Maintenance of Certification:
Navigating Your Way Through Two
MOCs
H2089 Section on Med-Peds Program
J. Thomas Cross, Jr., MD, MPH, FAAP, FACP
President, A-Cross Medicine Reviews
Faculty Disclosure Information
In the past 12 months, I have no relevant financial
relationships with the manufacturer(s) of any
commercial product(s) and/or provider(s) of
commercial services discussed in this CME activity.
I do not intend to discuss an
unapproved/investigative use of a commercial
product/device in my presentation.
But For FULL Disclosure
• From January 7, 2002 to January 6, 2013,
I worked for MedStudy Corporation.
• I have a non-compete with MedStudy until January 7,
2016.
• I currently own and teach for a Primary Care CME
company—that does not do ANY Board Review
Preparations—just fun CME courses.*
• I supplement my income by doing Home Health
assessments.
*This was true as of 8/19/15…In January 2016, ABIM will allow routine
approved CME to count for Part 2!
• If you plan on starting your own
company from scratch, plan on eating
Raman noodles and having to drink box
wine or really, really cheap gin/bourbon
during the first 3 years.
Changes You May Wish to
Make in Practice
1. Find an easier way to navigate MOC
2. Understand the whole process of
reciprocity and whether it helps you or
not
3. Demonstrate to you which “Parts” are
quick and easy if you are in a time
crunch
Preparation
• I meticulously went through the ABIM
and ABP websites
• I followed the total public decimation of
the ABIM (Newsweek to blogs)
• The ABP Response to ABIM temporarily
getting rid of “Part 4”
Preparation
• I surveyed the Med-Peds listserve
• Allen Friedland supplied documents from the APDIM
and APPD meetings from the ABIM and ABP
• I used my 18+ year knowledge of teaching at various
Board reviews and knowing what people have told
me personally about how they survived/navigated the
ABIM and ABP
Comments from Your Peers
“I approached the whole process with the view that it was a
stupid useless burdensome exercise and looked for the easiest
way to complete the requirements with no expectation I would
learn anything from the process. I went to the online Part 2
offerings on the board sites and selected ones that were free and
which I might have a chance of passing without further study
(e.g. General Medicine update). I took the tests without reading
anything, kept track of the answers, usually failed on the first try,
but with a retake or two I passed the test and got the credit with
very little investment of time. Part 4 I did by looking around on
the website for a free easy program and found the Joslin
Cardiovascular exercise. I quickly reviewed some charts, waited
a few months and reviewed some more charts and I was done. It
also was relatively painless. Both boards credited me for this.”
Part 4 is now easier as
my hospital's diabetes
performance
improvement program
now counts and I work
in a PCMH* which also
counts.
*An NCQA (National Committee for Quality Assurance) designated Primary Care
Medical Home (PCMH).
“I'm totally
overwhelmed
and confused
by the process”
“I tried to start one of the AAP practice
improvement modules - I thought that
hypertension would be easy - but I don't have
enough clinical volume to be able to complete
this in a reasonable timeframe. It's going to take
me two years of one half day clinic per week (in
a resident clinic that sees mostly kids <3) to
complete 2 initial and followup cycles with 25
charts at a time.”
“I have honestly not found any straightforward or useful MOC 4
activities. I think the modules through AAP Equipp are the
easiest to get through, especially now that there is no extra
cost on top of AAP membership. Having said that, I cannot say
these activities have changed my clinical practice. I learned a
lot more when mentoring a few QI projects with residents, but
at the time it was too cumbersome to have those projects
accepted to meet my MOC 4 requirements.
I completed one MOC 4 module through the ABP on influenza
vaccine. I had to give surveys to participating patients to
complete which I found really disrupted the flow of the
visits and would not recommend those. I prefer to go back and
do a chart review on my own terms.”
“My academic appointment is primarily IM, so I was planning
on using reciprocity for Peds and doing my points in IM (with
some medical knowledge points in Peds, too, just to keep up
my skills). However, my first Peds cycle ends in December
2016, and I don't have to earn any substantial IM points until
December 2018. My IM points don't even count until January
2016! My initial certification for both was in the same
year. I'm also leery of counting on ABIM part 4 points when
they're "suspended." I have just 4 hours/week of Peds clinical
activity (precepting residents) so getting part 4 points on Peds
is going to be really hard, but I'm afraid of putting off part 4
until I only have a few months to go... it's a dilemma.”
Editorial note from Tommy: (I would disagree and say this….)
Cost of Recertification
• Internists will incur an average of $23,607 (95% CI,
$5,380 to $66,383) in MOC costs over 10 years,
ranging from $16,725 for general internists to
$40,495 for hematologists-oncologists. Time costs
account for 90% of MOC costs.
• Cumulatively, 2015 MOC will cost $5.7 billion over 10
years, $1.2 billion more than 2013 MOC. This
includes $5.1 billion in time costs (resulting from 32.7
million physician-hours spent on MOC) and $561
million in testing costs.
Ann Intern Med. Published online 28 July 2015 doi:10.7326/M15-1011
ABIM unlinks MOC enrollment from
board certification (Dr. Baron
BLOG post—August 4, 2015)
• Diplomates who lost certification solely
on the basis of failure to enroll in MOC
or to pay MOC fees have now had their
certification status updated to “certified.”
ABIM Requirements (8/2015)
ABIM Changes January 2016
• Maintaining Cardiovascular Disease certification will no longer
be required to maintain certification in Advanced Heart Failure &
Transplant Cardiology, Clinical Cardiac Electrophysiology,
Interventional Cardiology and Adult Congenital Heart Disease
• Maintaining Gastroenterology certification will no longer be
required to maintain certification in Transplant Hepatology
• Maintaining another certification will no longer be
required to maintain certification in Adolescent
Medicine, Hospice & Palliative Medicine, Sleep
Medicine and Sports Medicine
ABIM Requirements 8/2015
• The MOC program requires that you complete some MOC
activity every 2 years and earn 100 points every five
years (at least 20 in Medical Knowledge).
• Points earned every 2 years will also count toward your fiveyear requirement, and also count toward the milestones for the
certifications you are maintaining. Points earned count toward
all certifications being maintained.
• If you are in fellowship, you can earn 20 MOC points for each
eligible year of fellowship training (10 in medical knowledge, 10
in practice assessment)
• If you are dual-boarded by one or more of the other American
Board of Medical Specialties (ABMS) member Boards, your selfevaluation requirements will be waived—if you fill out reciprocity.
ABIM Requirements Continued
• Pass the MOC exam in your
specialty(ies) every 10 years (first exam
attempt in each certification area you
maintain earns 20 MOC points).
• Part 4 is currently not required:
• Practice Assessment
• Patient Voice
• Patient Safety
ABIM Requirements for
Reciprocity
• To receive credit, ABIM diplomates will need to attest that they
are current and participating in the other Board's MOC program.
Diplomates will still need to meet the other ABIM MOC
requirements:
•
•
•
maintain a valid, unrestricted and unchallenged medical license
pass a secure ABIM MOC examination
meet any ABIM-specific, subspecialty-specific procedural requirements
• About attesting:
•
If you are eligible to participate, you will see a link on your home page. The
link takes you to the attestation form.
• Upon attesting, self-evaluation credit is applied to your ABIM
MOC Status Report.
ABIM Requirements for
Reciprocity
• ABIM will randomly audit attestations. Providing false
or misleading information could result in disciplinary
action by ABIM, including certificate revocation and
reporting of misrepresentation to state medical
licensing boards.
• You will be required to complete a new attestation
form every 2 years in order to continue to receive
ABIM MOC credit. When due, a link will appear on
your personal ABIM home page and a reminder email will be sent to your e-mail address.
ABIM “Free” General IM Part 2
Note. That there are only 74 Part 2 points available for “Free” from the ABIM.
Remember, you have to have 100 points total over 5 years. Hmm…..
So either do “non free” part 2’s or free part 4’s or specialty free part 2’s to reach 100 points.
ABIM “Free” General IM Part 2
Note. That there are only 74 Part 2 points available for “Free” from the ABIM.
Remember, you have to have 100 points total over 5 years. Hmm…..
So either do “non free” part 2’s or free part 4’s or specialty free part 2’s to reach 100 points.
ABIM Part 2 “Free”
• Easy to do quickly if you don’t care
about “failing” initially
• For example, run through 2013 ABIM
Update in Internal Medicine
• Answer questions off the top of your head
• If you pass, great; if you fail, they tell you which
ones you missed. Go back and answer those—
repeat process till you pass
• If you are an ACP member—the link takes you
directly to the answer—Yes, it is just that easy.
ABIM “Non-Free”
• MKSAP
• MOC Modules online from ACP Meeting
last/this year—gives you 30 points—but
you have had to pay registration for the
meeting for it to be “Free”
• NEJM
• SGIM
• Many other organizations
IM Certification Examination: First Taker Pass Rates
Categorical IM vs Medicine-Pediatrics
100%
88
83
80%
84
85
77
84
86
83
87 86
60%
IM
IM/Peds
40%
20%
0%
2010
2011
2012
2013
2014
Most Commonly Used MOC
Modules Med-Peds 2010-2014
ABIM Part 4 (PIMs)
• Tons of choices
• Easy chart reviews to patient surveys
• Osteoporosis noted by many
• Many do their own QI projects (PIMs)
and turn them in
• Only requires 25 patients at baseline and 1
repeat measurement after “intervention”
• Those in teaching do Clinical
Supervision PIM
ABP Requirements
• Every 5 years must have 100 points
• Part 2: 40 points
• Part 4: 40 points
• Part 2 or 4: 20 points
• Part 3 test every 10 years
• May change in 2017 with MOCA –
Maintenance of Certification Assessment!!
Exciting News for Peds and
Med-Peds Residents!
• All residents will be enrolled in November of
your PL1 year!!
• You have to complete 100 points within your first 5
years after graduation. Congrats! Welcome to our
nightmare.
• Do Part 4 now in residency and “bank it” (have your
preceptor do the Motivation Interviewing PIM—it
gives you and THEM credit).
• Those going into Fellowship get 10 points of part 2
and part 4 each year just for being in Fellowship
More Resident ABP MOC info
• Residents can now earn Part 4 MOC credit during residency for
meaningful participation in QI activities (just like a diplomate)
•
•
•
PIMs (like the motivational interviewing PIM)
Approved QI projects in institutions and organizations
Authorship of qualifying QI articles or posters/platform presentations
• Resident MOC credit will be “in the bank” for when they become
certified. It will then be applied to their first MOC cycle.
• Residents can access other ABP Part 2 activities (e.g. self
assessments), but will not receive bankable credit for any Part 2
activities.
ABP Part 2 (“FREE”)
• General Knowledge
• 200 questions, BUT you only get 10 points
• Save this till before your exam because it is VERY similar to
the testing center test—a good way to tell if you are ready
• One example: Asthma—30 questions for 20 points
• Simple if you manage asthma
• Just use the provided reference (300+ pages!) to answer all
the questions
• (took me less than an hour—hint…the reference is a PDF—
just do a keyword search based on the question; for example
question on increased risk of asthma from “infant
exposures”)
ABP Part 2 “Free”
• Unlike ABIM, you only get 1 chance to
get it right
• For example, on the asthma part 2, I had to
get 80% correct for it to “count”.
• Makes you nervous early on, and you
generally find yourself being overcautious
and looking up stupid things you know. It
tells you as you answer if you are
right/wrong.
Question of the Week
• “Approximately 20 minutes will be required to read
the case study, abstract and commentary and answer
the question presented in this assessment. You
must attest that you have read the materials by
committing your response. If your final response is
incorrect, you will not have another opportunity to
answer the question. You are not required to
complete the assessment in one sitting, and may
save and complete it later.”
• 25 questions correct = 10 MOC points
•
(No limit in 5 years—so you could do 250 questions in 5 years for 100 points if you
answered everything correctly)
Part 2 “Not Free”
• PREP
• Generally recommended because it has
“similar questions” to ABP testing center
exam
• Multiple Sources—generally all cost
money (Q&A series, etc. or specialty
society membership)
ABP Part 4 “Free”
• All require baseline + 2 post intervention
processes and various intervals
• Minimum time to complete: 2 weeks
(Handwashing and Reducing errors in
prescriptions!); most minimum 6-8
weeks; a few 4 weeks
ABP Part 4 “Free”
All Ages including adults!
•
•
•
•
Handwashing
Health Literacy
Influenza
Motivational
interviewing
• Patient Centered
Medication
Management
• Reducing errors in
prescriptions
ABP Part 4 “Age Specific”
• Adolescent Depression
screening
• Chlamydia (adolescent
females)
• Critical congenital heart
disease (newborns)
• Developmental survey
(9 months and 24
months)
• Enhancing breast
milk use in nursery
• Obesity (2-18 years)
• Preschool vision
screening (3-5
years)
Part 4 “Free” Patients/cycle
• 10: ADHD, Breast feeding in nursery,
adolescent depression screening, improving
asthma care
• 15: Reducing errors in prescriptions
• 20: Chlamydia, Developmental, Influenza,
obesity, patient centered medication,
preschool vision
• 30: Handwashing
• 40: Critical CHD
Part 4: Forms
• Only 1 form (no patient or staff):
• Critical CHD (newborns only)
• Patient centered medication management
• Only 1 form (just to patient)
• Handwashing
• All the rest are usually 2 forms
(commonly patient/parent and
physician)
Part 4 “Not Free”
• AAP has lots of resources including
EQUIPP!
Part 3—MOCA?
• MOCA is based on the American
Board of Anesthesiology (ABA),
which coined the term “MOC
Anesthesiology (MOCA) Minute” to
describe their assessment tool.
MOCA
• Last year, 1,400 ABA diplomates participated in the
initial MOCA Minute pilot.
• 1 multiple choice question via email every week.
• They could choose when to open the question, but once it was
opened, they had 1 minute or other time period depending on
complexity to answer.
• Immediately after submitting the answer, a feedback page
appeared indicating whether the answer was correct, as well as a
brief explanation of the correct answer, the learning objective, key
references, a comment box, and links to learning resources
provided by the various anesthesiology specialty societies.
• If the diplomate answered the question incorrectly, some follow-up
questions on the same general topic continued to appear in
subsequent weeks or months.
More on MOCA
• The Anesthesia Board announced that it will replace its current
every 10-year Part 3 MOC exam in general anesthesiology with
an expanded MOCA Minute pilot as part of their redesigned
MOCA program (i.e., MOCA 2.0).
• Their diplomates will be required to answer 30 questions per
quarter (120 questions per year). MOCA 2.0 will be
“summative,” meaning that a pass/fail decision is made based
on the diplomate’s answer pattern over time. Those approaching
the minimum standard will receive an alert and have the
opportunity to improve their performance.
ABP “MOCA”
• The ABP is planning to conduct its own pilot study
and will be developing a version of MOCA to be
launched no later than January 2017.
• Diplomates will establish a practice profile when
registering for MOCA, so that the content can be
weighted to suit the type of practice.
• Diplomates may receive 1-3 multiple choice
questions per week.
ABP “MOCA”
• Online resources or books may be used, but because
each question is timed, you’ll need to judge carefully
whether to invest time in searching through a
resource.
• A feedback page will pop up after submitting the
answer.
• If MOCA is ultimately adopted, the ABP will make
pass/fail decisions based on the response patterns.
Those who successfully participate will meet
standards for Part 3 of Maintenance of Certification.
ABP Reciprocity Credit with ABIM
• If you are ABP certified seeking reciprocal credit for
participation in MOC ABIM, you must satisfy the
following eligibility criteria:
• You are a diplomate of the ABIM.
• You are currently meeting MOC requirements with ABIM.
• You have earned at least 20 Part 4 MOC points with ABIM
within the last 5 years.
• You have/will continue to complete the required Parts 2 & 4
activities with ABIM.
• You are certified and according to your ABP Portfolio your MOC
cycle ends this year OR you are trying to regain your
certification/the designation of meeting MOC requirements.
MOC Enrollment exempts you
from CME requirements for
these State Licenses
•
•
•
•
•
Idaho
Minnesota
North Carolina
Oregon
West Virginia
• California!—Once
you take the exam
at testing center and
pass you get 100
hours credit for 4
consecutive years!
September 2015 ABIM Bombshell
• Assessment 2020 Task Force
Findings to Focus Discussion of
Changes to ABIM Certification and
Maintenance of Certification
• 150 page pdf
•
(http://transforming.abim.org/assessment-2020-task-force-findings-to-focus-discussion-of-changes-to-abim-certificationand-maintenance-of-certification/
• Bottom Line: Part 3 (the testing center
test) to go away for ABIM as well!
Members of the Task Force
•
•
•
•
•
•
•
•
•
•
Harlan Krumholz (Chair) Yale University
Richard Baron American Board of
Internal Medicine
Lee Berkowitz University of North
Carolina (Chapel Hill)
Jack Boulet Educational Commission for
Foreign Medical Graduates
David Coleman Boston University
Ezekiel Emanuel University of
Pennsylvania
Kevin Eva University of British Columbia
Ted Eytan Kaiser Permanente
David Johnson University of Texas
Southwestern (Dallas)
Rebecca Lipner American Board of
Internal Medicine
•
•
•
•
•
•
•
•
•
Marilyn Mann Patient Advocate
William McGaghie Loyola University
Chicago
André A. Rupp Educational Testing
Service
Martín J Sepulveda IBM Corporation
Candace Thille Stanford University
Graduate School of Education
Abraham Verghese Stanford University
School of Medicine
Robert Wachter University of California
San Francisco
Patrick Alguire (Ex-officio) American
College of Physicians
Steven Durning (Ex-officio) Uniformed
Services University
Subtle Difference Between IM
and Peds
“I just finished a set of PREP questions that were still
relevant to what I do (resident education), even
though some of them seemed to be less relevant (like
the one about teaching testicular self-exam.
Really?).”
IM versus Peds
• IM Testing Center Test
• HARD (similar to initial cert)! (as of 10/2015)
• Evidence-based
• Peds Testing Center Test
• Easy compared to initial exam
• Not-evidence based—AAP based
• Example: Testicular cancer screening
recommended by AAP but not by USPSTF
Options
• Do IM and Peds separately
• Still make sure you get the IM 30%
discount!
• Do IM and get reciprocity with Peds
• Do Peds and get reciprocity with IM
Do all IM and get Peds Reciprocity
• Pros:
• Most people need to study for the IM test
• If you use MKSAP you get CME and Part 2 credit all at the same
time to prepare you for Part 3
• For Peds reciprocity, you only need 20 points in IM Part 4
(which most people find the most painful) but, this has to be
within 5 years (so, you have to do a part 4 every 5 years no
matter which reciprocity you pick, but doing Peds requires 40
points every 5 years)
• Part 2 IM can be done in a weekend
• Cons:
• Every 2 years you need 20 new points
Do all Peds and get IM reciprocity
• Pros:
• Peds Part 4 are generally easy to do or do
EQUIPP if AAP member
• Only have to complete it every 5 years (no every 2
year requirement of doing “something”)
• Cons:
• Less easy to get Peds Part 2 points for free
• IM test requires more study so end up spending
time and money on part 2 products for IM anyway
Bottom Line
• Most of us do various Part 2
preparations in each IM and Peds
• Part 4 is the sticky point to figure out
• Unless you have lots of Part 4
opportunities: QI projects, Medical Home
designation, etc….then for you, it is easier
to get Part 4!
Bottom Line for Me
• Is Part 4 “Easy” or “Hard” for you
• Easy? Take your pick of whether you’d
like to do 40-60 points of Part 2 (to reach
total of 100 points) every 5 years (Peds) or
40-80 points of Part 2 every 5 years at 20
points a pop q 2 years (IM)
• Hard? Pick IM, otherwise you have to do a
Part 4 for 40 points every 5 years instead
of 20 points
If you are a resident…
• Bank as many part 4 points as you can (up to 60
points) for Peds.
• Then when enrolled in MOC, I’d do Peds and get IM
reciprocity. You only need 40 points in Part 2 Peds by
the end of 5 years and the reciprocity in Peds lasts
you 10 years in IM.
• Then, reevaluate in 9 years (when IM is due) based
on your ability to get Part 4 (remember you can do
nothing in Peds from years 6-9 and “still meet
requirements”, while IM requires something done
every 2 years).
References
• http://www.abim.org
• https://www.abp.org
• Ann Intern Med. Published
online 28 July 2015 doi:10.7326/M151011
• http://www.newsweek.com/certifiedmedical-controversy-320495