us physician and surgeon perspectives on …internal medicine subspecialties after january 1990,...
TRANSCRIPT
USPhysicianandSurgeonPerspectivesonContinuousBoardCertification–ANationalCross-specialtySurvey
WestbyG.Fisher,MD,FACC1,TimothySanborn,MD,MS,FACC1,andCharlesCutler,MD,MACP2
RunningTitle:USPhysicianandSurgeonPerspectivesonContinuousBoardCertification1NorthShoreUniversityHealthSystem,Evanston,ILandUniversityofChicago,PritzkerSchoolofMedicine2EinsteinMedicalCenterMontgomery,Norristown,PACorrespondingAuthor:WestbyG.Fisher,MDDirector,CardiacElectrophysiologyNorthShoreUniversityHealthSystem2650RidgeAvenue,WalgreensBuilding3rdFloorEvanston,IL60201Office:847-570-2640Fax:847-570-1865Email:[email protected]:TimothySanborn,MD,MS,FACC:[email protected],MD,MACP:[email protected]:Self-funded.WordCount:2887
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USPhysicianandSurgeonPerspectivesonContinuousBoardCertification–ANationalCross-
specialtySurvey
Background:ClinicalUSphysicianandsurgeonopinionsregardingABMSandAOAContinuous
Certificationprogramsareunknown.
Objective:Toassesspracticingphysicians’opinionsofABMSMaintenanceofCertification®
(MOC)andAOAOsteopathicContinuousCertification(OCC).
Design:AnInternet-basedvoluntarysurveyofUSphysiciansandsurgeons.
Setting:Aself-selectedcross-specialtysampleofUSphysiciansandsurgeonsfrom21January
2018through19March2018.
Participants:USphysiciansandsurgeonsengagedinclinicalpractice.
MainOutcome(s)andMeasures(s):Self-reportedperspectivesoftheABMSandAOABoard
initialandcontinuouscertificationprogramsincludingperceivedvalue,costs,conflictsof
interest,researchmethods,contributiontoburnout,andnegativeconsequences.
Results:Ofanestimated759421clinicalUSphysicians,avoluntarysampleof7007uniqueUS
physicians(0.92%)representing47subspecialtiesfromeverystateandnearlyeveryUSterritory
werereceived.6048(93%)wereBoardCertifiedbyatleastoneABMSmemberboardand4793
of6004respondents(80%)participatedinMOCorOCC.5831of6477(90%)feltABMSorAOA
BoardCertificationshouldbealife-longcredentialusingContinuousMedicalEducationcredits
todocumentongoingmedicaleducation.Costsforcertificationorrecertificationexceeded
$6000for2027of6477(31%)oftheparticipants.4059of4697(86%)feltMOC/OCCcould
interferewiththeirrighttowork.390of4697(8%)physiciansparticipatingincontinuous
3
certificationperceivednegativeconsequencesfromtheprocess.4436of4697(94%)of
recertifyingphysicianswereunawaretheircertificationstatuswassoldtothirdpartieswhen
enrollingforMOC/OCC.4624of5812(80%)expressedconcernthatMOCresearchwas
conductedonphysiciansortheirpracticewithoutinformedconsent.Perceptionswerenot
differentbasedongender,thetimefollowingtraining,orpracticesetting.
ConclusionsandRelevance:WhilemostphysiciansvaluedinitialBoardcertificationwith
lifelongcontinuingmedicaleducation,dissatisfactionandperceivednegativeconsequencesto
USphysicianswithcurrentABMSMOCandAOA“continuouscertification”programsexist.As
ABMSmemberboardsarecurrentlyredesigningtheentireMOCprocess,thesefindings
reflectingtheopinionsofUSphysiciansandsurgeonsshouldbecarefullyconsidered.
4
Background
Forthefirst33yearsofexistence,theAmericanBoardofMedicalSpecialties(ABMS)andits
memberboardsissuedlifetimecertificatesfollowingpassageofaone-timeboard
certificationexam.Todemonstratetheircommitmenttolife-longlearning,physicians
participatedincontinuingmedicaleducationprogramstoenhancetheirknowledge.
Somearguedthatone-timecertificationdidnotprovidesufficientevidencethatphysicians
couldremaincompetentthroughouttheircareers.1,2,3,4,5Atitsinceptionin1969,theAmerican
BoardofFamilyMedicineissuedtime-limitedcertificationslasting7years.In1976,the
AmericanBoardofSurgeryandAmericanBoardofThoracicsurgeryinstitutedarbitrarytime-
limitedcertificationsforsimilarreasons.TheAmericanBoardofInternalMedicine(ABIM)
implementedtime-limitedcertificationforcriticalcarespecialistsin1986andforallother
internalmedicinesubspecialtiesafterJanuary1990,afterphysiciansupportforacompelling
accoladefromvoluntarycontinuouscertificationprogramfailedtoemerge.6,7,8
In1998,theABMSestablishedtheirTaskForceonCompetence,whichledallABMSmember
boardstocreateanexpandedandmorestandardizedformoftime-limitedboardcertification
calledMaintenanceofCertification®(MOC).Thefour-partMOCprogramencompassed:(1)
licensureandprofessionalstanding,(2)life-longlearningandself-assessment,(3)cognitive
expertisethroughformalexamination,and(4)practiceperformanceassessment.By2006,all
24ABMSmemberboardshadreceivedapprovalfortheirindividualMOCproducts.9The
5
AmericanOsteopathicAssociationinstitutedasimilarcontinuouscertificationprogramcalled
OsteopathicContinuousCertification(OCC)forDoctorsofOsteopathyin2013.
PracticingPhysicianConcernswithMOCandOCC
Controversyeruptedwiththeimplementationofthenewfour-partMOC/OCCrequirements
forcontinuouscertification,mostprominentlyfromtheInternalMedicinecommunity.10
Whilemostphysicianssupportcontinuingprofessionaldevelopmentandlifelonglearning,11
substantiveconcernswereraisedabouttheprogram’seffectiveness,12,13finances,14cost,15
researchmethods,1undisclosedlobbying,16andbusinessconflictsofinterestexposedthrough
Congressionaltestimony.17InJuneof2015,Resolution309waspassedintheAMAHouseof
DelegatesadvocatingforamoratoriumonMOCrequirementsforallmedicalandsurgical
specialtiesuntilithasreliablybeenshowntoimprovepatientcare.18
InSeptember2017,afteracknowledgingphysicianconcernswithMOC,theABMSconveneda
“VisionInitiativeCommission,”comprisedofbothphysiciansandnon-clinicalprofessionals.
TheCommissionistaskedwithmakingrecommendationstoimprovethecurrent
recertificationprocess,however,theirfindingswillnotbepubliclyavailablefor12-18months.
ThereisstillcontroversyrelatedtowhetherABMSMOCimprovespatientoutcomes.12,19,20,21
Weundertookanindependentnationalsurveytoassessrecentphysicianperceptionsof
continuouscertification.
6
Methods
PracticingPhysiciansofAmerica,aphysicianmembershiporganizationwithitshomeofficein
NewBraunfels,TX,conductedaself-selectedInternetsurvey(SurveyMonkey,SanMateo,CA)
amongabroadsampleofboard-certifiedUSphysiciansfromJanuary12throughMarch19,
2018.The8-page,32-questionquestionnaireincludeddemographicvariablesandspecific
questionsregardinginitialcertification,maintenanceofcertification(MOC)andOsteopathic
ContinuousCertification(OCC)programs.
SamplingandHumanSubjects
Physicianswerevoluntarilyrecruitedusingsocialmediaandweb-basedchannels.According
tothelatest2016AssociationofAmericanMedicalCollegesPhysicianWorkforcereport,
thereare759421totalpatientcarephysiciansintheUnitedStates23.Weusedthisnumberto
estimatethetotalpopulationofUSphysiciansinclinicalpracticeandtodeterminethemargin
oferrorofoursurvey.Nomonetaryorin-kindincentivewasofferedforsurveycompletion.
Atthebeginningofthesurvey,physiciansweretoldtheywouldbeaskedfortheirnameand
emailattheendofthesurveytoverifytheirresponsesbutwerenotrequiredtoprovidethis
information.Thesurveyincludeddemographicvariables,Likertscalesfrom1to5toquantify
responsesofattitudesoninitialboardcertificationandcontinuouscertification,andother
nominalyes/noresponses.Priortodistribution,twelveABMSBoard-certifiedphysiciansfrom
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varyingsurgicalandmedicalsubspecialties(anesthesia,surgery,pediatrics,dermatology,
internalmedicine,cardiacelectrophysiology,interventionalcardiology,familymedicine,
osteopathicfamilymedicine,emergencymedicine,andpsychiatry)wereinvitedtoreview
surveystructureandwordingpriortodistribution.Toavoidmultiplesurveyresponsesfrom
thesamerespondentandtogeo-locaterespondents,Internetcomputeraddresseswere
tracked,andresponseslimitedtouniqueIPaddresses.Locationsofrespondentswere
assessedandquantified(BatchGeo,LLC,Portland,OR).Anonymoussurveyresponses
completedfromIPaddressesoutsidetheUSwerereviewedtoassureparticipantswereUS
physicians(e.g.,military,charitymissions,etc.).Skippagelogicwasusedinsomesurvey
questionresponsestodirectparticipantstoappropriatequestionsandtolimitresponsesto
physiciansinactiveorrecentclinicalpractice.Non-physicians,non-clinicalphysician
researchers,industry-employedphysicians,andphysiciansnotyetboardcertifiedwerepre-
specifiedtobeexcluded(Figure1).ThesurveywaspublishedtothePracticingPhysiciansof
Americawebsite(PracticingPhysician.org)andspreadthroughasecuresharableweblink
(https://www.surveymonkey.com/r/PPA_MOCSurvey)andsharedviasocialmediachannels
(Facebook,Twitter,LinkedIn).Dropoutsweretrackedforeachsectionofthesurveyexcept
theinitialdemographicssection,wherea100%completionrateoccurred(Figure1).After
release,thePennsylvaniaMedicalSocietydirecteditsmemberstothesurvey,asdidanonline
healthcareprofessionalnetwork(Doximity.com,SanFrancisco,CA).Theverbatimsurvey
questionsarelistedinAppendixA.
Statisticalanalyses
8
Weappliedstandardunivariatestatisticstocharacterizethesample.Respondent-reported
demographicinformationwasobtainedfromallparticipants.Wecomparedtheprimary
surveyresponsesofthoserespondingneartheendofthesurvey(thelast10%ofthe
responses)withthoserespondingearlierbecausepriorresearchsuggeststhosethat
respondedlatercloselyapproximatesthosewhoneverrespond.22Toassessnonresponse
bias,wecorrelatedthepercentageofself-reportedspecialtiesofourrespondentstothe
percentageofspecialtiesofpracticingUSphysicianpublishedinthelatest-availableAmerican
MedicalCollegesPhysicianSpecialtyDataBook2016.23Wepre-specifiedsub-analysesby
specialty,timesincecompletionoftraining,certificationstatus,andgenderwithoutspecific
hypotheses.Surgicalsubspecialtieswerepre-specifiedtoincludeanesthesiology/pain
management,cardiothoracicsurgery,generalsurgery,neurosurgery,obstetricsand
gynecology,oralandmaxillofacialsurgery,ophthalmology,orthopedics,otolaryngology,
otorhinolaryngology,plastic/reconstructive/aestheticsurgery,andurology.
GenerallinearmodelswereusedtotestassociationsbetweenMOCopinions(outcomes)and
respondentcharacteristics.IBMSPSSVersion25wasusedforstatisticalcalculations.
Hypothesistestingusedapre-specifiedtwo-tailedalpha=0.05.
RESULTS
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SurveyResponseandSampleCharacteristics
Wereceived7125surveyresponses.Afterexcludingduplicateornon-USanonymous
incompleteresponses,7007surveyresponseswereavailableforanalysis.Attheconclusionof
thesurvey,3619of7007(52%)physiciansincludedtheirnameandatleastoneemailaddress
forverification.PhysiciansfromeverystateandUSterritory(excepttheNorthernMarinas
Islands)contributed.DemographicinformationofrespondentsisreportedinTables1and2.
Toverifyrespondents,arandomlyselected100respondentswhosubmittedtheirnameand
atleastoneemailaddresswereverifiedagainstanABMSdatabase(CertificationMatters.org).
All100randomlyselectednon-anonymousphysiciansreportedtheirpracticesettingand
certificationstatusaccurately.
SurveycompletionrateofissuespertainingtoABMSboardcertificationwas90%(5812/6477)
(Figure1).Generalperceptionsofboardcertificationandcontinuouscertificationprograms
andtheirestimatedcostsareoutlinedinTable3andFigure2.Theoverwhelmingmajority
(5831/6477,90%)ofphysiciansfeltBoardcertificationshouldbealifetimecredentialusing
continuingmedicaleducationtodemonstrateacommitmenttolifelonglearning.Almostall
physiciansfeltMOC/OCCcontributedsignificantlyorverysignificantlytophysicianburnout
(5516/5805,95%)andposthocanalysisbyspecialtyshowednodifferenceinperceptions
betweensurgicalormedicalspecialties.Similarly,astrongmajorityacrossallspecialties
perceivedparticipationinMOC/OCCasnolongervoluntary(5787/6453,90%).Perceptionof
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MOC/OCCcostsexceeded$4000forthemajorityofUSphysicianswitheachtestingcycle
(3477/6477,54%).
Whilefewerinnumber,doctorsofosteopathyinvolvedinOCCfelttheAmericanOsteopathic
Associationshouldacceptalternaterecertificationboards’credentialsforcontinuous
certification(686/755,91%)andthevastmajoritydidnotthinktheprocessshouldbetiedto
statelicensure(685/754,91%).
Ofthe4793physicianswhodescribedthemselvesasparticipatinginMOCorOCC,3262of
4697(69%)didsobecausetheirhospitalrequiredthemtoparticipate,2141of4697(46%)
becausetheirinsurancecompanyrequiresparticipation,andonly903/4697(19%)didsoto
keepupwiththeirspecialty.Themajorityofphysiciansdisagreedorstronglydisagreedthat
MOC/OCCtestedconceptsrelevanttotheirpractice(2753/4697,58%),hadstrongscientific
evidencebasetoimprovepatientoutcomes(3973/4691,85%),accuratelyreflectedtheir
abilitytopracticemedicine(4180/4691,89%),orwasofferedatanacceptablecost(4307/
4692,92%).
Themajorityofphysicians(4303/4697,92%)didnotfailaMOCexamination,losetheir
Boardcertification(evenbriefly),orexperiencenegativeconsequencesbecauseofMOC/OCC
requirements.Forthe394physicianswhodid(Table3),psychologicalandeconomicalharms
predominatedand17%werecontemplatingretirementratherthanparticipateinMOC/OCC.
Ofthissamegroup,4059of4697(86%)felttheprogramcouldaffecttheirrighttoworkasa
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physician.MostphysiciansparticipatinginMOC(4436/4697,94%)wereunawarethatAMBS
Solutions,LLC(Atlanta,GA),awhollyownedsubsidiaryofABMS,sellstheirphysiciandatato
thirdparties.
OfallABMSboard-certifiedphysiciansparticipatinginMOCornot,only2065of5812
respondents(36%)feltphysiciansshouldbeautomatically“optedin”toaHIPAABusiness
AssociateAgreementasaconditionofenrollinginMOCand4624or5812(80%)ofphysicians
felttheABMSandAOAshouldofferphysiciansinformedconsentbeforeconductingresearch
involvingMOCorOCC.
Discussion
ThissurveyrepresentsthelargestassessmenttodateofpracticingUSphysiciansfroma
cross-sectionofsubspecialtiessincetheintroductionofcontinuouscertificationbyABMSand
theAOA.Socialmediaandsmartphoneusebyphysicianshasgrownrapidly,particularly
amongstyoungerphysicians,leadingtothedemocratizationofvoicesandpeerreviewby
crowd.24The7007responserateapproachesnearly1%ofallUSclinicalphysiciansin2016.
93%ofrespondentswereorareBoardcertifiedinatleastonesubspecialty.Only19%of
physiciansheldonelifetimeBoardcertificationissuedbefore1990(“grandfathers”).While
moremenrespondedthanwomen,thelargerproportionofwomenphysiciansreportingin
thisstudy(48%)isconsistentwiththetrendofagrowingfemalephysicianworkforce.25Ina
2006nationalsurveyonMOCconductedbymembersoftheAmericanBoardofInternal
12
Medicine,only23%ofrespondentswerefemale.26Posthocanalysesshowed1530of2330
(66%)ofphysicianrespondents0-10yearsfromtrainingwerewomen,whileonly152of912
(17%)ofphysicianrespondents30yearspost-trainingorretiredwerewomen.
PerceptionsofInitialBoardCertification
Ninetypercentofallphysicianssurveyedfeltinitialcertificationshouldbealifelong
credentialwithcontinuingmedicaleducationcreditsbeingadequatetodocument
maintenanceofcompetency(Table3).Thisperceptiondidnotchangebasedontimefrom
training.Thisfindingisconsistentwithearliersurveysofboard-certifiedphysicians27and
anesthesiologists.28Only666of6453(10%)USphysiciansfeltconfidentABMSboard
certificationwasavoluntaryprocess.Despitetheseconcerns,perceptionsregardingthe
integrityoftheinitialboardcertificationprocess,theeducationalcontent,andtheabilityto
maintainpracticeprivacywereneutral(Figure2).Posthocanalysissuggestedmostsurgical
subspecialtiesheldaslightlymorefavorableopinionofboardcertificationthanmedical
subspecialties.
PerceptionsofMOC/OCC
Mostphysicianswhoparticipatedincontinuouscertificationdidnotfeeltherewasastrong
evidencebaseforMOC/OCCtoaffectpatientoutcomes,theirabilitytoprovidegoodcareor
toimprovepatientsafety(Figure2).Mostphysiciansdisagreedorstronglydisagreedwiththe
13
abilityforMOC/OCCtotestrelevantconceptsbasedontheirspecificpracticesetting(Figure
2).86%ofphysicianrespondentsfeltcontinuouscertificationcouldinterferewiththeirright
toworkasaphysician,perhapsbecauseBoardcertificationisincreasinglytiedtohospital
credentialing29andinsurancepanelinclusion.Intermsofcost,themajorityofphysiciansfelt
theMOC/OCCfeesweretoohigh.2027of6477(31%)ofphysiciansestimatedtheir
expenditureswereinexcessof$6000,anamountthatcorrespondscloselytoten-yearcosts
forMOCreportedbyothers.15
WhilefewerrespondentswereDoctorsofOsteopathy(DO)thanMedicalDoctors(MD),91%
feltthattheAmericanOsteopathicAssociationshouldrecognizealternatere-certification
boards.Only9%ofDO’sfeltOCCshouldbetiedtostatelicensurerequirements.
ConflictsofInterest,ResearchConcerns,andPerceivedHarms
Mostphysicians(94%)wereunawarethatAMBSSolutions,LLC(Atlanta,GA),awhollyowned
subsidiaryofABMS,sellsphysiciandatatothirdpartiesandthatthisisaconditionof
enrollmentincontinuouscertification30.Likewise,80%ofphysiciansfelttheyshould
understandtheresearchbeingconductedonthemortheirpracticeandsigninformed
consentforresearchasrequiredbyDepartmentofHealthandHumanServicesProtectionof
HumanServiceregulations.31Finally,inthissurvey,95%ofphysiciansagreedorstrongly
agreedthatcontinuouscertificationcontributestophysicianburnout.(Figure2)Cooketal
14
foundasimilarcorrelationbetweenburdenandburnoutintheirsmallercross-specialty
nationalsurvey.32
Tothebestofourknowledge,priorsurveyshavefailedtoassessphysicianattitudesand
perceivednegativeconsequencesfromcontinuouscertifications’businessarrangementsand
researchmethodssincetheprocesswasintroduced.Inthissurvey,perceivednegative
consequencescausedbycontinuouscertificationwereexperiencedby8%ofMOC/OCC
participants(Table3).Psychologicalharmswerethemostcommon,with56%ofaffected
physiciansbecoming“depressed,anxious,embarrassed,orsuicidal”and44%ashamedto
sharetheirMOC/OCCfailureorlossofBoardcertificationwiththeirworkplace,family,or
friends.Economically,23%ofthosewhofailedMOClosttheirhospitalprivileges(10%),
insurancepanelpayments(8%),orjob(5%),andsome(4%)hadtorelocateasaresultof
failure.Asubstantialnumber(67/390,17%)ofphysiciansplannedtoretireearlyinlieuofre-
certifying.PosthocanalysisshowedthosewhofailedMOCorlosttheirboardcertification,
evenbriefly,geographicallydistributed,morelikelytobemale,older,andlaterintheir
career.
IntegrationwithPreviousResearch
Ourfindingsofdissatisfaction,lackofevidencebase,andconcernswithconflictsofinterest
areconsistentwithpriorcross-specialtysurveysperformedinPennsylvania33,andwith
nationalsurveysinpediatrics34.Likethesmallercross-specialtynationalsurveyperformedby
15
Mayoinvestigators32,theuniformdiscontentacrosssurveysubgroupsandmostsurveyitems
suggeststheproblemswithMOCarepervasive.Themajorityofphysiciansandsurgeons
agreedthatthesaleofpersonalMOCdata,researchmethods,andlackofevidenceto
supportimprovedpatientoutcomesorsafetysignificantlycontributestoburnoutand
physiciandissatisfactionwithMOC/OCC.GiventhesefindingsandtheperceptionthatMOC
haspotentialtoadverselyaffectaphysician’srighttoworkmayleavelittleroomfor
practicingphysicianacceptanceofalternativestoMOCthatdonotaddresstheseissuesinthe
future.
Limitations
OursurveyitemsdidnotaddressallcurrentissueswithMOC/OCCbutattemptedtogauge
thevaluephysiciansperceivefromtheprocess,physicianawarenessofpotentialconflictsof
interest,researchmethods,andnegativeconsequencesexperiencedbyphysiciansfromthe
process.Whilewecannotverifyhowmanysurveyresponseswerebasedonpersonal
experience,observations,orotherinformationsources,theseinsightsremainrelevanttothe
discussiononcontinuouscertificationprocesses.
Allsurveyssufferfromnon-responderbias,measurementbias,andresponderbias.The
voluntarynatureofthissocialmedia-promotedsurveysubjectsdatacollectiontovoluntary
responsebias.Assuch,thissurveymayover-representindividualswhohavestrongopinions
oncontinuouscertification.Whilethelargesamplesizeofphysicianrespondentstothis
16
surveyhelpsreducesamplingerror,itdoesnotmitigateundercoverageandnon-response
bias,especiallysinceweareawareofonlyonestatemedicalsocietythatcirculatedthis
surveytomembers.However,posthoccomparisonsoftheperceptionstowardMOC/OCC
fromPennsylvaniaphysicianswerenodifferentfromphysiciansfromotherstateswithalarge
numberofrespondents(CA,TX,NY,FL).
Itispossiblethatsomenon-physicianscompletedthesurvey,butthecorrelationofthe
percentofsubspecialtiesreportedbysurveyrespondentstothirty-twopublishedAAMC
specialtypercentages,coupledwiththerandomverificationof100non-anonymoussubjects,
suggestedrespondentswerelikelyclinicalphysicians.Responderbiasmayhavecontributed
tounderreportingoftheperceivedharmsofMOC/OCCbecauseofsocialandprofessional
concerns.Everyeffortwasmadetopermitrespondentanonymitytolimitthisbias.Finally,
ourestimatedtotalpopulationofpracticingphysicianswasreportedin201623andmaynot
representthetotalnumberofpracticingphysiciansin2018.Still,posthocanalysisusingan
estimateof10%morephysiciansforthetotalpopulation(835,362)estimatedaworst-case
surveymarginoferrorforsurveyresponsesof±1%atthe95%confidenceintervalfor
questionswithasamplesizesexceeding4247(Figure2).
WhilethebeliefsexpressedinthissurveycouldreflectmisunderstandingsaboutMOC/OCC
programrequirements,finances,conflicts,orbenefitstoselfandpatients,theseconcernsmust
beacknowledgedandaddressed.Beforetrustincontinuouscertificationformedical
professionalself-regulationisrestored,solidevidencemustbeproduced.
17
CONCLUSIONS
WhilemostphysiciansvalueinitialBoardcertificationwithlifelongcontinuingmedical
education,thislarge,cross-specialtynationalsurveysuggestswidespreaddissatisfactionand
evenperceivednegativeconsequencestoUSphysicianswithcurrentABMSMOCandAOA
“continuouscertification”programs.AsABMSmemberboardsarecurrentlyredesigningthe
entireMOCprocess,thesefindings,reflectingtheopinionsofUSphysiciansandsurgeons,
shouldbecarefullyconsidered.
18
Acknowledgment
Dr.FisherisanunpaidboardmemberofPracticingPhysiciansofAmericaDr.Sanbornhasnoconflictstodisclose.Dr.CutlerisPastPresidentofthePennsylvaniaMedicalSocietyandwasappointedasa
memberoftheAmericanBoardofMedicalSpecialties’VisionInitiativeCommissiontaskedwith
improvingthecurrentre-certificationprocess.HeisalsoanunpaidadvisortoPracticing
PhysiciansofAmerica,Inc.
TheauthorswouldliketoacknowledgeTedFeldman,MDandNiranAl-Agba,MDfortheir
editorialassistancewiththismanuscript.
19
Figure1.SurveyStructure,Logic,andNumberofRespondentsForEachSectionoftheSurvey
Degree
DO
MD or Non-US Med
Other
Survey ExitThank you
(Optional Name andEmail Entry)
DemographicsGender, Age, Practice set-
ting, State/Territory, Practice Specialty, Years post-training
Doctor Osteopathy (n=755)
1) Should AOA allow recert by others (NBPAS)?
2) Should FSLB require OCC for state licensure?
Ever ABMSBoard Certified?
No
Yes
Initial ABMSCertification DetailsTotal number, Number before 1990,
State license disclosure,Perceptions, Cost
Participatein MOC®/OCC?
No
Yes
Reason for participation,Perceptions of
Relevance/Value, COI’s, Effect right to work?
Failed MOC® or experienced
harm from it?
Perceived Harms from MOC®/OCC
(n=390)Fees, loss of adm privileges,
loss of employment, relocated, etc.
Thoughts on contract terms, burnout, monopoly,
CME enough?
MOC®/OCC
No
MOC®/OCC
Yes
(n = 7007)
(n = 801) (n = 33)
(n = 6173)
(n = 429)
(n = 6048)
(n = 4793)
(n = 1211)
(n = 394)
(n = 4697)
(n = 4303)
(n = 5812)
Non-clinicalResearcher or
Teacher?
No
Yes (n = 70)
(n = 6477)
( n = 6004 )
20
TABLE1.DemographicCharacteristicsoftheSurveySampleGender No.(%)Male 3632(52)Female 3373(48)Other 2(0) Age 21-35 771(11)36-50 3378(48)51-65 2307(33)66orolder 551(8) PracticeSetting PrivatePractice 1865(27)GroupPractice/Independent 1199(17)Hospital/University/HealthSystemEmployee 2939(42)GroupPractice/Contracted 637(9)Other 369(5) StageofSpecialtyTraining HaveMD/DObutnotfinishedwithclinicaltraining 120(2)Clinicalphysicianpost-training0-10years 2330(33)Clinicalphysicianpost-training11-20years 2048(29)Clinicalphysicianpost-training21-30years 1527(22)Clinicalphysicianposttraining>30years 760(11)Retiredclinicalphysician 152(2)Teachphysicians,don’tseepatients 32(0)Non-clinicalresearchphysician 38(1) PhysicianDegree MD 6084(87)DO 801(11)Non-US 89(1)None 33(0) CurrentlyorEverPreviouslyABMSBoardCertified? n/N(%)Yes 6048/6477(93)No 429/6477(7) NowmanyvalidABMSBoardcertificatesdoyoucarry? 0 437/6477(7)1 3998/6477(62)2 1515/6477(23)3 437/6477(7)4ormore 90/6477(1) HowmanyofyourABMSBoardcertificationswereacquiredbefore1990? 0 5258/6465(81)1 852/6465(13)2 299/6465(5)
21
3 50/6465(1)4ormore 6/6465(0)
22
Table2.SurveyParticipantDemographicsbyState/TerritoryandSubspecialty
US State/Territory
Survey Specialty
Survey AAMC
Clinicala No. %
No. % No. %
All Locations 7007
All Specialties 7007
759421 Alabama 78 (1)
Adolescent Medicine 5 (0)
Alaska 32 (0)
Allergy / Immunology 91 (1) 4019 (1)
American Samoa 1 (0)
Anesthesia / Pain Mgmt 325 (5) 38749 (5)
Arizona 131 (2)
Cardiovasc Diseases / EP 519 (7) 20275 (3) Arkansas 56 (1)
Cardiothoracic Surgery 29 (0)
California 506 (7)
Critical Care Medicine 76 (1) 8849 (1)
Colorado 123 (2)
Dentistry 0 (0) Connecticut 65 (1)
Dermatology 338 (5) 11062 (1)
Delaware 28 (0)
Emergency Medicine 433 (6) 36607 (5)
D.C.c 32 (0)
Endocrinology 117 (2) 5682 (1)
Florida 406 (6)
Family Medicine 879 (13) 103235 (14)
Georgia 181 (3)
Gastroenterology 124 (2) 13014 (2) Guam 2 (0)
General Surgery 192 (3) 22043 (3)
Hawaii 25 (0)
Genetics 9 (0) Idaho 67 (1)
Geriatrics 31 (0) 4422 (1)
Illinois 262 (4)
Gynecology and Obsterics 232 (3) 38690 (5) Indiana 124 (2)
Hematology / Oncology 107 (2) 12234 (2)
Iowa 66 (1)
Hospice / Palliative Care 24 (0) Kansas 79 (1)
Hospital Medicine 151 (2)
Kentucky 82 (1)
Infectious Disease 55 (1) 6548 (1)
Louisiana 86 (1)
Internal Medicine 624 (9) 101281 (13)
Maine 35 (0)
Neonatology 102 (1) 4406 (1)
Maryland 132 (2)
Nephrology 77 (1) 8885 (1)
Massachusetts 144 (2)
Neuromusc Med / OMM 6 (0) Michigan 174 (2)
Neurology 203 (3) 4920 (1)
Minnesota 106 (2)
Neurosurgery 43 (1) 11501 (2)
Mississippi 44 (1)
Occupational Medicine 12 (0) Missouri 118 (2)
Ophthalmology 145 (2) 17413 (2)
Montana 21 (0)
Oral and Maxillofacial Surg 1 (0) Nebraska 44 (1)
Orthopedics 138 (2) 18292 (2)
Nevada 45 (1)
Otolaryngology 56 (1) 8894 (1)
New Hampshire 27 (0)
Otorhinolaryngology 12 (0)
(0)
New Jersey 176 (3)
Palliative Medicine 3 (0)
(0) New Mexico 35 (0)
Pathology 81 (1)
(0)
23
New York 409 (6)
Pediatrics 756 (11) 52163 (7)
North Carolina 190 (3)
Physical Med / Rehab 121 (2) 8352 (1) North Dakota 15 (0)
Plastic/Reconstr/Aesthetic 45 (1) 6727 (1)
N. Marinas Is. 0 (0)
Podiatry 13 (0)
(0)
Ohio 326 (5)
Preventive Medicine 8 (0) 4091 (1)
Oklahoma 72 (1)
Psychiatry 330 (5) 33051 (4) Oregon 101 (1)
Pulmonary 94 (1) 4830 (1)
Pennsylvania 910 (13)
Radiation Oncology 5 (0) 4499 (1)
Puerto Rico 16 (0)
Radiology 255 (4) 24784 (3)
Rhode Island 46 (1)
Rheumatology 62 (1) 4831 (1) South Carolina 110 (2)
Sports Medicine 22 (0)
(0)
South Dakota 27 (0)
Toxicology 1 (0)
(0)
Tennessee 144 (2)
Urology 55 (1) 9325 (1)
Texas 504 (7)
p = 0.74 Correlation: 0.87
Utah 47 (1) Vermont 19 (0) Virginia 210 (3) Virgin Islands 1 (0) Washington 168 (2) West Virginia 33 (0) Wisconsin 108 (2)
`
Wyoming 18 (0)
p-value=Pairedt-testofthepercentageofphysiciansinthirty-tworeported2016AAMCsubspecialties23andthepercentagesofsimilarself-reportedsubspecialties.Correlationcoefficientreportedisbasedonthissamecomparison.aAAMCClinicalUSPhysicians2016bNorthernMarinasIslandscDistrictofColumbia
24
Table3.SurveyedPerceptionsofUSBoardCertificationandContinuousCertificationUSBoardcertification Shouldbealife-longcredential,usingCMEcreditsforcontinuingeducation 5831/6477(90)Shouldbeatime-limitedphysiciancredentialrequiringperiodicrenewal 646/6477(10)MostrecentestimatedcosttobecomeABMSBoardcertifiedorrecertified Employersubsidized 226/6477(3)$1-2000 580/6477(9)$2001-$4000 1731/6477(27)$4001-$6000 1450/6477(22)$6001-$10,000 1089/6477(17)$10,001-$20,000 615/6477(9)>$20,000 323/6477(5)I’mnotsure 463/6477(7)WhenenrollingforMOC®,IwasmadeawarethatABMSSolutions,LLC,afor-profitsubsidiaryoftheABMS,sellsmycertificationstatustothirdparties.
Yes 177/4697(4)No 4436/4697(94)NotApplicable 84/4697(2)HaveyoueverfailedaMOC®examination,lostyourBoardcertification(evenbriefly)orexperiencedharmbecauseofMOC®/OCCrequirements?
Yes 394/4697(8)No 4303/4697(92)PleasecheckalleffectsofMOCforfailingorlosingyourBoardcertification(checkallthatapply)
Paidforare-scoreofmyexamination 41/390(11)Re-tooktheexaminationforfree 28/390(7)Re-tooktheexaminationforanadditionalfee 218/390(56)Neverattemptedtoretaketheexaminationandletmyboardcertificate“expire”
56/390(14)
Lostmyhospital/admittingprivileges 38/390(10)Lostmyjob 21/390(5)Wasdis-enrolledfromaninsurancecompany’spaymentplan 30/390(8)Eventuallypassedmyrepeatexamination 204/390(52)Failedtotellmyworkplaceofmyexaminationresults 67/390(17)Failedtotellmyfamily/friendsaboutmytestresults 107/390(27)Becamedepressed,anxious,embarrassed,orsuicidal 220/390(56)Relocatedasaresultofthisfailure 15/390(4)PlantoretiretoavoidMOC/OCC 67/390(17)Iretiredbecauseofthisfailure 1/390(0)DoyoubelieveMaintenanceofCertification®(orOsteopathicContinuousCertification)couldthreatenyourrighttoworkasaphysician?
Yes 4059/4659(86)No 638/4659(14)PhysiciansshouldbeautomaticallyoptedintoaHIPAABusinessAssociateAgreementasaconditionofenrollinginMOC®orOCC.
Agree 2065/5812(36)Disagree 3747/5812(64)ShouldtheAOAorABMSmemberboardsconductingresearchonphysicians(ortheirpractice)berequiredtoobtaininformedconsentfromdiplomates?
Yes 4624/5812(80)
25
No 1188/5812(20)
26
Figure2.PerceptionsofInitialBoardCertificationandMaintenanceofCertification(MOC)
AplotofmeanandstandarddeviationsofphysicianresponsestoLikert-typescalesonattitudesaboutBoardCertificationandMOC/OCCusingrangesfrom1(“Verypoor”or“stronglydisagree”)to5(“verygood”or“stronglyagree”).Theestimatedmarginoferrorwas±1%atthe95%confidenceinterval.
Confidence in the integrity of the ABMS Board Certification process (n = 6459)
Confidence in Practice Improvement Modules to Improve my practice (n = 6459)
Confidence in preserving the privacy in my practice (n=6441)
Confidence that Board Certification is truly voluntary(n=6453)
MOC/OCC tests concepts relevant to my practice (n = 4696)
There is a strong scientific evi-dence base that MOC/OCC improves patient outcomes(n = 4691)
MOC/OCC accurately assesses my ability to provide good medical care (n = 4691)
Participating in MOC/OCC im-proves my patients’ safety(n = 4686)
MOC/OCC costs are acceptable(n = 4692)
MOC contributes to burnout(n = 5805)
Very Poor Neutral Good VeryPoor Good
Strongly Disagree Neutral Agree StronglyDisagree Agree
Physician Perceptions of MOC®/OCC
Physician Perceptions of Board Certification
27
FigureLegendsFigure1.SurveyStructure,Logic,andNumberofRespondentsForEachSectionoftheSurveyFigure2.PerceptionsofInitialBoardCertificationandMaintenanceofCertification(MOC)AplotofmeanandstandarddeviationsofphysicianresponsestoLikert-typescalesonattitudesaboutBoardCertificationandMOC/OCCusingrangesfrom1(“Verypoor”or“stronglydisagree”)to5(“verygood”or“stronglyagree”).Theestimatedmarginoferrorwas±1%atthe95%confidenceinterval.
28
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