Beginning with the June 2006 class, pathologists who pass the American Board of Pathology exams will be issued time-limited certificates and be required to recertify every 10 years to maintain their certification. Maintenance of Certification, or MOC, was specified by the American Board of Medical Specialties and applies to all physicians. Its aim is to track a physician’s learning throughout his or her career, and it requires that competence be assessed across six categories using four general methods. Though required only of those who become board-certified in 2006 and beyond, the expectation is that pathologists with lifetime certificates, who are not required to participate in MOC for board certification, will eventually be expected to do so by other parties, such as payers and institutions granting privileges. The CAP Education Committee, chaired by Elizabeth H. Hammond, MD, has been working to ensure that CAP members understand MOC requirements and have access to CME programs and services that will make it easier to meet the requirements. Writer Mariann Stephens spoke in July with Dr. Hammond, a pathologist at Intermountain Health Care, Salt Lake City.
has never before been required for pathologists; this seems like a big change.
Are other specialties going through a change like this?
Recertification is for all of medicine; we all have to do it. Most of the other specialties have already gone through the process. The pathologists are actually one of the last groups to implement.
The ABMS is a board of boards, a group of individuals representing specialties, and the people on that body are members of each specialty board. Our board, the American Board of Pathology, or the ABP, is a member board of the ABMS. The ABMS and ABP agreed that MOC would apply to everyone completing their residency and passing the boards in 2006 but not before.
Why did the American Board of Pathology decide to implement Maintenance of Certification?
The ABP recognized the challenges of implementing MOC but probably had little choice, since the ABMS adopted a strategy that included recertification. But even if we could have been exempted as the only specialty without MOC, other forces in the marketplace would have continued to press us to meet the requirements.
Let’s forget the ABMS and the ABP for a moment. Here I am, applying for privileges to practice at my institution. Most of the other specialties are already under mandatory recertification. So one question likely to be on the list is whether I have been recertified. If I say that I don’t have to recertify, their next question is, “Why not? What are you doing to prove you’re competent?”
I am an older pathologist and I have an unrestricted license and an unrestricted certificate to be a pathologist; you could say this whole thing doesn’t apply to me. However, since it applies to virtually all other medical specialties, even if the American Board doesn’t expect me as an individual to do this, it’s likely that my institution, LDS Hospital, will expect it at some point.
This brings us to the College, as a provider of continuing education for pathologists. The question for me, as chair of the Education Committee, becomes, “Liz, what are you making the other pathologists do to show they are competent?”
On the Education Committee, we believe strongly that whether or not we have lifetime certificates, on a practical level, we will all be expected to do these activities. We expect hospitals and insurers to begin requiring all pathologists, including those who were board-certified before 2006, to be recertified. So even though the ABP won’t care, our institutions will care and, more important, our patients will care.
The public is tuned in to having doctors who are recertified or who are in
compliance with the latest requirements. A recent Gallup Poll revealed that
three out of four patients surveyed would choose a board-certified physician
over a physician who was recommended by a trusted friend or family member but
not board-certified (Brennan TA, et al. JAMA. 2004;292:1038–1043). Because of that survey, I would say it is incumbent on pathologists to at least recertify. The safest position is to take courses to qualify for MOC in areas you’re interested in, so you can show your institution you’re keeping up.
In practical terms, what is new about MOC, and how is MOC different from the ABP voluntary recertification program?
Voluntary recertification does not require a closed-book exam and diplomates must accrue 150 hours of CME during the three-year window before recertification. Of those 150 hours, 100 must be category 1 CME, and of the 100 category 1 credits, 80 hours must be directly related to the applicant’s field of practice. The remainder may be in areas of general relevance to pathology, such as administration or ethics.
Recertification under MOC requires a closed-book exam. The CME requirement is 25 hours of category 1 per year for each two-year period in the MOC cycle, plus completion of two self-assessment units during each two-year period. Again, 80 percent of the CME must be directly related to the diplomate’s practice, and the balance must be of general relevance.
For voluntary recertification, you fill out extensive documents and if they’re sufficient you don’t have to take the exam. I was voluntarily recertified without taking a test. Some people, when they go through, have to take the test, but mostly it’s a voluntary program.
Voluntary recertification for those with pre-2006 certificates and MOC for newly graduated residents involve two entirely different examinations. The MOC categories aren’t in the old exam. Taking the voluntary exam is a good hedge. But what could still happen is they could tell you, “OK, you have a certificate on your wall that says you are recertified, but everyone else is doing MOC and turning in these documents that say they’re doing these self-assessments. Why don’t you do this?” Now because I do a lot of CME with the CAP, I can download a copy of my transcript and show them I am doing MOC-related activities. So that’s why the CAP is making this such a high priority.
How does a pathologist recertify in more than one subspecialty?
Maintenance of Certification is a good concept, but we do have some concerns about it. For example, the ABP has structured the recertification process around separate examinations for AP, CP, and subspecialty certificates. The ABP approach, saying you have to choose what part of pathology (AP or CP and/or a subspecialty) to recertify in, may create problems. Promoting voluntary certificates is a good way to prevent potential problems because with voluntary recertification you don’t have to declare one or the other and you can get a piece of paper that says you’re recertified in both. The first recertifications are 10 years off; they won’t come up until 2016. We have a lot of years to influence the American Board to change its mind about dual AP/CP and to try to persuade pathologists to prepare themselves for more broad aspects of the recertification exam. We may in that time create a curriculum that would train pathologists to pass all aspects of the test. There are a lot of educational steps that could mitigate the danger of a decline in the number of board-certified clinical pathologists that could occur if pathologists had to take separate tests.
Why can’t pathologists wait until just before their
time-limited certificates expire before worrying about this?
The ABP expects you to communicate with them every two years throughout the 10-year cycle and show the documents that relate to your qualifications in all these categories.
MOC is critical for every resident coming into practice; they have to start doing it this year. They have to show every year that they are following these requirements. The ABP says it will come up with a tracking system but they don’t have it yet. The CAP is working hard to provide a simple way for you to record what you do; if you take a course from the CAP it is now automatically entered into your online transcript.
Where can pathologists go for help in understanding the new MOC requirements and determining how to meet them?
As the head of education for the College, I knew I had to have courses in place to help our members deal with their institutions and others who would begin to impose MOC requirements. Step No. 1, we decided, would be to look at those categories the ABMS had come up with and make them more specific for pathologists. Remember, the categories were for all of medicine.
The ABP has a challenge in defining the requirements because pathology comprises all of medicine. It’s divided into two big boxes, anatomic and clinical, and there are diverse disciplines within those boxes. The American Board has to figure out a way to assess all of those pathologists for these different competency categories. They have chosen, wisely I think, to be vague about those requirements. They’re broad brushstroke requirements.
One problem is that because it’s such a difficult task, they can’t do all the work themselves. So they’ve assigned a lot of the work to be done by what they call the cooperating societies. The College is one of the cooperating societies, USCAP [U.S. and Canadian Academy of Pathology] is one, ASCP [American Society for Clinical Pathology] is one—there are eight in all. These cooperating societies are the groups that commonly give courses on these subjects. So they need to structure their courses to help pathologists meet requirements for lifelong learning and self-assessment. They give courses that fit the different requirements, classes the pathologist can take in person or online. The ABP has said, “We want you to do more of that.” So the cooperating societies provide those courses and pathologists then are required to take 50 category 1 credits plus two self-assessment units every two years for MOC of lifelong learning and assessment.
The ABP is responsible for coming up with the MOC requirements for pathologists but they have to fit in the framework of what the ABMS says all doctors should be competent in. So the way the ABMS did this was to define six categories in which doctors should be competent and four methods by which the competence would be assessed. For example, several methods can be used to assess competence in medical knowledge. If we have a course about breast pathology, that’s medical knowledge related to breast. A CME-related course on breast pathology would be the method by which it would be assessed. It could also be assessed by an ABP test. And another way it could be assessed would be by the way that every pathologist handled breast cases in their practices. It’s unlikely that reviewing professional standing and credentials, another of the methods, would be used to assess competence in breast pathology.
The CAP Education Committee went through an involved process to define what each of the six competency categories were in pathological terms. What is medical knowledge of pathology? We evaluated each category and created knowledge and skill statements that relate to pathology for each one of them. That information has been published (Hammond EH, Filling CM, Neumann AR, Homburger, HA, for the Education Committee, College of American Pathologists. Addressing the Maintenance of Certification Challenge. The College of American Pathologists Response. Arch
Pathol Lab Med. 2005;129:666–675).
We began by asking ourselves, “What are we really asking the pathologist to know about?” After that, we took all the courses the CAP gives, and using the knowledge and skill statements we had created, we mapped our curriculum back to these MOC categories. So we know how many courses we are delivering in each of the six competency categories and what kinds of courses they are. The Education Committee is using this information to make sure the curriculum that is planned meets the needs of these categories.
Of course, our members get CME from other societies and institutions outside the CAP, so we are now trying to coordinate with the other cooperating societies so we don’t work at cross-purposes. That is why we published our paper [in the May 2005 issue of Archives], so that it would be out there as a published document. And we are going to encourage everyone to publish what they’re saying, too. We can have a dialog in print.
The second thing we’re doing is that the American Board has to find out what you as an individual have done about MOC, so we have marked every course with icons that tell which category it fits in and we have developed a tracking system on our Web site, so pathologists can keep track of what educational courses they took. Because ultimately they have to be able to say, “I’ve done it in a whole group of courses.”
The American Board recently described the MOC requirements further and defined further some other specifics we have to do work on now. One is that it’s not good enough to just allow pathologists to take courses in a subject. They have to actually perform a self-assessment activity, which is like a pre- and post-test on material that lets them see that they actually learned something, and the ABP has required that each pathologist do at least two of those self-assessment activities over a two-year period. We are working to develop initial guidelines for self-assessment activities consistent with what ABP’s application requests, and our Education Committee will be working to develop self-assessment modules for our courses and online programs that will qualify with the American Board for this purpose.
With pathology practices so diverse, how will the ABP assess performance in practice?
The ABP will not assess performance in practice. It is going to expect the cooperating societies to do that by a variety of means, and it is going to expect the individual to provide documentation of it.
Individuals will be required to show adequate performance in practice by several mechanisms. First, they must show they have letters from a peer attesting to their interpersonal and communication skills, professionalism, ethics, and effectiveness in systems-based practice. Second, they have to show that their laboratory is accredited by a valid accreditation group such as the CAP or Joint Commission. Third, they must show they have participated in inter- and intralaboratory improvements and a quality assurance program in an area related to their specific area of practice. And fourth, they are expected to document the use of appropriate protocols, outcome measures, and practice guidelines.
Take the example I used previously. To assess skills in breast pathology, the pathologist would ask himself or herself, “How do I as a pathologist do on breast cancer when I’m actually looking at a breast cancer? How well am I performing as a breast pathologist?” That is a difficult thing to assess, and, again, the American Board is looking to the cooperating societies to do that. So as a chair of education for one of the cooperating societies, I have to find a way to help pathologists meet these requirements.
The way the College has applied to be a valid source of these kinds of activities is through our Laboratory Accreditation Program, where we send individuals into labs where they can talk to pathologists and see what they’re doing. They are also likely to evaluate pathologists based on the patient activities they complete. And then they will evaluate pathologists by other activities they do that show they have analyzed their own work.
Now that means that if I want to know how well our practice is doing in breast cancer, the way that would be evaluated would be by my looking at my own performance and that of my colleagues and saying, Are we getting the right answer on breast cancer every time? So we would have to do a form of outcome analysis and figure out how our practice stacked up in terms of accuracy of reports, what we can do to improve, and then implement that new process. That kind of outcome and practice analysis will be something the ABP will also accept, but it doesn’t have a mechanism for how that will be structured.
So the College is going to create job aids, such as a form, that will help pathologists in their everyday practices. The first step would be to identify people looking at breast cancer and review their reports. The form—maybe an algorithm—would say these are the steps you take, this is what you need to find out. It would sift through and aid them in doing their activity and document what they did. One charge to the Education Committee—and one thing we’re working on now—is to create those job aids.