Larry Faulkner, MD

The American Board of Medical Specialties (ABMS) consists of 24 medical specialty Member Boards. Each specialty board within the ABMS adheres to 4 components in their individual Maintenance of Certification (MOC) programs. MOC ensures that the physician is committed to lifelong learning and competency in a specialty and/or subspecialty by requiring ongoing assessment of 6 core competencies. Assessment of these competencies happens in a variety of ways and is carried out by all Member Boards using a process that is designed to keep certification continuous.

The 4 components of the MOC process assess (

• Professionalism and professional standing (Part 1)

• Lifelong learning and self-assessment (Part 2)

• Assessment of knowledge, judgment, and skills (Part 3)

• Improvement in medical practice (Part 4)

These components are outlined in detail on the American Board of Psychiatry and Neurology (ABPN) Web site, along with a list of ABPN-approved MOC products for self-assessment, CME, and improvement in practice.

The internal objective of MOC is to encourage diplomates to participate in lifelong learning. The external objective is to demonstrate and document ongoing competence of board-certified physicians to the public and outside organizations. ABPN Directors, President, and CEO, as well as MOC Examination Committee members must participate in MOC.

The ABMS provides an evidence library on their Web site that highlights research studies and articles that support the value of board certification and MOC.

 It reflects an effort to systematically present the empirical evidence in the current peer-reviewed literature.

MOC cognitive examination: information and pass rates

The ABPN MOC written examinations are designed to measure clinical competencies required for patient care. They are developed by nationally and internationally renowned volunteer content experts in the fields of psychiatry and neurology who serve on the various committees. The content experts determine the critical knowledge and skill domains that define the core competencies for experienced practicing physicians. Every item is reviewed, modified, and approved by a committee of content experts to ensure they address topics that are significant to practice and are reasonably challenging and scientifically written. The final examinations are made up of items selected by the examination committees from the approved item pool. All ABPN examinations meet the published content specifications and possess all major desired psychometric properties.

The pass-fail standards for ABPN MOC examinations are recommended by the Standard Setting Committee and reviewed and finalized by an oversight committee for the specialty or subspecialty. They use standard-setting methods to review the content of every question in the examination and make content-based judgments. The oversight committee reviews the recommended standards and makes the final decision.

The standard-setting methods the ABPN uses are criterion-based and not norm-based. Therefore, theoretically, everyone can pass or everyone can fail. The recent average pass rate for the psychiatry MOC cognitive examination is 99%. High pass rates are expected, since diplomates are about 10 years into their practice and in tune with current knowledge in the field. Another reason for the high pass rate is that diplomates have gone through the arduous process of becoming board-certified and have demonstrated their knowledge by passing the certification examination. A diplomate has 2 opportunities to pass the MOC cognitive examination before being reported as “Not Certified.” The two opportunities often fall within the same calendar year.

Security measures are in place at test centers to prevent cheating on the examinations:

• Examinees may not access personal items (eg, cell phones, pagers, study materials, notes)

• Examinees may use the restroom but cannot leave the test center

• Electronic devices are not permitted in the exam room

• Two forms of identification are required

• Examinees are required to place each hand on a palm vein device on arrival at the testing center and whenever entering or leaving the testing rooms

• Electronic signatures and photographs are taken of the examinees

In keeping with the evolving nature of the MOC requirements for all physicians, the ABPN must remain consistent with the ABMS guidelines. The ABMS recently approved new MOC program standards for implementation in 2015, which have been adopted by the ABPN.

With the adoption of the new standards, the ABPN is in the process of implementing many changes for the MOC program that it expects will be well received by diplomates. For example, the ABPN will now be able to adopt a more flexible approach to the Feedback Module requirements by allowing a diplomate to complete one of the following options (per 3-year MOC cycle):

• Institutional peer review of general competencies

• Resident evaluation of general competencies

• 360-degree evaluations of general competencies

The new Feedback Module requirements will be implemented immediately. Free downloadable patient and peer surveys are available on the ABPN Web site.

 By the end of 2014, the ABPN will post more examples of approved surveys on their Web site. If a diplomate wants to use a survey that does not appear on the ABPN approved products page, the diplomate is required to submit the survey for pre-approval to Questions@abpn.com.

Approaches to specific non-CME self-assessment activities for Part 2 MOC credit will be announced in July 2014. Activities under consideration are grants, ABPN cognitive examinations, peer-reviewed journal publications, and non-CME self-assessment activities that are part of patient safety courses. Different approaches to the cognitive examination, such as choosing content areas and focus of questions, are also under consideration.

Beginning in 2012, diplomates who pass their initial certification or MOC examination enter into the ABPN Continuous MOC program (C-MOC). The focal point of the C-MOC program is the ABPN Physician Folio that offers a single source for personalized information regarding certification and MOC status. There is a large catalog of ABPN-approved MOC products in self-assessment, CME, and improvement in medical practice on the ABPN Web site.

While passing the cognitive examination is still required at least every 10 years, a diplomate’s certification status is dependent on fulfillment of all 4 MOC program components, along with payment of an annual MOC registration fee. The ABPN continues to monitor the landscape and gather feedback from the diplomates about the MOC program, and it strives to give MOC credit to diplomates who are already participating in practice improvement activities that meet the ABPN MOC program requirements.

Some examples of ABPN responses to diplomate feedback on MOC include development of an MOC expert group referred to as the “MOC Ambassadors.” This group of individuals has been trained on the ABPN MOC message and can attend local professional meetings and speak about the program (ie, presentations at APA district branches, state neurological societies, Grand Rounds, etc).

The ABPN provides Part 4 credit for team projects completed at institutions that join a formal institutional recognition program (the Multi-Specialty MOC Portfolio Program

) and gives credit for one stage of MOC activities (on the ABPN Web site) for diplomates who complete Accreditation Council for Graduate Medical Education– accredited/ABPN-approved subspecialty training and pass an ABPN subspecialty examination. The ABPN also accepts institutional quality assurance programs and patient and peer surveys that meet its requirements. The ABPN plans on continuing efforts to obtain feedback on the MOC program and small focus groups will be conducted to solicit feedback from diplomates about communication of the MOC message on the Web site and in printed materials.

The ABPN runs 2 MOC programs simultaneously, the 10-year MOC program and the C-MOC program (the ABPN Web site outlines the details of and differences between the two programs), which may make it challenging for a diplomate to determine which is the correct program for him or her. The main difference between the two programs is that the C-MOC program requires a diplomate to attest to completion of the various MOC activities in 3-year increments.

The diplomate is required to log on to his Physician Folio page on an annual basis to attest to MOC activities and submit an annual MOC program fee. The 10-year MOC program applies to certificates issued in 2011 or earlier. The C-MOC program applies to all certificates issued in 2012 and after. This may be confusing, so the simplest solution is to log on to the ABPN Physician Folio page where MOC requirements and deadlines are personalized for each diplomate. If there is any confusion, please contact the Board office with any questions.

In addition, it is prudent to not wait until one’s certificate is about to expire to find out what the requirements are for the examination. In other words, diplomates should allow ample time to meet requirements because certification status is no longer tied only to passing the examination. The ABPN Executive Office has increased technology and support services to provide diplomates with individualized assistance and a smooth experience during the MOC process. For additional questions, you can contact the ABPN by e-mail or phone.

Ms Vondrak is Director of Examination Administration and MOC and Dr Faulkner is President and CEO of the American Board of Psychiatry and Neurology, Inc, in Buffalo Grove, Ill. They report no conflicts of interest concerning the subject matter of this article.

 American Board of Psychiatry and Neurology, Inc. http://www.abpn.com. Accessed March 26, 2014.

 American Board of Medical Specialties. ABMS Evidence Library. http://www.abms.org/ EvidenceLibrary/default.aspx. Accessed March 27, 2014.

 American Board of Psychiatry and Neurology, Inc. Approved MOC Products. http://abpn.com/moc_products.asp. Accessed March 27, 2014.

 Multi-Specialty MOC Portfolio Approval Program. http://mocportfolioprogram.org. Accessed March 27, 2014.

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