of the ABIM and ABIM Foundation. 1. Cook DA, Holmboe ES, Sorensen KJ, Berger RA, Wilkinson JM. Getting maintenance of certification to work: a grounded theory study of physicians’ perceptions. JAMA Intern Med. 2015;175(1):35-42.
sage—that “physicians view MOC as an unnecessarily complex process that is misaligned with its purposes,” and that physicians, patients, and MOC programs will all benefit as these misalignments are corrected.1 We emphasize in particular our suggestions that MOC create tangible value for physicians, integrate tightly with physicians’ daily work, and build in support for tasks that do not require physicians' expertise and have low learning and/or experiential benefit. We recognize that our model offers only partial answers. We further believe that lasting improvement will require rigorous research into what works (or does not) for MOC, for whom, and in what circumstances.3 It is helpful to distinguish the concept and philosophy of MOC—which the participants in our study generally endorsed1—from the programs of MOC, which have varied widely over time and between specialty boards. Any given program in any field will provide only a partial solution.3 As such, we should not expect that a single program of assessment and professional development can meet every need of all physicians working in the complex US health care system. The scope of MOC is also in dispute. Should MOC programs focus exclusively on assessment and certification? Or should they also actively assist physicians in acquiring the competencies required to keep pace with the transformative changes occurring in health care delivery? As much as we would like to simplify the MOC program to a single written test every 10 years, we do not believe this would provide evidence sufficient to make valid decisions4 about a physician’s performance in core competencies, such as practice-based learning and improvement, systems-based practice, and interpersonal and communication skills—all core skills required to function as a physician in 21st-century health care.5 However, we do believe that programs of assessment need not be onerous, and our suggestions to promote value, integration, and systemic support apply to assessment as much as to training. We believe certification boards should continue to engage the academic research community to assist in the evaluation and evolution of MOC. Past conceptions of professional self-regulation incorporated a rigid separation between regulators and those regulated. Such conceptions are no longer sufficient or effective. We need new models that break down these barriers and create an arena in which physician regulators and physicians in the trenches work in collaboration, along with education experts, patients, and other professionals, to first co-create better programs (innovative and high-value approaches, tools, and systems for meaningful assessment) and then to co-produce physicians whose certification reflects not only competence but a also commitment to ongoing professional development.6 We look forward to continued dialogue around co-created and coproduced research and development in MOC.
In Reply We appreciate the efforts of certification boards to continually improve the maintenance of certification (MOC) process. While the substantial changes implemented in MOC since our study’s data collection1 ended in 2012 have been wellintended, the time, effort, and emotional investments expected of physicians continue to be critical and contentious. The American Board of Internal Medicine’s decision to review and revise its MOC program2 aligns with our key mes-
Eric S. Holmboe, MD David A. Cook, MD, MHPE
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Author Affiliations: Accreditation Council for Graduate Medical Education, Chicago, Illinois (Holmboe); Mayo Clinic College of Medicine, Rochester, Minnesota (Cook). Corresponding Author: David A. Cook, MD, MHPE, Division of General Internal Medicine, Mayo Clinic College of Medicine, 200 1st St SW, Mayo 17-W, Rochester, MN 55905 ([email protected]).
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Conflict of Interest Disclosures: Dr Holmboe was at the American Board of Internal Medicine during the design, data collection, and most of the qualitative analysis stages of the study. No other disclosures are reported. 1. Cook DA, Holmboe ES, Sorensen KJ, Berger RA, Wilkinson JM. Getting maintenance of certification to work: a grounded theory study of physicians’ perceptions. JAMA Intern Med. 2015;175(1):35-42. 2. Baron R. ABIM announces immediate changes to MOC program. http://www .abim.org/news/abim-announces-immediate-changes-to-moc-program.aspx. Accessed February 25, 2015. 3. Pawson R, Tilley N. Realistic Evaluation. London, England: Sage; 1997.
zation of Care,” published in the August 3, 2015, issue of JAMA Internal Medicine (doi:10.1001/jamainternmed.2015.2047), the Role of the Funder/Sponsor statement was incorrectly reported. The beginning of that statement should have read “The Commonwealth Fund had no role….” This article was corrected online.
Errors in Figure Labels: In the Invited Commentary titled “Vitamin D and Falls— Fitting New Data With Current Guidelines” published online March 23, 2015, and in the May 2015 issue of JAMA Internal Medicine (2015;175(5):712-713. doi:10.1001 /jamainternmed.2015.0248), the labels in the Figure were transposed. This article was corrected online.
4. Cook DA. When I say… validity. Med Educ. 2014;48(10):948-949. 5. Lucey CR. Medical education: part of the problem and part of the solution. JAMA Intern Med. 2013;173(17):1639-1643. 6. Sabadosa KA, Batalden PB. The interdependent roles of patients, families and professionals in cystic fibrosis: a system for the coproduction of healthcare and its improvement. BMJ Qual Saf. 2014;23(suppl 1):i90-i94.
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Error in Figure and Text: In the Original Investigation titled “Epidemiology of the Homebound Population in the United States,” published online May 26, 2015, in JAMA Internal Medicine,1 there was an error in the Figure. The arrow from the box “Rarely, most times, or sometimes” was incorrectly placed. Also, in the first paragraph of the Discussion section, the third sentence should have read “The homebound population included approximately 400 000 people who were completely homebound and approximately 1.6 million people who rarely went out.” This article was corrected online.
Incorrect Role of Funder/Sponsor Statement: In the Original Investigation titled “Effects of a Medical Home and Shared Savings Intervention on Quality and Utili-
1. Ornstein KA, Leff B, Covinsky KE, et al. Epidemiology of the homebound population in the United States [published online May 26, 2015]. JAMA Intern Med. doi:10.1001/jamainternmed.2015.1849.
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