Meeting the Challenge of MOC

Part 1: Life is not always fair, but I am determined.

BY ANDREW RABINOWITZ, M.D.

To practice medicine in today’s world takes a dedicated soul who is willing to commit time, energy, thought and funds to remain viable. As I approach my mid 40s with a wonderful family, a solid career and a hefty mortgage, the last thing I thought I would be considering at this point in my life was studying to maintain my certification as a board-certified ophthalmologist.

However, that is exactly what I am facing this year. For the next few months, I will be trying to find the time in an already crowded schedule to prepare for a process that I consider unfair and, at least in my case, unnecessary. I may not like it but I am determined to face the Maintenance of Certification (MOC) challenge and successfully conquer it.

I also would like to make it clear that while I consider the MOC program as currently structured an imposition on me and many other qualified physicians, I do understand that if the medical community does not find ways to maintain and monitor professional performance then government will do it for us. Self-regulation is preferable to government regulation, but as I will explain here, I believe there are better ways than the MOC process to ensure competency.

In this series of three articles, I will chronicle my experience with the MOC process. This process includes a proctored, closed-book examination as well as an on-line chart review known as an On-Line Review of Records (ORR). I will also discuss the personal and professional sacrifices necessary to successfully maintain my board certification. In addition, I will evaluate the resources available to the practicing ophthalmologist to facilitate MOC.

A Reluctant Pioneer

I am not looking forward to sacrificing family or professional time to achieve the task at hand. That being said, I have never been one to shy away from a challenge.

Through my articles, I will attempt to ease the path of those who will follow in my footsteps during the coming decades. I hope that coming generations of physicians can pursue the MOC process with less anxiety than those of us who will be the first to take these steps.

Here is a brief recap of the process that I — along with thousands of other highly competent physicians — am currently facing:

The American Board of Medical Specialties (ABMS) is a governing body that encompasses 24 unique specialties. The American Board of Ophthalmology (ABO) is a participant in the ABMS. The ABO has mandated that all ophthalmologists who attained board certification after July 1, 1992 must recertify every 10 years. MOC is the process through which ophthalmologists will achieve recertification.

I am among the thousands of ophthalmologists who attained board certification after July 1, 1992. All of us who share this distinction have been mandated to participate in the MOC process. The American Academy of Ophthalmology (AAO) has developed a unique new section of its Web site aimed at assisting ophthalmologists through the MOC process.

The Elements of MOC

The process of recertification will encompass four main areas of proficiency. These broad areas have been well conceived and articulated by the ABO, which says that “the primary purpose of MOC is to protect the interests and welfare of our patients.” The four areas include:

■ Evidence of professional standing. Candidates will be required to submit proof of licensure when they begin the MOC process and when they register for the examination.

■ Evaluation of practice performance. Candidates will be required to perform an Office Record Review (ORR), a self-review of clinical practice

■ Evidence of commitment to lifelong learning and self-assessment.

• candidates must achieve an average of 30 category 1 CME credits per year
• candidates must attain 3 hours of ethics of CME certification
• candidates must take two 50-item, Web-based self-review tests referred to as Periodic Ophthalmic Review Tests (PORT). One of these tests will be in core ophthalmic knowledge and one will be in an area of practice emphasis of the candidate.

■ Evidence of cognitive expertise. This area involves a closed-book, 150-question exam known as the demonstration of cognitive knowledge (DOCK) exam. The DOCK exam is given to show evidence of cognitive expertise. The DOCK is a proctored examination that will replace the previously used take-home, open-book CREW exam. The DOCK must be completed once during the MOC cycle and consists of three 50-item sections (one in Core Ophthalmic knowledge, and two drawn from a choice of a maximum of two practice emphasis areas.

The mandate for periodic recertification will undoubtedly be fodder for fervent debate in years to come. Currently, ophthalmologists throughout the United States practice without having passed their initial written and oral qualifying board examinations. Many patients are unaware as to whether their physician is board-certified or board-eligible. There is no public record to which they can refer to determine if their doctor has taken the exam and failed, or if their doctor simply chose not to sit for the exam at all.

Potential confusion among patients may increase if candidates who are eligible for recertification fail to achieve it, or opt not to complete the process. Today, there is no mandate that a physician attain board certification to practice medicine. Few, if any, third-party insurers will “only” credential board-certified doctors. Most plans will willingly credential board-eligible physicians. The paradox is that there is no enforceable time limit to the board-eligible status.

A Better Standard

A more transparent credentialing process is needed. We could end any chance of potential confusion if ophthalmology adopted a standard that all licensed, practicing physicians achieve board certification within 5 years of completing their residency or fellowship. A physician who could not achieve a passing score on the written and oral qualifying examination would not be allowed to practice medicine until successfully repeating a training program and reaching a proficiency level necessary to pass the requisite tests.

If this “mandatory” achievement of board certification becomes a requisite for state licensure, then and only then do I feel it would be reasonable to ask physicians to recertify on a periodic basis. I find it hypocritical to mandate that some doctors must recertify while not mandating that all physicians achieve an initial certification following completion of their formal residency and fellowship training.

My Plan of Attack

Between now and Sept. 30, 2007 I am going to attempt to complete all the tasks necessary to achieve MOC. My first step will be to enroll for the DOCK exam and complete my ORR. As I study for my DOCK exam, I will complete the requisite PORT modules, which will serve to prepare my for the DOCK exam. Additionally, I will ensure that I have attained the requisite number of CME credit hours in order to meet the required 30 hours per year, as well as the additional 3 hours of ethics CME.

The exam questions for the PORT and DOCK questions are based on the Practicing Ophthalmologists Curriculum (POC), a knowledge base of information developed by teams of practicing ophthalmologists. The POC comprises the clinically relevant information a practicing ophthalmologists needs to know to remain certified.

I have purchased all of the AAO resources (online and printed material) that have been created to help physicians achieve of MOC. I will also be enrolling in the AAO- sponsored MOC Review Course, which will be held in Illinois in July.

Finally, in September, I will sit for the 150-question, closed DOCK examination in hopes of completing all of the requisite standards and become a recertified ophthalmologist. I will savor the victory for the next 7 years, save my money for the next round of MOC, and try to get back to the tasks of being a clinical physician, father and husband.

Creating Resources for MOC

In future articles, I will share my observations regarding the process and its intricacies. I will evaluate the currently available study-guide resources, and attempt to create additional tools that will serve my peers when they pursue their quest for recertification. Additionally, with the sponsorship of the Dulaney Foundation, I am going to create an online resource that will help future physicians pursue MOC with greater confidence and clarity.

I hope to make this resource available to all physicians who choose to enlist our help. OM