ABMS President Defends MOC Part 4, Calls for Physician Engagement in Quality

“I absolutely believe we should keep the performance-in-practice component of maintenance of certification (MOC),” American Board of Medical Specialties (ABMS) President and Chief Executive Lois Margaret Nora, M.D., J.D., told the APA Assembly last month at APA’s 2015 annual meeting in Toronto. “I know that many of you do not agree with me about this, but I would ask you to reconsider.”

David Hathcox

Nora spoke of a profound “disconnect” when it comes to Part 4 performance in practice. “I have heard from physicians who say, ‘Part 4 has changed my practice for the better; we are doing things now that have improved the quality of care our patients receive.’

“But I have also heard from people who say, ‘I was forced to do something that was not relevant. And not only that, I tried to do something that was relevant, and they did not give me credit.’ ”

Nora acknowledged that the MOC process, and in particular the Part 4 performance-in-practice component (also referred to as “improvement in medical practice”) needs to be improved and refined. She vowed that the ABMS is responding to physician concerns by a “relaxation” of requirements and an expansion of activities that count toward fulfillment of Part 4.

“Performance in practice” refers to a requirement that physicians build into their routine practice the capacity to assess their performance continually against guidelines for best practices and make improvements to meet those guidelines.

(Just before the start of APA’s annual meeting, the American Board of Psychiatry and Neurology [ABPN] announced that the feedback module in Part 4 will become optional as of January 1, 2016. The Part 4 clinical module component, or chart review, will remain a requirement, and additional approved activities are now available on the ABPN website.)

“I do not believe complaints like that are going to continue with [the inclusion of new activities] that meet standards for improvement but much more broadly,” Nora said at the Assembly meeting. “With the appropriate flexibility, I believe that performance in practice will be embraced by physicians.”

Up to now it has been a chilly embrace. The ABMS has mandated that all medical specialties require physicians to demonstrate competence in four categories: professional standing, self-assessment and lifelong learning, cognitive expertise, and performance in practice.

In an interview with Psychiatric News last year, ABPN President Larry Faulkner, M.D., explained that the “the performance-in-practice issue is a controversial and difficult one. … It boils down to a quality-improvement process. In general, physicians are going to have to demonstrate that they have looked at their practices and identified issues that need to be improved.”

But Part 4 has been the object of widespread physician concern and even anger. At the March meeting of the APA Board of Trustees, the Board voted to write a letter to Faulkner requesting that the ABPN advocate to the ABMS that Part 4 be eliminated. The ABPN operates under criteria established by the ABMS.

The letter was the result of a motion, spurred by the Assembly Executive Committee, reflecting concerns over the limited evidence base for Part 4. Also at its March meeting, the Board of Trustees established a joint Board-Assembly work group to evaluate the broad issue of MOC in psychiatry and its relationship to maintenance of state licensure and requirements of other accrediting bodies.

At the Assembly meeting, Nora pitched the benefits of quality improvement, saying that if physicians themselves do not enforce quality improvement in their ranks, then it likely will be enforced by outside authorities.

Also, she encouraged physicians to become engaged in quality improvement and to help the ABMS improve the system. “It is well documented that physician engagement improves quality-improvement projects, that when there is physician engagement, there is greater buy-in and there are more relevant activities included,” Nora said. “As a consequence, health systems want physician engagement. I believe also that there is potentially great benefit to physicians.”

Nora said that the American College of Physicians was finalizing work on a module to be included in Part 4 addressing physician resilience and burnout. Physician satisfaction is intimately connected to quality of care and quality improvement, she said.

“Many physicians are dissatisfied with their career choice, and as a profession we have concerns about burnout and physician suicide,” Nora said. “Physician satisfaction is the ‘canary in the coal mine’ for quality improvement. If physicians believe they are delivering high-quality care to their patients, they will be happy as physicians.”

She solicited the input of psychiatrists in this area. “I believe that psychiatry has a unique expertise in this area that the rest of the profession would benefit from,” she said. “I ask you to consider taking ownership of some of these topics and help to push these materials [on burnout and resilience] out to your physician colleagues.” ■