Rheumatology Board Certification

Transcription

1 Rheumatology Board Certification Exploring Change As ACR leaders travel around the country and listen to our members talking about issues affecting our profession, few issues have engendered as much impassioned debate as Maintenance of Certification (MOC). In response to the ABIM s MOC changes and the ongoing concerns expressed by rheumatologists, the ACR has been advocating for MOC reform that is in line with the needs and goals of rheumatologists for life-long learning and for maintaining board certification. This effort has led to consideration of other options for MOC. Although the ACR does not have a direct say in determining the pathway for board certification, the ACR Board of Directors has held that these issues are of vital importance to our members, and it is important that we help make the voices of our members heard on this issue. As part of this ongoing effort, herein we summarize the current state of affairs related to board certification and the recently completed ACR survey on this issue. The ABIM was founded in 1936 and is a nonprofit, independent evaluation organization. Board Certification Since 1933, the American Board of Medical Specialties (ABMS) has established the professional and educational standards for medical specialty practice and certification in partnership with its 24 certifying Member Boards. The American Board of Internal Medicine (ABIM) is one of the ABMS certifying Member Boards. ABIM governs internal medicine and its 20 subspecialties. The ABIM was founded in 1936 and is a non-profit, independent evaluation organization. ABIM is accountable to both the medical profession and the public. ABIM is not a membership society. ABIM began offering certification in the subspecialty of rheumatology in 1971 for diplomates who had already achieved an ABIM certification in internal medicine. The majority of the ACR s 7,200 physician members are certified by the ABIM, which represents approximately 3.5% of ABIM s 200,000 diplomates. In 1990, all certificates for internal medicine and its subspecialties became time limited, requiring recertification every 10 years. ABIM continued to revise this program over time, which is known as Maintenance of Certification (MOC). In 2014, ABIM introduced its most significant changes to the requirements for MOC. ABIM MOC Reform While there has been longstanding confidence in the value of the ABIM initial certification exam in rheumatology, dissatisfaction with the ABIM MOC program has steadily grown since ABIM implemented changes in In response to member feedback, the ACR has taken a very active stance in advocating for MOC reform, particularly since ABIM s we got it wrong announcement on Feb. 3, In September 2016, the ABIM proposed a new assessment consisting of either a 2-year pathway or a 5-year pathway that would be launched in 2018, alongside the 10-year secure MOC examination. Because of widespread complaints from members about this change, the ACR sought the community s feedback on these options through a survey that was released on Sept. 8, Of the members who responded to this ACR survey, most were not supportive of either pathway. In their comments, our members noted that both the 2-year pathway and 5-year pathway represented minimal change, did not reflect current medical practice, and offered no opportunity to identify knowledge gaps or learn. During an ABIM s Liaison Committee on Certification and Recertification meeting on Sept. 15, 2018, 26 societies were asked to present their preference for a 2- or 5-year pathway. On the basis of our membership survey, the ACR stated that neither pathway was adequate; 17 other societies stated a similar position. The ACR membership feedback was also provided directly to Dr. Richard Baron, ABIM President and CEO, who was invited to attend the ACR Board of Directors meeting in November In December 2016, the ABIM announced their plans to move ahead with the development of the 2-year knowledge check-in option. In response to the ABIM s decision and concern expressed by ACR members, the ACR Board of Directors established an MOC taskforce to examine alternative options for MOC. 1

2 ABIM MOC Program Changes In 2018, the ABIM released a 2-year knowledge check-in assessment option for internal medicine and nephrology. Based on information published on the ABIM s website, each check-in includes 90 multiple-choice questions to be answered in a 3-hour time span, resulting in an average time allotment of 2 minutes per question. Both the 10-year and 2-year options for internal medicine and nephrology allow use of a singlesource information resource (UpToDate). Home test-takers are recorded via webcam in order to validate their identity. These changes reflect some response to input from specialty societies, including the ACR, requesting that MOC assessments allow for real-life open book review and less intrusive testing locations. However, the ACR does not believe that the 2 minutes per question is a realistic approximation of the cognitive and deliberative aspects of medical assessment and decision making that characterize the modern practice of rheumatology, especially given the length and complexity of the questions. The 2-year knowledge check-in is a continuation of the same high pressure, high stakes experience as the 10-year exam, and does not provide a valid assessment of physician competence. Although ABIM has indicated that additional external resources may be added in the future, they do not envision providing a true open-book format; as such, the assessment does not reflect the way that rheumatologists access specialty information. The ACR believes that requiring a webcam is unnecessarily intrusive, detracts from ABIM s goal of providing a comfortable testing experience, and is not appropriate for recertification assessment.? The 2-year knowledge check-in is a continuation of the same high pressure, high stakes experience as the 10-year exam, and does not provide a valid assessment of physician competence. In pursuing their directive, the ACR Board Certification Taskforce examined the approaches to MOC being taken by other member boards within the ABMS. The 2-year knowledge check-in option for rheumatology, with a single-source resource feature, is scheduled to be released in ACR members have indicated that increasing the frequency of assessments is not consonant with decreasing the burden of MOC. The ACR has advocated that ABIM consider revising the 2-year knowledge check-in to cover a subset of rheumatology content, rather than the broad field of rheumatology. The ACR believes assessment should drive learning and that MOC should be used to guide physicians selfdirected study. The ACR has taken the position that for the assessment to be most effective, physicians must be provided with the opportunity for rapid remediation if performance is not satisfactory, rather than waiting for the next scheduled testing window. The ACR further advocated that the ABIM consider recommendations to approve meaningful open-book access, introduce unobtrusive security features for assessments to be completed at home, offer immediate remediation, provide detailed feedback reports that allow physicians to recognize and address knowledge gaps, and be transparent in the pricing of the new assessment. ACR Explores Change In pursuing their directive, the ACR Taskforce examined the approaches to MOC being taken by other member boards within the ABMS. A shared interest in immunologically mediated disease led the ACR taskforce to contact the American Board of Allergy and Immunology (ABAI) to learn more about their MOC program. The taskforce was particularly interested in the continuous assessment program (CAP) launched by ABAI at the beginning of 2018, which is based on recently published medical articles and general knowledge questions. This program appeared to address many of the learning goals directly expressed by ACR members, while also providing a meaningful model for rheumatologists to demonstrate continual professional development with the application of evidence-based standards During a meeting with ABIM leadership, ACR representatives discussed the feasibility of piloting a similar program with the ABIM, but learned from the ABIM that a model based on literature review does not align with ABIM s MOC principles. The goals that are at the core of the ABIM principles of physician certification are meritorious insofar as they help document that physicians have achieved sufficient competence in the care of patients. However, the fact that ABAI and other ABMS certification boards have developed alternative approaches to MOC underscores the fact that there are other ways to align these principles with ABMS standards. 2

3 Exploring a New Combined Board - Allergy, Immunology, and Rheumatology In an effort to address membership concerns about MOC, the ACR Board of Directors requested ACR representatives begin to have more detailed discussions with the ABAI. To date, discussions have included the feasibility, advantages, and disadvantages of moving rheumatology to ABAI and forming a new combined board of Allergy, Immunology, and Rheumatology. If this potential option is pursued, the new board would remain as a conjoint board with ABIM in that ABIM would still provide initial certification in Internal Medicine. However, initial certification in Rheumatology would no longer be obtained through ABIM, but rather through this newly formed board of allergy, immunology, and rheumatology. ABMS requires that initial certification and MOC be issued by a single board... thus, the conversation has expanded beyond MOC to include the initial rheumatology certification.. While there has been no concern raised from the community about the initial ABIM rheumatology certification and there continues to be significant confidence in the value and validity of this exam, ABMS requires that initial certification and MOC be issued by a single board. Thus, formation of a combined allergy, immunology and rheumatology board would require development of a new initial certification exam. Thus, the conversation has expanded beyond MOC to include the initial rheumatology certification. While exercising due diligence in exploring this option, the ACR further engaged the rheumatology community in a discussion related to the future of rheumatology certification by commissioning a survey released to rheumatologists in June The purpose of this initiative was to gauge rheumatologist s perceptions on certification and help determine if an application should be prepared and submitted to the ABMS to request that rheumatology certification be moved from the ABIM to the ABAI with the formation of a new combined board of Allergy, Immunology, and Rheumatology. Quantitative Research Study The ACR undertook a significant communication effort to ensure that rheumatologists (both members and non-members) were informed about the issues related to board certification through the ABIM and the ABAI. The communication included information regarding the changes the ABIM has implemented/is implementing and the feasibility, process, and implications of moving rheumatology certification and recertification to a combined board with the ABAI. Communications included an explanation of the ACR s role as an intermediary and outlined the foundational assumptions that affirm the role of continuing board certification as part of the professional self-regulatory system and the commitment of rheumatologists to professional self-regulation as both a privilege and a responsibility. Because the validity and utility of the survey were dependent on the community of rheumatologists being well informed, the ACR was encouraged by the engagement statistics throughout the process. All s generated by the ACR received more than double the industry averages for engagement, and the ACR s website traffic surpassed any prior ACR communication efforts. In addition, the quality of questions posed by the rheumatology community indicated that thoughtful consideration had been given to the information shared. This experience underscores the importance the rheumatology community places on the issue of board certification. 1 All s generated by the ACR received more than double the industry averages for engagement, and the ACR s website traffic surpassed any prior ACR communication efforts. 3

4 To ensure the quality and validity of the survey results, the ACR engaged an independent research and consulting firm. The electronic survey launched on June 19 and closed on July 10, An invitation to participate in the survey was successfully delivered to 7,454 individual addresses and included ACR members and non-members. A total of 1,820 surveys were collected, with a completion rate of 91% and an overall response rate of 25%. The survey s margin of error of +/-2% at the 95% confidence level is a more important measure. The industry standard for member research studies is to achieve a margin of error of +/-5% at the 95% confidence level. The ACR is well within that goal; thus, the results are considered representative of the ACR s audience overall. In other words, if the survey were conducted over and over, 95 times out of 100, one would obtain results within +/-2% of the results garnered in this survey. 1,820 A total of 1,820 surveys were collected, with a completion rate of 91% and an overall response rate of 25% Study Participants* Work Status Employed by others fulltime Self-employed full-time 28% 46% # of Rheumatologists in Practice 21% 24% One 2 to 4 Work part-time Fellow in training Other 12% 7% 7% 23% 32% 5 to 9 10 or more 0% 10% 20% 30% 40% 50% 86% Spend most of their time in patient care *Please note this is an overview of the demographics and some figures have been rounded or excluded. Please refer to the Excel file for all data. 88% have hospital privileges 3 91% A total of 1,820 surveys were collected, with a completion rate of 91% and an overall response rate of 25%. Comparison of Survey Respondents to ACR Members* Main Work Setting Respondents Members Academic Medical Center Group Practice: Multispecialty Group Practice: Single specialty 27% 30% 23% 14% 20% 13% Solo Practice 13% 14% Hospital Based Practice Government: Clinical Setting VA 7% 7% 4% 1% Other NA 21% *Please note this is an overview of the demographics and some figures have been rounded or excluded. Please refer to the Excel file for all data. Primary Time Spent - Area Respondents Members Patient Care 79% 77% Patient Care with Trainees 7% 4% Research 7% 13% Other 6% 6% Division or Program Director Respondents Members Division Director 7% 1% Program Director 6% 2% Neither of the above 87% 97% 4 4

5 Key Findings 1. Most rheumatologists are satisfied or neutral toward the ABIM initial certification program for rheumatology, but are dissatisfied with the ABIM MOC program for rheumatology. Twenty-eight percent are extremely dissatisfied with ABIM MOC, while only 3% are extremely satisfied. Eighty-one percent of rheumatologists who have been certified by ABIM plan to maintain their rheumatology certification 2. Most ABIM-certified rheumatologists are pursuing MOC for rheumatology, but less than half are pursuing MOC for internal medicine. Eighty-one percent of rheumatologists who have been certified by ABIM plan to maintain their rheumatology certification, and 65% are currently enrolled in the ABIM rheumatology MOC program. Forty-two percent plan to maintain their certification for internal medicine, and 32% are currently enrolled in the ABIM internal medicine MOC program. Two percent or fewer plan to maintain other specific board certifications. Eight percent do not plan to maintain any board certifications, and one-quarter are not currently enrolled in any MOC program. Among Fellows-in-Training, 92% have obtained/plan to obtain ABIM rheumatology certification in rheumatology, and 65% have obtained/plan to obtain ABIM internal medicine certification. 100% Plan to Maintain ABIM Certification 81% 75% 50% 42% 25% 0% Rheumatology Internal Medicine 5

6 3. Many ABIM-certified rheumatologists, but few Fellows-in-Training, have prepaid rheumatology MOC program fees to ABIM. Among rheumatologists who hold an ABIM certification in rheumatology, 40% prepaid some or all of their rheumatology MOC program fees to ABIM in 2017 or 2018, 42% did not and 18% are unsure/don t know. Among Fellows-in-Training, 4% prepaid any rheumatology program fees to ABIM, 70% did not and 26% are unsure/don t know. Prepay Rheumatology Fees to ABIM? 100% 18% 26% Rheumatologists are somewhat more likely to pursue this 2-year MOC knowledge check-in (34%) than wait and take the 10-year MOC exam (23%), while 30% don t know which pathway they will pursue. 75% 50% 25% 0% 42% 40% Rheumatologists 70% 4% Fellows-in-Training Unsure 4. More than two-thirds of board-certified rheumatologists are aware of ABIM s plan to offer a knowledge check-in for rheumatology in Rheumatologists are somewhat more likely to pursue this 2-year MOC knowledge check-in (34%) than wait and take the 10-year MOC exam (23%), while 30% don t know which pathway they will pursue. No Yes No, 31% Aware of ABIM Knowledge Check-In for Rheumatology Most Likely Pathway Don't know, 30% 2-year check-in, 34% Yes, 69% Not participate, 13% 10-year MOC exam, 23% 6

7 5. Most rheumatology specialists do not expect major differences between the ABIM and ABAI rheumatology initial certification programs. The majority expect ABIM and ABAI to be similar or are unsure of the differences for each area of comparison. 6. Rheumatologists tend to expect an ABAI rheumatology MOC program to be better than an ABIM program with respect to the time required to prepare for assessment(s), ability to identify educational gaps, impact on clinical knowledge, and ability to demonstrate they are staying current in the field of rheumatology. More than half expect ABIM and ABAI to be similar or are unsure of the differences in cost, advancement opportunities, and impact on insurance reimbursements. Comparison of ABIM and ABAI Rheumatology MOC Programs Rheumatologists tend to expect an ABAI rheumatology MOC program to be better or similar than an ABIM program. Time required to prepare for the assessment/s Ability to accurately identify my educational gaps ABAI Better ABIM Better ABIM & Don t Know/ ABAI Similar Unsure 51% 15% 13% 21% 41% 17% 21% 21% Impact on my clinical knowledge 38% 16% 28% 19% Ability to demonstrate that I am remaining current in the field of rheumatology Relevance to my practice, including referrals Costs associated with preparing and taking the assessment/s Opportunities to advance in the field of rheumatology 36% 16% 31% 17% 31% 17% 26% 26% 24% 12% 42% 23% 24% 16% 32% 28% Impact on my insurance reimbursements 9% 11% 30% 51% 7. Rheumatology specialists are slightly more likely to prefer moving the rheumatology initial certification and MOC to ABAI than to prefer staying with ABIM. However, 3 in 10 need more information to decide. First Choice for Initial Certification & MOC Program Need more information, 30% Move to ABAI, 39% Stay with ABIM, 31% Groups defined by work status, work setting, year first certified (including time unlimited certification), certifications currently held, and member status are similar to total rheumatology specialists in their preferences for moving vs. staying. However, Program Directors prefer staying with ABIM to moving to ABAI, and Division Directors are divided between staying, moving, and needing more information to decide. 7

8 8. Many rheumatologists believe that moving to ABAI would provide a better approach to MOC and assessments. The most important advantages of moving to ABAI for rheumatology initial certification and MOC are the change from MOC points to CME requirements, flexibility in taking the assessment, and journal-based continuous learning format with access to reference material during the test. Many believe that staying with ABIM is the safer choice. The most important advantages of staying with ABIM are that it s a known entity and less disruptive. Staying would maintain the synergy with internal medicine and keep the initial certification process with ABIM. Advantages of ABAI CME requirements, not MOC (82%) Flexibility taking assessment (36%) Journal-based continuous learning (32%) Advantages of ABIM Known entity, less disruptive (35%) Synergy w/ internal medicine (32%) Keep initial certif. with ABIM (29%) 4 5 Choice of time of assessment (29%) (40%) Open-book access (28%) 4 5 Same board internal & rheum. (28%) ABIM more prestigious (23%) 9. Those who are dissatisfied with the ABIM MOC program for rheumatology are likely to want to move to ABAI. Most of those who are neutral or satisfied with the program prefer to stay with ABIM or need more information to decide. Move vs. Stay Preference by Satisfaction with ABIM MOC Program for Rheumatology The most important advantages of moving to ABAI for rheumatology initial certification and MOC are the change from MOC points to CME requirements, flexibility in taking the assessment, and journal-based continuous learning format with access to reference material during the test.. Dissatisfied Neutral Satisfied Not applicable Move to ABAI 51% 20% 12% 35% Stay with ABIM 19% 39% 69% 36% Need more information to decide 30% 41% 19% 29% Indicates responses that are significantly higher/lower for segment than for total respondents 8

9 10. Rheumatologists who want to stay with ABIM are more likely to be enrolled in an ABIM MOC program, have prepaid rheumatology MOC program fees to ABIM, and know which MOC pathway they are more likely to pursue. Those who prefer to move to ABAI are less likely to be enrolled in ABIM s internal medicine MOC program, to have paid any rheumatology MOC fees to ABIM in 2017 or 2018, or to know which ABIM MOC pathway they are more likely to pursue. Move to ABAI Stay with ABIM Need more information Currently Enrolled in: Rheumatology certified by ABIM 63% 70% 66% Internal medicine certified by ABIM 28% 38% 30% Not enrolled in MOC program 30% 21% 28% Other, please specify: 5% 3% 3% Prepaid Any Rheumatology MOC Fees to ABIM? Yes 34% 46% 42% No 48% 39% 38% Unsure/don t know 18% 14% 20% More Likely ABIM MOC Pathway Take the 2-year knowledge check-in 31% 41% 33% Wait and take the 10-year MOC exam 19% 32% 18% Don t plan to participate in ABIM MOC 16% 10% 14% Don t know 34% 17% 35% Indicates responses that are significantly higher/lower for segment than for total respondents Rheumatologists who need more information are looking for clarification and additional information about the ABAI program and testing and how it might impact them professionally. 11. Rheumatologists who need more information to decide between ABIM and ABAI are looking for clarification and additional information about the ABAI program and testing and how it might impact them professionally. Most of these undecided rheumatologists are unsure whether ABIM or ABAI would be better or think that the two programs would be similar. They have questions about ABAI s exam content, testing process, and cost, and they want to know if ABAI credentialing will be accepted in the medical community. Undecideds are demographically similar to all rheumatologists who assessed the ABIM and ABAI programs. Uncertain about ABAI test questions and process for initial certification and MOC Unsure/need more information/time to review differences Reasons Undecided, Information Need to Decide MOC is a waste of time and money 16% 19% 30% Uncertain about acceptability ofabai credentialing 14% Uncertain about cost 13% Unsure about impact on insurance reimbursement 6% The ACR will continue to explore all avenues for improving the process for rheumatologists so that they may better serve their patients. 9

10 Survey Key Findings There are reasons for rheumatologists to pursue moving the rheumatology initial certification and MOC program to ABAI, but there are also reasons to continue with an ABIM program. Reasons to move to ABAI: Most rheumatologists are dissatisfied with the ABIM MOC program for rheumatology. More rheumatologists want to move to ABAI than to stay with ABIM. Rheumatologists like the proposed ABAI MOC program more than the ABIM program. Many undecided rheumatologists indicated if their questions and concerns about the ABAI testing and program are addressed to their satisfaction, they could support a move to ABAI. Although most rheumatologists understand the changes the ABIM is implementing, the rheumatology community wants a different and better MOC process. Reasons to stay with ABIM: Fewer than half of rheumatologists indicate that they want to move to ABAI. Most rheumatologists are not dissatisfied with the ABIM initial certification program, which would have to move to ABAI along with the MOC program. Program Directors tend to prefer staying with ABIM to moving to ABAI, and Division Directors have mixed opinions. Rheumatology is thought by many to fit more naturally with internal medicine than with allergy and immunology. Next Steps In follow-up discussions during the 2018 ACR/ARHP Annual Meeting, rheumatologists again reaffirmed their position to seek a certification model based on the principles of physician self-regulation that assess knowledge while providing the ability to improve knowledge in a manner that not only meets but enhances patient care. Although most rheumatologists understand the changes the ABIM is implementing, the rheumatology community wants a different and better MOC process. In response, the ACR will continue to explore all avenues for improving the process for rheumatologists so that they may better serve their patients. The ACR Board of Directors will continue discussions on this topic during their next meeting in February Authors: The ACR thanks for the following members for serving on the 2018 ACR Board Certification Taskforce and for their review of this publication released Jan 24, Anne R. Bass, MD Hospital for Special Surgery New York, NY David Daikh, MD, PhD (Immediate-Past President and Taskforce Chair) University of California, San Francisco San Francisco, CA William F. Harvey, MD, MSc Tufts Medical Center Boston, MA Charles M. King, II, MD North Mississippi Medical Center Tupelo, MS Carol Langford, MD, MHS Cleveland Clinic Foundation Cleveland, OH Kelly Weselman, MD Wellstar Medical Group Atlanta, GA 10