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Maintenance of Certification Does NOT Equal Maintenance of Quality

November 15, 2013

The good folks at The Health Care Blog kindly pointed out a post on MOC that they asked me to comment on.  MOC, for those blissfully ignorant of this recent regulatory development, stands for Maintenance of Certification.  In Anesthesia it’s called MOCA for obvious reasons.  Dr. Lois Margaret Nora, head of the American Board of Medical Specialties, invited constructive feedback on this process, which is mandatory for everyone certified after 2000, at least in Anesthesia. What happens to the old guys certified before 2000?  I guess their skills never decline and their knowledge is forever renewing automatically through a chip implanted in their elderly brains.

MOC is actually a good idea.  You might be surprised to hear this coming from me.  It is.  Skills and knowledge decline over time.  That’s what CME’s (Continuing Medical Education) credits used to be for.  Let’s put off for the moment consideration of the considerable time, effort and money each physician must expend on this 10 year process every 10 years.  Let’s look at what’s really required.  Here’s what the ABA (American Board of Anesthesiology) website says:

“Each MOCA cycle is a 10-year period that includes continuing assessment of Professional Standing (medical licensure), ongoing Lifelong Learning and Self-Assessment, a decennial assessment of Cognitive Expertise, and periodic assessments of Practice Performance. MOCA is an opportunity for physicians to improve their skills in six general competencies: Medical Knowledge; Patient Care; Practice-Based Learning and Improvement; Professionalism; Interpersonal and Communication Skills; and Systems-Based Practice.”

There are four parts to MOCA:  1. Maintenance of Licensure (MOL), which has it’s set of requirements separate from MOC. 2. Lifelong Learning and Self-Assessment, translated = CME’s!  But you cannot apply more than 60 credits a year and over the 10 years 90 must be “self-assessment” and 20 must be “patient safety” credits.  3. Cognitive Examination = a very long multiple choice test that costs, get this, $2,100. Yep.  Two thousand big ones. 4. Practice Performance Assessment and Improvement, which you can do with an online module.  Very effective.  But wait! Look what else you can do!

“We are pleased to announce that participating in MOCA in 2013 can qualify ABA diplomates for a bonus incentive payment if they also participate in the Physician Quality Reporting System (PQRS). MOCA participants will receive an additional 0.5% incentive payment (MOC:PQRS incentive) based on their estimated Medicare Part B Physician Fee Schedule allowed payments for Centers for Medicare and Medicaid Services (CMS). This bonus is in addition to the 0.5% incentive payment allowed for participation in PQRS only. CMS will be offering the MOC:PQRS incentive in 2013 and 2014 as defined by the Affordable Care Act. The MOC:PQRS incentive is not currently defined beyond 2014.”

Ah.  Now we get down to it.  I don’t even know what most of that means but two things catch the eye:  CMS and PQRS.  CMS is of course the Centers for Medicare and Medicaid Services, and PQRS is the Patient Quality Reporting System.  Government regulatory agencies.  The federal government has figured out a way to make doctor’s requirements for MOC  translate into data points for itself.  This is no surprise.  Not only will CMS want data, it will use that data to generate data about whether or not MOC increases quality of care.  And how will it define quality?  The same way it does now.  Meaningful Use.  Criteria that are easily measured and have little to do with actual quality of the care given to any one patient.

Want to improve quality of care and maintenance of the skill set and knowledge needed to be a good anesthesiologist?

1. Provide doctors with more time with patients and less time on MOC paperwork

2. Develop an open-access and curated central location for all significant recent clinical research

3. Provide time for “professional development” like my pre-schooler’s teachers do.  And no, I don’t mean the grand rounds where the guy researching natriuretic peptide puts of slides of the Krebs cycle for an hour.

4. Provide MEANINGFUL ways doctors can improve their skills.  Why not provide “mini residencies”?  If a doctor needs practice on fiberoptic intubations, give him a month- or week-long intensive airway “rotation” where he gets to intubate everything hard and spends time with the ENT guys who do this in the office every day.  Or schedule the ORs in such a way that the poor slob who does cataracts and knee scopes all day every day gets a chance to do some thoracic cases and practice lines and double-lumen tubes.

If all this is too technical, that’s because it is for us anesthesiologists too.  Skills can be lost in the slotting of doctors into specialty groups.  No amount of simulation or on-line courses or grand-round CME’s will be as effective as these measures in making sure everyone knows what they are doing for the best interests of every patient every time.


  1. Randy B permalink

    LOVE the idea of ‘mini residencies’. I could think of a couple that could be done in a day or two, longer ones a week. I think this would help doctors and patients together a lot better than most all the other ideas I’ve seen.

    • I know right? There’s the pesky problem of money of course. In my field you’d have to have a department that didn’t need every living soul to staff the ORs every day, and you’d have to have a big enough program to support attending residents as well as real residents. But I could certainly go for one or two refresher rotations myself!

      • Randy B permalink

        Is it possible to have “webinars” for more … documentary? … type of stuff? that could be held at the hospital? For example, these would be learning about new drugs. Does everything have to be hands on? If so, I know there are locums, maybe those could be used to help teach?

        What about the academic docs?

  2. Dana Seidl, MD permalink

    A most wonderful post on a subject near to my heart.

    I possess one of those elderly brains that took the oral board exam in 1986 and thus received a lifetime certification as was the custom in the old days. For all of my professional career I’ve tried to make my CME exposure meaningful and to gain at least one usable idea from the courses I’ve attended. I’ve tried hard to keep up with the major journals, reading those articles that I can understand and shaking my head at the rest. Oh, and yes, I took the ABA voluntary recertification exam in 2009 and passed it along with 99.9% of my colleagues that took it. Now that was a feeling of accomplishment, let me tell you.

    Though my 60’s have yet to overtake me, at this point I’ve had enough of exams, blowing into dummies, and being told that simulation labs are the new standard for evaluating competence. I try to provide what I can honestly think of as good clinical care. In the pre-op interview, I usually manage to make most of the patients that I encounter feel at ease and sometimes even make them laugh a little before a major operation. The experiences I’ve had give me confidence in approaching clinical encounters, yet I know I’m always close to adding one more clinical misadventure to the hundreds I’ve seen or done. I aspire someday to be thought of as a good doctor, not just one who places endotracheal tubes or twiddles dials on an anesthesia machine.

    I’m sure that the next step will be that “board eligible” will no longer be sufficient to be on a hospital’s medical staff indefinitely or eligible to receive payments from CMS. That will be a shame to those who are not good test takers or simulation lab participants. They’ll be put on the revolving door program of test taking and more test taking. Any bets what the exams fees will do then?

    I’ve no real point to make here other than one can only rely on testing so much. Science supposedly began when we began to measure things and put a number on physical phenomena. Is it likewise true for clinical competence? Not so much.

    • Thanks for reading! You took that interminable exam voluntarily??? Good for you! I think what regulators fail to realize is that by the time you’ve been an attending in medicine for a few years you’ve been there and done that when it comes to standardized testing and regulatory hoops. It would be OK if it made any difference clinically, but it probably doesn’t. I can’t imagine I’d be a better doctor if I remembered what physostigmine was for or the partition co-efficient of desflurane, but someone thinks so…

      • Randy B permalink

        Its possible that this could be true in some areas. I have seen one friend, who had GI problems after a lap band was placed. She was told to go to a GI and they had no idea, went round and round and round, said they couldn’t do anything with it, etc. and the person went back to the surgeon. The surgeon, for all intents and purposes, said the GI was clueless.

        Lap bands have been around for years. I find out later that this guy just had no clue, in effect, wasn’t keeping up with new things. You are right, a colonoscopy is a colonoscopy, but when you have new patient populations coming up, the doc should keep on top of them.

        This one left the patient in pain for over a year because they didn’t know what to do.


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