By Ruth Carol, contributing writer, August 01, 2013
Think of Maintenance of Certification (MOC) as a long car ride with your kids. The destination, in this case, is the land of improved patient outcomes. Are we there yet? Not yet, but we expect to be there soon.
Seven years after the American Board of Dermatology (ABD) began its MOC program, progress has been slow, but steady. Simply put, data takes time to accumulate. But once it emerges, the data is expected to link MOC participation with improved physician performance and patient outcomes as it has in other specialties.
“Maintenance of Certification takes on a variety of competencies that, in theory, make people better physicians,” said Robert S. Kirsner, MD, PhD, vice chairman of dermatology at the University of Miami Miller School of Medicine and chair of the American Academy of Dermatology’s Council on Education and MOC. The six core competencies, adopted by the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties, are professionalism, patient care and procedural skills, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, and systems-based practice.
The idea is that physician performance, which is the process part of MOC, will lead to better outcomes, whether that means fewer deaths from melanoma or improved quality of life for patients with acne, Dr. Kirsner explained. “While we’re beginning to scratch the surface on process, we still have a long way to get true outcomes data for dermatology.” [pagebreak]
Behind, but moving forward
This specialty is behind the others when it comes to quality data for several reasons. There are fewer dermatology-specific quality measures and guidelines. To date, many dermatologists do not participate in disease registries or have an electronic health record, hampering their ability to readily collect data about their practice that can be used to assess quality measures. Much of this has to do with the fact that dermatology is a relatively small specialty.
“The main reason we don’t have the data for improved patient care is that we don’t have a large number of national quality metrics or participants like those specialties that manage the big-ticket chronic diseases such as hypertension and diabetes,” said Erik Stratman, MD, chair of the department of dermatology at the Marshfield Clinic and past chair of the Academy’s Council on Education and MOC. It takes a while to accumulate data on enough patients treated for melanoma, for example, to determine whether an intervention implemented as part of MOC activities led to an improvement in physician performance or patient outcomes, he said, adding, “This information will come, and I think the leadership of AAD will help bring it forward.”
While the number of dermatologists available to contribute to the specialty’s data is not expected to grow, their rate of participation in MOC is. Beginning in 2006, successfully certifying and recertifying dermatologists were automatically enrolled in the MOC program. According to an article in the July issue of the Journal of the American Academy of Dermatology, it is anticipated that by 2015, nearly all board-certified dermatologists will be entered into the MOC program (2013; 69:1-11).
Additionally, the AAD may be poised to become the leader at demonstrating the impact of MOC on improving patient care because it manages one of the largest groups of approved part 4 activities that address the assessment of practice performance, Dr. Stratman said. [pagebreak]
The time and cost
Of course, the MOC program is not without its critics, who say that it is too time-consuming and costly. “A key part of MOC is understanding that it’s critical for physicians to commit their time to ongoing or continuous learning to provide the best possible care for their patients,” said Nicole DeYampert, MD, a staff dermatologist in the Department of the Army, who is a Lean Six Sigma Black Belt. She points out that medical knowledge changes rapidly and it’s imperative that physicians keep current. Moreover, the literature shows that:
- the quality of care physicians provide deteriorates with time,
- traditional continuing medical education (CME) does not improve physician performance,
- physicians do a poor job of assessing their own skills, and
- there is variation in practice among physicians.
Dr. DeYampert noted the AAD has taken some measures to decrease the time commitment for dermatologists. For example, staff members are able to supply the clinical practice data for the Performance Improvement CME (PI CME) modules that fulfill part 4 while the dermatologist participates in the actual activity. Dr. Stratman believes that the most time-consuming activity is associated with the PI CME. But he points out that dermatologists can earn as many as 20 CME credits for this activity, and that it is far more closely connected to making real or lasting changes in practice than traditional CME.
Because the MOC program is designed to engage physicians in looking at their current state of knowledge and performance in areas relevant to clinical practice in an ongoing and deliberate fashion, he continued, it is more likely to decrease or prevent a decline in skills, knowledge, and performance than more passive CME, such as listening to a lecture. “By engaging the physician to self-reflect, self-identify, and make improvement efforts, it is reasonable to think that skills would be maintained or even enhanced in some cases,” Dr. Stratman said. [pagebreak]
Over time, dermatologists will get more comfortable with interactive CME, Dr. DeYampert added.
Regarding the cost, she said that the AAD has worked diligently to keep costs nominal and that the ABD offers both a patient and peer communication survey for free. Dr. Stratman believes that as more options are developed each year by more organizations, the price for MOC activities will remain reasonable.
If MOC shows what it is expected to, that it improves patient outcomes, then the time and cost will be worth it, and the critics will be silenced, said Dr. Kirsner, who understands the criticism because the data doesn’t yet exist in dermatology.
Relevance to practice
Critics suggest that MOC is irrelevant to practice. However, supporters question how much more relevant an activity can be when it identifies clinical gaps in one’s own practice and/or compares oneself to colleagues.
Part 2 self-assessment activities allow dermatologists to identify clinically relevant gaps in their knowledge base followed by instruction to improve knowledge in these various areas, Dr. Stratman said. The first self-assessment modules offered when the MOC program began were very broad, covering pediatric, medical, and surgical dermatology as well as dermatopathology, all in one module. Those may hold minimal clinical relevance to the subspecialist dermatologist, Dr. Stratman acknowledged. However, the modules currently being developed by the AAD target specific topics such as contact dermatitis and infectious disease. “The creation of subspecialty and topic area modules will decrease concerns over relevance,” he said. “The same is true of practice improvement modules; the more options there are, the greater the chance that one of the choices will be relevant for each dermatologist to use to assess his or her practice.” [pagebreak]
Dr. DeYampert points out that most dermatologists have limited control over who comes into their practices. Consequently, they should be prepared to treat a broad patient population. Using self-assessments enables dermatologists to keep current with the conditions they routinely see and those they don’t. “The farther removed from residency dermatologists are, the fewer opportunities they have to see different or unusual cases,” she said.
Comparing themselves to their colleagues, which they do in Part 4 activities, is another way for dermatologists to ensure that they are meeting quality standards and keeping current. “Many physicians may be practicing appropriately,” Dr. DeYampert said, “but they may not be using best practices.”
Dr. Kirsner agrees. “Regardless of how good of a physician you are, you can always be better,” he said. “Many of the components of MOC challenge you to be better.”
Moving beyond medical knowledge
Critics argue that the six competencies (professionalism, patient care and procedural skills, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, and systems-based practice) are too overarching as they go beyond medical knowledge. But Dr. DeYampert argues that this criticism indicates a too-narrow view of medicine. [pagebreak]
“Being a physician is so much more than having a basic understanding of disease,” Dr. DeYampert said. “It requires one skill set to make a diagnosis and treat a condition and another skill set to communicate well with patients and peers.” Dermatologists may assume all of their patients are happy, but they don’t know until they obtain feedback. The same is true for colleagues.
“The best clinicians have great skill in each of the six competency areas, even if they were not trained in the era of the competencies,” Dr. Stratman said. “How you interact with your patients, how you attempt to improve areas in which you are weak, how you serve and interact with your colleagues and those requesting your consultation, and how you navigate the often complex system of care all impact the quality of your care and how your patients experience the care you deliver.” Part 4 activities help dermatologists recognize that many care issues needing improvement have little to do with a lack of knowledge, but rather are about processes of care delivery, such as a lack of reminder systems or evidence-based template use.
The criticisms of MOC miss an essential point, Dr. Stratman said. “It is important that we transition away from MOC as a check box’ activity and instead turn it into what it is meant to be: continuing professional development,” he said.
Dr. Kirsner agrees. “There are two benefits of MOC. One is that it’s a continuous process, not an episodic one. The second is that it’s more comprehensive in its approach than recertification,” he said. Many physicians spend more time worrying or having angst about participating in MOC than the time it actually takes to do it. “Since we have to do this process if we want to maintain certification, I would encourage dermatologists to spend less time worrying about whether they should do it as opposed to doing it and trying to learn the most they can from it.” [pagebreak]
Need assistance? Just ask
Although the American Board of Dermatology administers MOC, the AAD offers members information, tools, and services to help dermatologists fulfill MOC requirements. The Academy’s goal is to try to help dermatologists improve their performance and patient outcomes in the easiest and most efficient way, noted Robert Kirsner, MD, PhD. “The Academy is only a phone call or click away to getting information,” he added. (Visit www.aad.org/education/moc to learn more.)
But don’t wait until the end of an MOC period to get started, particularly on part 4 activities, urged Erik Stratman, MD. And don’t hesitate to contact the ABD, whose staff is very helpful and ready to answer all levels of MOC questions. Additionally, he noted, the MOC tab on the ABD website contains a listing of all local, regional, and national products and services designed to meet one’s MOC needs.
Who has to do MOC?
Dermatologists who wish to remain certified by the American Board of Dermatology have to complete a maintenance of certification cycle (see sidebar for requirements) every 10 years — unless they hold a lifetime certificate. Dermatologists who completed their residency after 1990 hold time-limited certificates and are required to participate in MOC in order to remain board-certified. Dermatologists with lifetime certificates may still participate in MOC; so far only 8 percent are (N Engl J Med. 2010;362:948-52), perhaps because some states are considering allowing board-certified physicians to use MOC to maintain their licenses. (Medical societies, including the American Medical Association, favor states allowing physicians to use MOC to meet licensure standards, but oppose making it the only path to licensure.)
One dermatologist’s MOC journey
Erik Stratman, MD, enrolled in MOC after completing the first closed-book recertification exam in 2010. He took the AAD’s regional MOC examination preparation course, which was not only beneficial for studying, but for helping alleviate many fears of the participating dermatologists. “I thought the test was very fair and I learned a lot preparing for it,” Dr. Stratman said.
To date, he has completed several different regional and national part 2 self-assessment activities, the patient safety module, one set of patient experience surveys, and one performance in practice assessment module. Dr. Stratman has yet to complete a peer survey.
The most valuable aspect of MOC has been participating in the performance in practice assessment, through which he identified process and documentation issues in the melanoma care he provided patients, Dr. Stratman said. For example, he wasn’t always translating his knowledge into documented patient care, following appropriate guidelines of care, and specifically contacting a patient’s primary care physician after making a melanoma diagnosis. Dr. Stratman had never really participated in a structured quality improvement exercise before, either. After reviewing the pre-intervention numbers and post-intervention improvement, “I definitely know that this is the most meaningful CME I have experienced in my professional development,” he said.
Among the improvements Dr. Stratman has seen in his practice as a result of participating in MOC are the following:
- Improved communication with primary care physicians regarding melanoma patients.
- Better health screenings and primary care connection for psoriasis patients.
- Improved use of templates for medication review of systems and side effect counseling.
- Improved bone protection for dermatology patients on chronic prednisone.
MOC requirements for dermatologists
The four components of MOC are as follows:
Part I: Evidence of professional standing
The first MOC component simply requires ABD diplomates to hold a valid, full, and unrestricted license to practice medicine or osteopathy in the candidate’s state, territory, or province.
Part 2: Evidence of commitment to lifelong learning and periodic self-assessment
This component includes three aspects:
- Earn 25 AMA PRA Category 1 Credits in dermatology-related activities per year
- Complete 300 self-assessment questions during the 10-year MOC cycle
- Complete one patient safety module during the 10-year cycle
Part 3: Cognitive expertise
The third component requires successful completion of an examination. Beginning in 2011, the ABD moved to a secure, proctored, closed-book examination that is administered at Pearson Vue testing centers in the United States and Canada. The examinations are administered annually and diplomates may take the examination in the eighth, ninth, or 10th year of the MOC cycle.
Part 4: Evaluation of practice performance
The fourth component includes two aspects:
- Complete an evaluation of practice performance twice during the 10-year cycle. This evaluation will include completion of a practice assessment/quality improvement program approved by the ABD.
- Complete a patient communication survey and a peer communication survey twice during the 10-year cycle: one set by year five and again by year 10.