Overview: MOC/Life Long Learning Update
By Michael L. Ritchey, M.D., LLL Chairman, H. Ballentine Carter, M.D., President, Gerald H. Jordan, M.D., Executive Secretary
Recertification was required for all Diplomates whose certificates were issued after January 1985 and before 2007. This process mandated a review of the Diplomates practice every ten years. Maintenance of certification (MOC) is required for all Diplomates with certificates issued after January 1, 2007. MOC is a mandate of the American Board of Medical Specialties (ABMS). This program requires completion of different levels every 2 years. There are several components that are examined: Professionalism and Professional Standing (Licensure and Peer Review), Life Long Learning and Self-assessment (CME), Assessment of Knowledge, Judgement and Skills (Examinations) and Improvement in Medical Practice (Outcomes and Quality Improvement). The MOC process has been an evolving one and will continue to do so. The ABMS continuously re-evaluates these programs through the Committee for Continuous Certification (C3). ABMS standards for MOC allow medical boards some flexibility in development of the programs. The C3 committee reviews all member boards annually. Each year they undertake a review of one of the four parts of the MOC process.
In recent years, many member ABMS boards have been making changes to the MOC process. The ABU has done the same. Prime in this process has been the evolution in mindset concerning just exactly what MOC was designed to accomplish. In that evolution was the development of a concept that certification was not a singular process, but rather a process that needed to be “maintained continuously” throughout the physician’s practicing lifetime. However, after significant discussion with our Diplomates we realize that certification is a singular process followed by a process where the ABU (via a number of mechanisms) assesses a physician’s performance in practice throughout that practicing lifetime, but from the standpoint of identification of potential areas of weakness. We then work with the physician to remediate those areas. Thus, we are not using the term Maintenance of Certification any longer, as it implies a process contrary to our current process and, in its place, will use Life Long Learning (LLL) program.
Last year, we made the decision to revert to a modular examination. This was due to the recognition that many urologists specialize in very narrow areas and the previous exam tested the entire spectrum of adult urology. We have also made a decision to include a large percentage of questions that have been used on the AUA SASP exam. Moreover, we are making an effort to have more questions on the exam that are related to AUA guidelines. The purpose of the exam is to assess our Diplomates to ensure that they are maintaining a good knowledge base. In the past, a poor exam score could result in “failure” but the rate has been generally quite low. We have noted in recent years that the “failure” is higher for our older Diplomates in their 3rd recertification/MOC cycle. As already mentioned, we have listened to our Diplomates concerns about the MOC process, particularly the exam.
Our Trustees have attended AUA section meetings to discuss the MOC program and, this year, we conducted a town hall at the AUA to listen to your concerns. The board recognized that the MOC examination caused great anxiety. As a result, the ABU Trustees no longer support a “high stakes” exam. We feel that our Diplomates are better served through Life Long Learning. We do expect that our Diplomates maintain criteria standards for safe and effective urologic care.
The ABU is now taking the approach that we will be assessing all the components of LLL to determine if our Diplomates can continue forward in the process. The examination is just one of these components. It is the entire process that will be used to make a summative decision. One advantage our Board has is the submission of billing logs. Although this is time consuming for all involved (Diplomate, ABU staff and Trustees), it provides great insight into the actual practice of the Diplomate and assessment of their practice standards. We will use the billing logs to verify that our Diplomates are taking the modular exam that best fits their clinical practice. This allows a much better assessment of their knowledge base required for their individual practice. In addition, the practice logs allow the Trustees to be certain that the Diplomate has a sufficient case load to maintain their skills. Most importantly, we have the opportunity to provide feedback to the Diplomate.
In lieu of formal scoring, we will use the results of the modular exam to provide our Diplomates with metrics on their performance. We will be able to identify those individuals who demonstrate some knowledge gaps and then assign individually directed CME requirements. Diplomates will be required to complete CME related to content areas where they performed poorly. They will have to document completion of the assigned CME before proceeding in LLL. This lifelong learning is an essential component of all “MOC” programs. If one does not complete the required CME or does not elect to just retake the exam, you will not be allowed to continue in the LLL process. In addition, if one does not take the LLL exam assessment, you will not be allowed to continue in the LLL process.
Another major change to our prior MOC process is the frequency of LLL cycles. In the past, we have required completion of some element of the process every two years. These components included: verification of licensure, completion of Practice Assessment Protocols (PAPs), submission of CME, peer review, professionalism/ethics modules, patient safety modules, peer review and billing logs and the exam. We have changed from four cycles to only two cycles. This will, hopefully, decrease the time required to participate in LLL throughout the 10-year window.
Lastly, other recent changes to the “MOC” program are the ability to use registry participation to obtain credit for LLL. We currently allow participants in the MUSIC registry in Michigan, and the AUA AQUA registry to receive credit for this quality improvement work. Another avenue to receive credit is participation in the ABMS Multi-specialty Portfolio program. This is more likely to be used by Diplomates who are part of a large health system, e.g. Kaiser, or those in academic practices. However, the number of opportunities to receive credit will grow over time. The ABU only recently joined the Portfolio program.
We will continue to annually reassess our Life Long Learning program. We do have to ensure that our program is compliant with the overarching standards developed by ABMS, of which we are a part. Just as medicine in general requires continuous learning, the ABU and ABMS also have to continue to learn. We will always welcome your feedback regarding the program.
Schedule and Fees:
In 2009, the Board implemented a $200 Annual Certificate Fee to streamline and replace all Recertification and Life Long Learning (LLL) fees. The Annual Certificate Fee, payable by April 1, is charged to every ABU Diplomate who certified after 1985.
Life Long Learning Handbook:
Life Long Learning Level 2 General Knowledge Assessment:
The knowledge assessment portion of the Life Long Learning program will not be used as a primary single metric that influences certificate status but rather to help the diplomate to identify those areas of strength versus weakness in their medical knowledge, knowledge that is pertinent to their practice. To that end we will continue the modular format for the Lifelong Learning knowledge assessment. The knowledge assessment will be based on Criterion referencing, thus allowing the identification of two groups, those who unconditionally pass the knowledge assessment and those who are given a conditional pass. The group getting a conditional pass will consist of those individuals who score in the band of one standard error of measurement above the pass point down to the lowest score. That group would be required to complete additional CME in the areas where they demonstrate low scores. After completion of the designated CME activity, they would continue in the Lifelong Learning process and the condition of their pass would be lifted. Going forward, it will be strongly recommended for all diplomates to take the knowledge assessment in year 7 of their Lifelong Learning cycle. This allows all to have three knowledge assessment attempts before expiration of their certificate. Those electing to not take advantage of the three opportunities to take the knowledge assessment would risk the possibility of their certificates expiring before the knowledge assessment is either unconditionally passed or conditionally passed with the conditions lifted on completing the assigned CME.
Life Long Learning Level 2 Pediatrics Knowledge Assessment:
The Life Long Learning Program Pediatric Subspecialty knowledge assessment is a 150 multiple choice question assessment designed to assess knowledge in the field of pediatric urology.
The knowledge assessment will include all aspects of pediatric urology, including but not limited to: congenital abnormalities, childhood acquired urologic problems such as tumors and trauma, and overlapping problems of adolescence.
The examination is a four-hour, proctored, computerized knowledge assessment which is administered at over 200 Pearson VUE testing centers located throughout the United States, Canada, and Puerto Rico.