Meeting Higher Standards Through MOC
Better understanding of the requirements for maintenance of certification leads to an easier and more fulfilling recertification process.
Most will agree that the establishment of board certification by the American Board of Ophthalmology (ABO) was a deliberate choice made to affirm a commitment to higher standards and a patient-centered outlook on the practice of medicine. Disagreements arise, however, on the subject of Maintenance of Certification (MOC). Although some critics of the program have dismissed MOC as a process that delivers more burden than benefit, a strong case for MOC can be made on the basis that it provides structure and support for the lifelong learning endeavors that we as physicians already want to pursue.
We want to demonstrate professionalism to our patients and peers. We believe in promoting patient safety. And we certainly strive to improve the quality of our practices. MOC embraces these goals and provides a means to achieve them.
At a time when we face increasing pressure from regulators outside the realm of medicine, it is important to remember that MOC is overseen entirely by our peers in ophthalmology. Rather than a list of demands, MOC is a simple call to action—a challenge to grow as physicians, from our very first days in practice to our final days before retirement.
More than 8000 ABO diplomates are rising to meet the challenge issued by MOC, including 34% of those who indicate a practice focus in retina. This article is an attempt to walk through the MOC process and arrive at an understanding about its aims and purpose.
EVOLUTION OF MOC
MOC is not based on a new idea. In some medical specialties, the concept of recertification was introduced as early as 1969. ABO diplomates have been asked to demonstrate continued knowledge and skills in ophthalmology for more than 20 years. But it has taken the ABO several attempts to arrive at a design for MOC that both achieves its patient-focused goals and encourages professional development in a way that is relevant and useful to practice.
Recertification in ophthalmology initially centered on a single examination that served as a knowledge and skills checkpoint for midcareer physicians. Gradually, a more comprehensive MOC process emerged, employing self-evaluation modules to identify and remediate gaps in knowledge, and a practice evaluation involving the review of patient charts. This version of MOC is known as Track 1 (Figure 1).
Because MOC Track 1 activities are assigned to only certain specific years within the 10-year period, it became difficult to ensure that opportunities for critical learning and practice improvement took place throughout the entire 10-year cycle. For this reason, the MOC Track 2 program, which harnesses the continual nature of learning and improvement to break MOC into small yearly activities, was launched in 2012 (Figure 2).
Diplomates certified and recertified prior to 2012 are finishing out their Track 1 cycles and will transition to Track 2 upon renewal of their certificates. New diplomates and those certified since 2012 are already enrolled in Track 2. (If you are not sure which MOC Track to follow, log into your MOC Status Page on the ABO website or contact the ABO Office.)
UNDERSTANDING THE MOC PROCESS
For both MOC tracks, activities are divided into 4 parts. Part 1 addresses professionalism and professional standing; Part 2 focuses on lifelong learning and self-assessment activities; Part 3 evaluates cognitive expertise with a closed-book examination; and Part 4 assesses practice performance and quality improvement through a chart review process.
Part 1: Demonstrating Professionalism
To meet higher standards in ophthalmology, diplomates must first meet the minimum standard to practice. Board rules require that all diplomates maintain a valid medical license free of restrictions. Meeting this requirement involves logging into the ABO website to submit updated medical license information with each license renewal.
Part 2: Engaging in Lifelong Learning and Self-Assessment
Diplomates in Track 2 must earn 25 continuing medical education (CME) credits every year to facilitate continuous learning. All AMA PRA Category 1 credits are accepted and can be logged through the ABO website, submitted to the ABO via e-mail, or transferred from the American Academy of Ophthalmology’s CME tracker. A minimum of 8 of the 25 CME credits must include self-assessment (the use of a pretest and posttest to help gauge knowledge acquisition). Diplomates who are still in Track 1 can submit a lump sum of 250 CME credits instead of an annual summary.
Within the first 3 years of a new MOC cycle, Track 2 diplomates must complete a patient safety activity. The Board offers a free ophthalmic Patient Safety Module worth 2 CME credits and provides links to other acceptable patient safety activities. All diplomates are encouraged to complete a patient safety activity.
The final component of Part 2 is the completion of 2 Periodic Ophthalmic Review Tests (PORTs), which are 50-question, online, open-book examinations. All diplomates complete 1 PORT module in core ophthalmology (knowledge that spans all areas of general or subspecialty practice) and choose a second module in a specific area of practice focus, such as retina/vitreous. Since 2006, diplomates have selected retina/vitreous modules more than 1500 times, averaging a score of 91.6% correct. An 80% correct score is the passing standard.
Diplomates are encouraged to complete PORTs prior to taking the closed-book examination to help identify gaps in knowledge. A third PORT is available free to all diplomates for use in the examination preparation process.
Part 3: Putting Ophthalmic Knowledge to the Test
Between years 6 and 10 of the MOC cycle, diplomates are eligible to take the Demonstration of Ophthalmic Cognitive Knowledge (DOCK) examination. The DOCK exam is a 150-question closed-book test designed to test knowledge considered fundamental to the practice of ophthalmology. The examination is given annually throughout the month of September. After registering for the examination, diplomates are invited to select the date, time, and nearby test center location for their examination.
As with the PORTs, diplomates must take 1 module of 50 questions in core ophthalmology and can select up to 2 focus areas for their remaining 2 modules (for example, 2 retina/vitreous modules or 1 retina/vitreous module and 1 comprehensive module). Examination content is derived from an MOC Content Outline developed by panels of practicing ophthalmologists and is freely available on the ABO website.
Each year, the DOCK passing score is determined through psychometric analysis and comparison with previous examinations, taking into account changes in examination difficulty and the abilities of the examinee group. Diplomates have passed the DOCK exam more than 98% of the time; however, numeric DOCK scores are not released in order to avoid the development of any rankings based on examination performance. All test-takers receive feedback on missed item topic areas based on the Content Outline.
Part 4: Aiming for Quality Improvement in Practice
The Practice Improvement Module (PIM) asks diplomates to assess their practice performance, identify areas for improvement, develop a plan for change, and measure the impact of this change on their practice.
Diplomates may choose from 28 available PIMs in specific diagnoses, such as diabetic retinopathy and exudative age-related macular degeneration. From there, diplomates supply a minimum of 30 patient charts to begin the evaluation and development of an improvement plan. Mandatory improvement periods of up to 395 days are built into the process based on the modules and measures selected. All patient data is anonymized, and the results of improvement efforts are used for self-assessment only.
Track 2 diplomates complete a PIM once between years 1 and 5 and once again between years 6 and 10. Track 1 diplomates who have not already completed the now-discontinued Office Record Review (ORR) must complete a PIM prior to taking the DOCK exam.
Track 1 diplomates pay individual registration fees for each activity. Diplomates in Track 2 pay a flat fee of $200 per year. All fees cover access to ABO-sponsored MOC activities and include a new certificate at the end of 10 years. The total cost for MOC is the same for both diplomate groups.
The value of MOC is in maximizing every learning opportunity so that each day we can become better ophthalmologists than we were the day before. We met high standards in our journey to become physicians, but continuously improving the quality of patient care through MOC is a higher standard that embodies the very principles that drove us to pursue a career in medicine. n
H. Culver Boldt, MD, is the Marion and Frederick Fuerste Professor of Ophthalmology in the department of ophthalmology and visual sciences at the University of Iowa Carver College of Medicine in Iowa City, Iowa. He is a director of the American Board of Ophthalmology, where he serves on the MOC Committee and chairs the MOC Part 2 Subcommittee and the PORT/DOCK Subcommittee. Dr. Boldt may be reached at email@example.com.
Diana V. Do, MD, is an associate professor of ophthalmology and vice chair for education in the department of ophthalmology and visual sciences at the University of Nebraska Medical Center in Omaha, and is the director of the Carl Camras Center for Innovative Clinical Trials in Ophthalmology and the director of the ophthalmology residency training program. She is a member of the New Retina MD Editorial Board. Dr. Do may be reached at firstname.lastname@example.org.