Editorial: Preparing for the Maintenance of Certification (MOC) Examination in Rhinology

In 2000, the American Board of Medical Specialties (ABMS) adopted Maintenance of Certification (MOC), as a change in physician self-regulation.¹ Specifically MOC is designed to encourage physician self-assessment, lifelong learning and continuous performance improvement. Multiple factors brought about this change, including an increase in the complexity of health care delivery that parallels improvements in development of new methods of diagnosis and treatment.² Consumers became more interested in the delivery of appropriate health care in the setting of unsustainable cost increases, and heightened scrutiny over the use of limited funds. Additionally, technological improvements allowed for more careful monitoring of health care delivery, leading to increased accountability. The demand for increased value, quality and accountability is what effectively led to MOC.²

The idea of MOC was met with a fair amount of controversy. While most physicians support the need to demonstrate their ongoing competence through formal MOC programs, more extensive debates have focused on how to develop MOC methods, how to demonstrate competency, and how to pay for these initiatives.² The cost-effectiveness of the MOC is also a point of debate. Many physicians were not interested in the time and financial burdens associated with the MOC, given the uncertain benefits and questionable importance. However, the risk of government agencies bypassing the ABMS to institute their own regulations exists, particularly if they are not satisfied with the stringency of the current MOC. There is also a conflict between the desire for change and the transparency of cost effectiveness data on various MOC components.

Substantial evidence exists for the need of MOC; studies have shown that up to 12% of physicians fail to maintain standards and patients receive approximately 50% of the care that is indicated for their specific conditions.¹ The data consistently shows that physician knowledge and skills, evidence based medicine and outcomes decline, while adverse actions by state licensing boards increase as the time from medical training increases.

While various specialty boards are approaching the MOC differently, all MOC programs consist of 4 parts:³

1. Professional standing

2. Continuing education and self-assessment

3. Cognitive experience

4. Performance in practice

Each part is meant to enhance physician competence with a goal towards improvement in quality of care and patient outcomes. For MOC part 1, data shows that physician communication skills impact patient satisfaction, quality of life, and outcomes, and have been linked to malpractice as well as state licensing board actions.¹ Patient feedback has also been shown to motivate providers to improve communication skills. The feedback from peers and other medical personnel provide reliable, valid information for professional development. Although the data is skewed toward higher ratings, there exists enough variability to distinguish performance levels. Physicians have responded favorably to feedback from peers and co-workers. Both peer and patient assessments may be implemented with time to enhance and maintain professional standing.¹ Currently the ABOto requires that all of its diplomats possess a valid ABOto certificate and hold an unrestricted medical license in each state that they practice medicine. Adverse actions taken by state licensing boards, hospitals or others against ABOto diplomats can be communicated to the ABOto via the Disciplinary Alert Notification System (DANS).¹ This process allows the ABOto to maintain and enforce standards on its board certified diplomats.

Part II of the MOC process focuses on education and learning. There is increasing data that lifelong learning and continuing medical education (CME) improves physician performance and outcomes.¹ Live sessions with multiple media types provide the greatest positive results. Currently the ABOto requires its diplomats to earn as many category 1 CME credits as are required by their state licensing boards. In those states in which there is no CME credit requirement, the ABOto requires a minimum of 15 hours of category 1 CME credits.³ 60% of these CME credits must pertain to the specialty of Otolaryngology – Head and Neck surgery. In the future the ABOto may implement patient simulation on-line modules that will allow certified Otolaryngologists to participate in interactive patient cases. Their clinical decisions in these cases can be assessed and areas of deficiencies can be identified in order to provide feedback to assist with ongoing learning.³

The MOC Part III involves medical knowledge and clinical diagnostic reasoning. It has been shown that physicians need strong knowledge and clinical skills in order to appropriately synthesize data, a skill required while making differential diagnoses. Research shows that failure to acquire new knowledge, declining cognitive skills, and inaccuracies in self-assessment support the need for periodic assessment.¹ Exam scores correlate with other measures of clinical performance, as well as peer assessment. Board certification has been shown to be associated with better quality of care and outcomes. Currently at the end of a 10 year cycle following initial board certification, diplomats must pass a computer based multiple choice examination. This examination may be made available to the MOC participants three years prior to the expiration of their certificate so that the individual has three opportunities to pass the examination. There are two components to the exam. The first part is a fundamental module that consists of questions that all otolaryngologists should know such as fluid management, ethics, antibiotics, anesthesia and patient safety. The second module is a specialty module that the examinee can choose based on the focus of their practice. These subspecialty modules are outlined in Table 1.

Table 1³:

MOC Part III Subsecialty Areas

*For individuals subcertified in these areas

The MOC part IV is specifically designed to help physicians assess and improve the quality of safety of their practice and health care in general. Physicians can meet these requirements either through assessment of their own practices using performance based methods or involvement in group, institutional or national QI projects. With the growing changes in health care and initiatives by the Federal government to regulate health care delivery, quality and costs, this component of the MOC will certainly grow in importance and new initiatives by ABMS and ABOto will likely be ongoing.¹

The purpose of this supplement is to provide the reader with review articles^4–27 and associated board style questions. This MOC Review (available at www.AJRA.com) should help Otolaryngologists to study and enhance their medical knowledge in order to prepare them for the MOC part III 10 year examination. Specifically this MOC Review is meant to focus on topics relating to the subspecialties of Allergy and Rhinology.