It seems like many people think MOCA is not really a way for us to remain educated physicians, but really a way for the ABA and ASA to make money (see article below). For example, you are required to buy ASA products to become ABA certified. The entire MOCA process costs a lot of money, and quite a bit of time. If MOCA really is a scam and represents corruption between the ABA and the ASA, what can be done about it? Perhaps it would be worth bringing it up with your state anesthesia society, and with your delegates that attend the annual ASA meeting. Others have mentioned that a separate board certification process should be enacted to bypass the ABA.
On a side note, I just heard that the new pediatric anesthesia board exam is going to cost more than $2000, and that many pediatric anesthesia fellows won't be able to take it because they don't have the money for it (they already have to pay more than $2000 for the general anesthesia board certification exam)! I don't understand how a multiple choice exam costs that much and I think the ABA has gone too far on this one.
These issues are of even greater importance to current residents. MOCA is a relatively new program, and once it gets long term acceptance and precedence as an acceptable means of board certification, I imagine it's going to be much harder to change it.
When a speaker gives a lecture or when you read a journal article, it is almost mandatory these days to have a disclaimer about conflicts of interest or a statement about money the speaker or author has received. It seems like a failure of ethics for the ABA and ASA to push forth the MOCA program the way it stands now. MOCA needs reform.
http://www.anesthesiologynews.com/V...ntary&d_id=449&i=May+2012&i_id=839&a_id=20771
Simulation and the MOCA (Part 2)
by Tania Haddad, MD
This article is the second in a two-part series. The first installment can be read here.
Are the required components for successful completion of the Maintenance of Certification (MOC)/Maintenance of Certification in Anesthesiology (MOCA) process based on evidence or opinion? The answer depends on the question.
The majority of the literature that supports recertification extrapolate outcomes data from studies comparing performance between physicians with primary certification and their non-certified counterparts,16,17 as well as evaluating treatment outcomes in relation to the time since last board certification. Norcini and colleagues also demonstrated a 15% reduction in mortality among patients treated by certified physicians following acute myocardial infarction,18,19 while another group demonstrated an increased rate of treatment intensification (the initiation of new drugs or an increase in an existing antihypertensive medication) by physicians who were more recently board-certified.20
Because mandated recertification is a fairly new phenomenon, little if any evidence has demonstrated improvement in clinical outcomes from the process. Only one study by Holmboe evaluated the association between performance on the American Board of Internal Medicine (ABIM) MOC exam and basic quality-care performance measures.21 Although this study found a positive correlation between examination score on the MOC and performance on most of the care measures, more research is required to firmly establish a relationship between the care provided and performance on any cognitive examination.21,22
Continuing Education
For decades, continuing medical education (CME) credits have been the accepted currency for physician education after training, required by professional organizations, state licensing boards and hospitals. As the number of institutions requiring physician participation has grown, so has the CME enterprise. It has long been the belief that CME brings physicians up to date in their knowledge base, which in turn produces improvements in practice and patient outcomes. Despite its wide use and acceptance, little evidence exists to show that physicians who participate in CME improve their ability to care for patients.23-27
Simulation-based Training
Simulation-based training is currently being used by medical schools, residency programs and licensure and recertification programs. Proponents of simulator-based training argue that simulators allow for the identification of deficiencies such as lapsed skills of an anesthesiologist, improve the dynamics in high-acuity team situations and provide more rapid acquisition and retention of skill sets.28-29 Although these objectives are impressive, few studies have demonstrated an improvement in patient outcome from simulator training.28 A comparison of the relative effectiveness of case-based learning (CBL) and simulation-based learning (SBL) in critical care unit teams found a nonsignificant trend toward greater benefit of SBL over CBL.30 These results suggest that a mix of the two learning approaches likely is most effective.
What Will It Cost?
To examine the costs of recertification, it is important to ask what drives the process to begin with. In the United States, the United Kingdom and Canada, four main factors have shaped the development of recertification systems: economic, political, social and professional.31 Because health care in the United States is supported by a mix of public and private funding, recertification unsurprisingly is influenced most heavily by economic considerations. The medical boards refute accusations by physicians that recertification has less to do with improving the quality of care and outcomes than with the collection of revenuebut money undeniably plays an important role.
Obvious conflict of interest between medical boards and their affiliated societies has been noted, with the creation of products that must be purchased in order to fulfill the recertification requirements. David Brown, MD, secretary of the American Board of Anesthesiology, told Anesthesiology News, for example, that unlike other boards that have developed products to sell to their physicians, the ABA has made a conscious decision not to do so, to avoid conflict of interest.32 Even so, MOCA requires mandatory CME credits obtainable only from the ASA (Table 1). Mark Warner, MD, immediate past-president of the ASA, has said that the society is not the exclusive provider of educational materials and activities for the MOCA and that other organizations may work with the ABA to develop products.32 However, at the moment, the ASA is the sole provider of these materials.
Table 1. Requirements and Cost Associated With the MOCA Exam
MOCA Requirements Number Needed Cost
CME credits 240 Varies
CME from ACE or SEE: ASA member 90 $300/60 CME requiring 2 y = $600
CME from ACE or SEE: NonASA member 90 $830/60 CME requiring 2 y = $1,660
CME from ACE or SEE + ASA membership 90 $300/60 CME requiring 2 y, $600 + $625 = $1,225
CME patient safety education: ASA member 20 $120/10-CME module, 20 modules = $240
CME patient safety education: NonASA member 20 $160/10-CME module, 20 modules = $320
Simulation training 1 $1,500-$2,000
ASA membership fee
$625
Exam fee
$2,100
Total cost (worst-case scenario, nonASA member)
$6,080 (+ cost of additional 240 required CME, airfare and hotel)
ASA, American Society of Anesthesiologists; CME, continuing medical education; MOCA, Maintenance of Certification in Anesthesiology; SEE, Self-Education and Evaluation Program
Even the required simulation-based training must be performed in an ASA-endorsed simulation center. These institutions must go through a rigorous process for initial approval, subsequent site visits and recertification, and pay a $2,500 fee to the ASAa cost thats ultimately borne by the recertifying physician.
Simulation training costs roughly $2,000 per doctor, with modest discounts available for groups. But that outlay merely covers the course fee. With only 27 endorsed centers in the country to date, most physicians must cover the costs of travel, housing and food for the one-day course, in addition to losing revenue while away from their practice.
The ABA said it has tried to make the MOCA the least onerous we can for our docs, with as much clarity and transparency as we can for society.32 Given the lack of evidence to support the components of the MOCA, however, why does the board continue to increase the requirements of existing components while adding new ones? Instituted in 1990, the MOC is now in its third decade (Table 2). Perhaps the ABA should look to the ABIM as a model. How is it possible for the MOC to offer a written exam, computer modules that provide enough credits to complete the 100 CME credit requirement and a simulation course, for an application fee roughly one-third that of the MOCA?
Table 2. Requirements and Cost Associated With the MOC Exam
MOC Requirements Number Needed Cost
CME credits 100 0
Simulation training 0 may count toward CME requirement 0 $35 fee for cancellation or failure to show
Application fee $1,675 ($1,840 for subspecialty) Fee provides access to unlimited ABIM Self-Evaluation Modules for CME credit in addition to simulation training
Total cost
Application fee
ABIM, American Board of Internal Medicine; CME, Continuing Medical Education; MOC, Maintenance of Certification
Conclusion
Maintenance of currency and proficiency within all of the medical subspecialties is, without question, a necessity. Anesthesiologists take great pridejustifiablyin shepherding patients through their procedures and incorporating the most up-to-date knowledge and equipment to provide safe and excellent care. But that does not obviate questions about the continuously increasing requirements of the MOCA process, as well as the exemption of certain individuals from participation in that process based solely on the date they obtained initial certification.
As previously demonstrated, evidence supporting the components of the exam is lacking. Even so, the requirements continue to increase. Where are the data demonstrating that the addition of 140 CME credits from the inception of the MOCA in 2000 improves physician care when traditional CME has been shown to be ineffective? Where are the data that demonstrate that simulation in a remote endorsed center is superior to a locally based and less costly simulation center? Meanwhile, although the data to support these questions are not available, the revenue that these requirements generate is easy to calculate.
The ABA argues that it is attempting to create an exam that is not onerous for the physician. But is the MOCA a better recertification examination process than the MOC because it has more requirements and costs three times as much? The MOC has been in existence since 1990 (indeed, the MOCA is based on it). Does the MOC fail to satisfactorily maintain its physicians competence because it is more convenient and manageable than the MOCA? Are anesthesiologists more current and proficient than our other colleagues who take the MOC?
Lastly, but not least important, where are the data to support the grandfather status? The ABA publicly preaches its support of recertification of anesthesiologists. The public has expressed its views regarding the value and expectation for physician recertification. In addition, the data demonstrate that physicians farther from initial certification are most in need of external assessment. This exemption, and the questions previously posed, undermine the validity of the entire recertification process.
--------------------------------------------------------------------------------
Dr. Haddad is an anesthesiologist at Valley Anesthesiology Consultants, in Phoenix, Ariz.
References
1.Sharp LK, Bashook PG, Lipsky MS, Horowitz SD, Miller SH. Specialty board certification and clinical outcomes: the missing link. Acad Med. 2002;77:534-542.
2.Silber JH, Kennedy SK, Even-Shoshan O, et al. Anesthesiologist board certification and patient outcomes. Anesthesiology. 2002;96:1044-1052.
3.Norcini JJ, Kimball HR, Lipner RS. Certification and specialization: do they matter in the outcome of acute myocardial infarction? Acad Med. 2000;75:1193-1198.
4.Norcini JJ, Lipner RS, Kimball HR. Certifying examination performance and patient outcomes following acute myocardial infarction. Med Educ. 2002;36:853-859.
5.Turchin A, Shubina M, Chodos AH, Einbinder JS, Pendergrass ML. Effect of board certification on antihypertensive treatment intensification in patients with diabetes mellitus. Circulation. 2008;117:623-628.
6.Holmboe ES, Wang Y, Meehan TP, et al. Association between maintenance of certification examination scores and quality of care for Medicare beneficiaries. Arch Intern Med. 2008;168:1396-1403.
7.Landon BE. What do certification examinations tell us about quality? (editorial). Arch Intern Med. 2008;168:1365-1367.
8.Davis DA, Taylor-Vaisey A. Translating guidelines into practice: a systematic review of theoretic concepts, practical experience, and research evidence in the adoption of clinical practice guidelines. CMAJ. 1997;157:408-416.
9.Schrock JW, Cydulka RK. Lifelong learning. Emerg Med Clin N Am. 2006;24:785-795.
10.Davis D, OBrien MA, Freemantle N, Wolf FM, Mazmanian P, Taylor-Vaisey A. Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? JAMA. 1999;282:867-874.
11.Mazmanian PE, Davis DA. Continuing medical education and the physician as a learner. JAMA. 2002;288:1057-1060.
12.Grimshaw JM, Shirran L, Thomas R, et al. Changing provider behavior: an overview of systematic reviews of interventions. Med Care. 2001;39:112-145.
13.Boulet JR, Murray DJ. Simulation-based assessment in anesthesiology. Anesthesiology. 2010;112:1041-1052.
14.Cooper JB, Murray D. Simulation training and assessment: a more efficient method to develop expertise than apprenticeship. Anesthesiology. 2010;112:8-9.
15.Frengley RW, Weller JM, Torrie J, et al. The effect of a simulation-based training intervention on the performance of established critical care unit teams. Crit Care Med. 2011;39:2605-2611.
16.Shaw K, Cassel C, Black C, Levinson W. Shared medical regulation in a time of increasing calls for accountability and transparency: comparison of recertification in the United States, Canada, and the United Kingdom. JAMA. 2009;302:2008-2014.
17.Agres T. Mounting board demands foster growing unease. Anesthesiology News. October 2011.
On a side note, I just heard that the new pediatric anesthesia board exam is going to cost more than $2000, and that many pediatric anesthesia fellows won't be able to take it because they don't have the money for it (they already have to pay more than $2000 for the general anesthesia board certification exam)! I don't understand how a multiple choice exam costs that much and I think the ABA has gone too far on this one.
These issues are of even greater importance to current residents. MOCA is a relatively new program, and once it gets long term acceptance and precedence as an acceptable means of board certification, I imagine it's going to be much harder to change it.
When a speaker gives a lecture or when you read a journal article, it is almost mandatory these days to have a disclaimer about conflicts of interest or a statement about money the speaker or author has received. It seems like a failure of ethics for the ABA and ASA to push forth the MOCA program the way it stands now. MOCA needs reform.
http://www.anesthesiologynews.com/V...ntary&d_id=449&i=May+2012&i_id=839&a_id=20771
Simulation and the MOCA (Part 2)
by Tania Haddad, MD
This article is the second in a two-part series. The first installment can be read here.
Are the required components for successful completion of the Maintenance of Certification (MOC)/Maintenance of Certification in Anesthesiology (MOCA) process based on evidence or opinion? The answer depends on the question.
The majority of the literature that supports recertification extrapolate outcomes data from studies comparing performance between physicians with primary certification and their non-certified counterparts,16,17 as well as evaluating treatment outcomes in relation to the time since last board certification. Norcini and colleagues also demonstrated a 15% reduction in mortality among patients treated by certified physicians following acute myocardial infarction,18,19 while another group demonstrated an increased rate of treatment intensification (the initiation of new drugs or an increase in an existing antihypertensive medication) by physicians who were more recently board-certified.20
Because mandated recertification is a fairly new phenomenon, little if any evidence has demonstrated improvement in clinical outcomes from the process. Only one study by Holmboe evaluated the association between performance on the American Board of Internal Medicine (ABIM) MOC exam and basic quality-care performance measures.21 Although this study found a positive correlation between examination score on the MOC and performance on most of the care measures, more research is required to firmly establish a relationship between the care provided and performance on any cognitive examination.21,22
Continuing Education
For decades, continuing medical education (CME) credits have been the accepted currency for physician education after training, required by professional organizations, state licensing boards and hospitals. As the number of institutions requiring physician participation has grown, so has the CME enterprise. It has long been the belief that CME brings physicians up to date in their knowledge base, which in turn produces improvements in practice and patient outcomes. Despite its wide use and acceptance, little evidence exists to show that physicians who participate in CME improve their ability to care for patients.23-27
Simulation-based Training
Simulation-based training is currently being used by medical schools, residency programs and licensure and recertification programs. Proponents of simulator-based training argue that simulators allow for the identification of deficiencies such as lapsed skills of an anesthesiologist, improve the dynamics in high-acuity team situations and provide more rapid acquisition and retention of skill sets.28-29 Although these objectives are impressive, few studies have demonstrated an improvement in patient outcome from simulator training.28 A comparison of the relative effectiveness of case-based learning (CBL) and simulation-based learning (SBL) in critical care unit teams found a nonsignificant trend toward greater benefit of SBL over CBL.30 These results suggest that a mix of the two learning approaches likely is most effective.
What Will It Cost?
To examine the costs of recertification, it is important to ask what drives the process to begin with. In the United States, the United Kingdom and Canada, four main factors have shaped the development of recertification systems: economic, political, social and professional.31 Because health care in the United States is supported by a mix of public and private funding, recertification unsurprisingly is influenced most heavily by economic considerations. The medical boards refute accusations by physicians that recertification has less to do with improving the quality of care and outcomes than with the collection of revenuebut money undeniably plays an important role.
Obvious conflict of interest between medical boards and their affiliated societies has been noted, with the creation of products that must be purchased in order to fulfill the recertification requirements. David Brown, MD, secretary of the American Board of Anesthesiology, told Anesthesiology News, for example, that unlike other boards that have developed products to sell to their physicians, the ABA has made a conscious decision not to do so, to avoid conflict of interest.32 Even so, MOCA requires mandatory CME credits obtainable only from the ASA (Table 1). Mark Warner, MD, immediate past-president of the ASA, has said that the society is not the exclusive provider of educational materials and activities for the MOCA and that other organizations may work with the ABA to develop products.32 However, at the moment, the ASA is the sole provider of these materials.
Table 1. Requirements and Cost Associated With the MOCA Exam
MOCA Requirements Number Needed Cost
CME credits 240 Varies
CME from ACE or SEE: ASA member 90 $300/60 CME requiring 2 y = $600
CME from ACE or SEE: NonASA member 90 $830/60 CME requiring 2 y = $1,660
CME from ACE or SEE + ASA membership 90 $300/60 CME requiring 2 y, $600 + $625 = $1,225
CME patient safety education: ASA member 20 $120/10-CME module, 20 modules = $240
CME patient safety education: NonASA member 20 $160/10-CME module, 20 modules = $320
Simulation training 1 $1,500-$2,000
ASA membership fee
$625
Exam fee
$2,100
Total cost (worst-case scenario, nonASA member)
$6,080 (+ cost of additional 240 required CME, airfare and hotel)
ASA, American Society of Anesthesiologists; CME, continuing medical education; MOCA, Maintenance of Certification in Anesthesiology; SEE, Self-Education and Evaluation Program
Even the required simulation-based training must be performed in an ASA-endorsed simulation center. These institutions must go through a rigorous process for initial approval, subsequent site visits and recertification, and pay a $2,500 fee to the ASAa cost thats ultimately borne by the recertifying physician.
Simulation training costs roughly $2,000 per doctor, with modest discounts available for groups. But that outlay merely covers the course fee. With only 27 endorsed centers in the country to date, most physicians must cover the costs of travel, housing and food for the one-day course, in addition to losing revenue while away from their practice.
The ABA said it has tried to make the MOCA the least onerous we can for our docs, with as much clarity and transparency as we can for society.32 Given the lack of evidence to support the components of the MOCA, however, why does the board continue to increase the requirements of existing components while adding new ones? Instituted in 1990, the MOC is now in its third decade (Table 2). Perhaps the ABA should look to the ABIM as a model. How is it possible for the MOC to offer a written exam, computer modules that provide enough credits to complete the 100 CME credit requirement and a simulation course, for an application fee roughly one-third that of the MOCA?
Table 2. Requirements and Cost Associated With the MOC Exam
MOC Requirements Number Needed Cost
CME credits 100 0
Simulation training 0 may count toward CME requirement 0 $35 fee for cancellation or failure to show
Application fee $1,675 ($1,840 for subspecialty) Fee provides access to unlimited ABIM Self-Evaluation Modules for CME credit in addition to simulation training
Total cost
Application fee
ABIM, American Board of Internal Medicine; CME, Continuing Medical Education; MOC, Maintenance of Certification
Conclusion
Maintenance of currency and proficiency within all of the medical subspecialties is, without question, a necessity. Anesthesiologists take great pridejustifiablyin shepherding patients through their procedures and incorporating the most up-to-date knowledge and equipment to provide safe and excellent care. But that does not obviate questions about the continuously increasing requirements of the MOCA process, as well as the exemption of certain individuals from participation in that process based solely on the date they obtained initial certification.
As previously demonstrated, evidence supporting the components of the exam is lacking. Even so, the requirements continue to increase. Where are the data demonstrating that the addition of 140 CME credits from the inception of the MOCA in 2000 improves physician care when traditional CME has been shown to be ineffective? Where are the data that demonstrate that simulation in a remote endorsed center is superior to a locally based and less costly simulation center? Meanwhile, although the data to support these questions are not available, the revenue that these requirements generate is easy to calculate.
The ABA argues that it is attempting to create an exam that is not onerous for the physician. But is the MOCA a better recertification examination process than the MOC because it has more requirements and costs three times as much? The MOC has been in existence since 1990 (indeed, the MOCA is based on it). Does the MOC fail to satisfactorily maintain its physicians competence because it is more convenient and manageable than the MOCA? Are anesthesiologists more current and proficient than our other colleagues who take the MOC?
Lastly, but not least important, where are the data to support the grandfather status? The ABA publicly preaches its support of recertification of anesthesiologists. The public has expressed its views regarding the value and expectation for physician recertification. In addition, the data demonstrate that physicians farther from initial certification are most in need of external assessment. This exemption, and the questions previously posed, undermine the validity of the entire recertification process.
--------------------------------------------------------------------------------
Dr. Haddad is an anesthesiologist at Valley Anesthesiology Consultants, in Phoenix, Ariz.
References
1.Sharp LK, Bashook PG, Lipsky MS, Horowitz SD, Miller SH. Specialty board certification and clinical outcomes: the missing link. Acad Med. 2002;77:534-542.
2.Silber JH, Kennedy SK, Even-Shoshan O, et al. Anesthesiologist board certification and patient outcomes. Anesthesiology. 2002;96:1044-1052.
3.Norcini JJ, Kimball HR, Lipner RS. Certification and specialization: do they matter in the outcome of acute myocardial infarction? Acad Med. 2000;75:1193-1198.
4.Norcini JJ, Lipner RS, Kimball HR. Certifying examination performance and patient outcomes following acute myocardial infarction. Med Educ. 2002;36:853-859.
5.Turchin A, Shubina M, Chodos AH, Einbinder JS, Pendergrass ML. Effect of board certification on antihypertensive treatment intensification in patients with diabetes mellitus. Circulation. 2008;117:623-628.
6.Holmboe ES, Wang Y, Meehan TP, et al. Association between maintenance of certification examination scores and quality of care for Medicare beneficiaries. Arch Intern Med. 2008;168:1396-1403.
7.Landon BE. What do certification examinations tell us about quality? (editorial). Arch Intern Med. 2008;168:1365-1367.
8.Davis DA, Taylor-Vaisey A. Translating guidelines into practice: a systematic review of theoretic concepts, practical experience, and research evidence in the adoption of clinical practice guidelines. CMAJ. 1997;157:408-416.
9.Schrock JW, Cydulka RK. Lifelong learning. Emerg Med Clin N Am. 2006;24:785-795.
10.Davis D, OBrien MA, Freemantle N, Wolf FM, Mazmanian P, Taylor-Vaisey A. Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? JAMA. 1999;282:867-874.
11.Mazmanian PE, Davis DA. Continuing medical education and the physician as a learner. JAMA. 2002;288:1057-1060.
12.Grimshaw JM, Shirran L, Thomas R, et al. Changing provider behavior: an overview of systematic reviews of interventions. Med Care. 2001;39:112-145.
13.Boulet JR, Murray DJ. Simulation-based assessment in anesthesiology. Anesthesiology. 2010;112:1041-1052.
14.Cooper JB, Murray D. Simulation training and assessment: a more efficient method to develop expertise than apprenticeship. Anesthesiology. 2010;112:8-9.
15.Frengley RW, Weller JM, Torrie J, et al. The effect of a simulation-based training intervention on the performance of established critical care unit teams. Crit Care Med. 2011;39:2605-2611.
16.Shaw K, Cassel C, Black C, Levinson W. Shared medical regulation in a time of increasing calls for accountability and transparency: comparison of recertification in the United States, Canada, and the United Kingdom. JAMA. 2009;302:2008-2014.
17.Agres T. Mounting board demands foster growing unease. Anesthesiology News. October 2011.
