Introducing the Gastroenterologist-accountable Professionalism in Practice (G-APP) Pathway: Bridging the G-APP-Replacing MOC With a Model for Lifelong Learning and Accountability

Abstract

The American Gastroenterological Association (AGA) has a long-standing commitment to education, serving members, trainees, the public, and all potential learners. Education is a core component of the AGA’s refreshed strategic plan (Figure 1).1Allen JI. AGA strategic plan 2015–2016: something that matters. http://www.gastro.org/news_items/2015/5/3/aga-strategic-plan-2015-2016-something-that-matters. Accessed June 29, 2015.Google Scholar The AGA Education and Training Committee oversees activities such as creation of the Gastroenterology Training Examination, review of AGA-sponsored continuing medical education (CME) activities, development of the annual Spring Postgraduate Course, and production of the Digestive Diseases Self-Education Program, among many others. Recent achievements of the Education and Training Committee include development of an online learning management system, creation of a maintenance of certification (MOC) subcommittee tasked with the development of educational modules for knowledge self-assessment, establishment of the AGA Academy of Educators (a home for educators to share materials, gain support for educational endeavors, and promote scholarly activity in education), and establishment of the Oversight Working Network (OWN), for which educational leaders from the 5 gastrointestinal (GI) societies convened to establish entrustable professional activities (EPAs) that define the tasks of the profession of gastroenterology.2Rose S. Fix O. Shah B.J. et al.Entrustable professional activities for gastroenterology fellowship training.Gastroenterology. 2014; 147: 233-242Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar These recent accomplishments have thrust education into the forefront, along with other areas of strategic importance: practice and quality, research and innovation, advocacy, publications, and organizational vitality. The AGA is positioned as a leader in medical education, particularly in the novel applications of learning tools. In 2004, the AGA established the position of education councillor on the AGA Governing Board, a role that advocates for, fosters, and nurtures educational programming and initiatives while bringing an education lens to all considerations for the direction of the organization. While discussions often involve areas of concern across the continuum of medical education and must address the needs of a diverse membership, the topic of recertification of gastroenterologists gained the attention of the AGA Education and Training Committee and the AGA Governing Board, prompted in part by members who contacted the AGA expressing concern about the declining pass rate on the American Board of Internal Medicine (ABIM) recertification examination (Table 1).3American Board of Internal Medicine. First-time taker pass rates—maintenance of certification. https://www.abim.org/pdf/pass-rates/moc.pdf. Accessed June 29, 2015.Google Scholar Furthermore, changes in the ABIM’s requirements related to the overall recertification process elicited a robust response, as outlined in more detail in the following text. In the recently updated AGA strategic plan, one of the education goals is to engage members and other GI health providers through personalized education across the continuum of their careers. Through this strategic directive, and in response to members’ concerns, the Governing Board of the AGA convened a task force of key and diverse members to address issues related to the ABIM MOC process in a scholarly way. This task force was charged with evaluating educational theory, the educational literature and considering factors that affect education, the changing health care environment, technology in medicine and education, and influences that are affecting learners. After a scholarly review and consideration of these factors, the task force was asked to identify their vision of the ideal pathway for recertification of gastroenterologists.Key Information Items for AGA Members•The AGA Governing Board convened the MOC Task Force in response to physician dissatisfaction with the current MOC process. The task force proposed the G-APP as the ideal pathway to recertification.•The task force recommends replacing MOC with individual pathways that would incorporate self-assessment activities, allowing physicians to achieve a high level of competency in one or more areas while maintaining a more modest level of competency in other areas.•The individualized self-assessment activities would provide constant feedback and opportunities for learning and removes the secure high-stakes examination required every 10 years.•The G-APP pathway would allow physicians to get credit for activities they are already doing in practice, research, or teaching.Table 1Pass Rates for First-Time Takers of the ABIM Gastroenterology Recertification ExaminationData from the American Board of Internal Medicine.3American Board of Internal Medicine. First-time taker pass rates—maintenance of certification. https://www.abim.org/pdf/pass-rates/moc.pdf. Accessed June 29, 2015.Google ScholarYearNPass rate (%)201450287201388184201253685201170085201034884 Open table in a new tab •The AGA Governing Board convened the MOC Task Force in response to physician dissatisfaction with the current MOC process. The task force proposed the G-APP as the ideal pathway to recertification.•The task force recommends replacing MOC with individual pathways that would incorporate self-assessment activities, allowing physicians to achieve a high level of competency in one or more areas while maintaining a more modest level of competency in other areas.•The individualized self-assessment activities would provide constant feedback and opportunities for learning and removes the secure high-stakes examination required every 10 years.•The G-APP pathway would allow physicians to get credit for activities they are already doing in practice, research, or teaching. The task force convened at the AGA headquarters in Bethesda, Maryland, on June 5 and 6, 2015. The task force included all of the authors of this paper, representing practitioners in small and large practice settings (R.J. [a member of the AGA Governing Board], L.S.K. [an attendee at the American College of Physicians meeting], and K.P. [a member of the AGA Academy Advisory Board]), a gastroenterologist with expertise in novel forms of assessment (S.A.P., a member of the AGA Academy Advisory Board), the Liaison Committee on Certification and Recertification (LCCR) representative and chair of the MOC Subcommittee (A.J.D.), the chair of the Education and Training Committee (J.O.), and a leader of OWN (B.J.S.), and all were led by the education councillor on the AGA Governing Board (S.R.) and the AGA educational professional staff (L.N.M. and M.H.D.). In addition, the group received advice from Dr John Allen, immediate past president of the AGA. The invited guest speaker was Dr Eric Holmboe, Senior Vice President for Milestones Development and Evaluation of the Accreditation Council for Graduate Medical Education (ACGME). This report outlines a brief history of the ABIM and documentation of the concerns of AGA members, identifies factors affecting GI practice and education, and reviews adult learning theory, including milestones and competencies, assessment strategies, and recertification processes in other specialties and professions. This report also discloses how the task force developed a rubric for recognizing individualized needs and clinical practices, which in turn informs the details of a proposal for a new pathway. Finally, the implications for practice and how this new pathway relates to accountability to the public are explored. This proposal endorses a strong commitment to lifelong learning and accountability but concludes that the current process is problematic with its overemphasis on an assessment-focused system that culminates in a high-stakes examination without a defined curriculum. The task force concluded that this high-stakes examination is not effective and does not address individual educational needs. The task force therefore proposes discarding the existing concept of recertification and embracing a new concept of continuous lifelong professional development tailored to individual needs. This proposal is consistent with educational principles of adult learning theory and focuses on continuous improvement through both assessment and defined, tailored curricula for gaps in knowledge, skills, and attitudes identified through the assessments. This type of program does not penalize committed professionals for gaps in knowledge but rather provides tools for engaged, active learning that is meaningful and relevant and benefits sound practice and, ultimately, our patients. In 1935, the American College of Physicians adopted a resolution for the establishment of an “American Board for the Certification of Internists.” From this resolution, the ABIM was established in 1936 to respond to public pressure to set standards for physicians with accountability to the public and to the profession. The American Board of Medical Specialties (ABMS) collaborates with 24 medical boards to support standards for certification. The ABIM is one of the largest medical boards and accounts for the certification of approximately one of every 4 physicians in the United States, with more than 200,000 ABIM board-certified physicians.4American Board of Internal Medicine. Candidates certified. https://www.abim.org/pdf/data-candidates-certified/all-candidates.pdf. Accessed June 29, 2015.Google Scholar From its inception, the ABIM recognized the need to develop “similar qualification and procedure for additional certification in certain of the more restricted and specialized branches of internal medicine, as gastroenterology, cardiology….” Gastroenterology was one of the first 3 established subspecialties, with the first gastroenterology examination administered in 1941. The subspecialty boards were created to address the “impending danger” presented by non-ABMS boards (particularly the American Board of Gastroenterology and the American Board of Tuberculosis) that would set their own standards if the ABIM did not.5Baron R, American Board of Internal Medicine. Who we are (PowerPoint) 2014. Retrieved from lecture notes: changes to ABIM's Maintenance of Certification process.Google Scholar “Board certified” has been a valued credential by physicians in the United States and one that is readily recognized by the public. To achieve board certification in internal medicine, after graduating from medical school, a physician must first complete an accredited postgraduate residency training program in the specialty of internal medicine and then successfully pass a certification examination in general internal medicine. Oversight of training is rigorously conducted by the ACGME at the level of the training program environment, in addition to the sponsoring educational institution, to ensure that the educational curriculum and assessment of trainee progress meets the prescribed standards set forth by the ABIM. The ABIM has oversight of the content and process of the certification examination and is the organization that issues a certificate to diplomates in internal medicine, commonly designated as “board certification.” To achieve board certification in the medical subspecialty of gastroenterology, a physician must complete an ACGME-accredited fellowship training program in gastroenterology subsequent to the training in internal medicine, must pass the certification examination in internal medicine, and then must additionally pass the initial certification examination in gastroenterology. It is of little surprise then that the “board certified” credential is viewed as a mark of distinction and a culminating achievement after years of effort. Over the years, there have been changes in the content and format of the certification examinations. Written and oral examinations were required until the oral examination was phased out in 1972. Before 1989, certification was “lifetime,” with no additional requirements necessary to maintain certification. Beginning with the 1990 examination, however, the ABIM restricted board certification to a 10-year, “time-limited” certificate. To retain the credential, physicians with a time-limited certificate must comply with the ABIM MOC program, which has included passage of a (re)certification examination every 10 years as well as participation in various medical knowledge self-assessment and practice improvement assessment activities for MOC points. More changes to the recertification process occurred in 2014, when the ABIM began moving toward a model of more continuous development. The 2014 changes included a doubling of MOC points required as well as an additional designation to a diplomate’s status on the ABIM website as “meeting” or “not meeting” MOC requirements. For lifetime certificate holders (also known as “grandfathers” or “grandmothers”), this was perceived as a move to push them into the MOC process. Although the ABIM acknowledged they could not remove the certification status of any diplomate holding a time-unlimited certificate, the ABIM website listing changed to inform the public as to whether or not a diplomate was meeting the MOC requirements. After an outcry and feedback regarding the negative connotations of such a designation, the ABIM revised the language in 2015 to “participating” or “not participating” in MOC. For diplomates holding a time-unlimited certificate, the decision to participate in MOC is voluntary. As long as the physician possesses a valid medical license, the lifetime certificate holders will never lose their board certification status. However, the consequences of being listed on the ABIM website as “not participating in MOC” are still unknown. Lifetime certificate holders who choose to participate in MOC must follow the same MOC point guidelines as those with time-limited certificates. Additionally, lifetime certificate diplomates who enroll in MOC must take the recertification examination by December 31, 2023. It is the ABIM’s belief that many of these lifetime certificate holders will likely retire by 2023. Lifetime certificate holders who do not take the examination by the end of 2023 will not lose their certification but will be listed as “not participating in MOC.” In addition to doubling the number of MOC points required to 100 every 5 years, the 2014 ABIM changes introduced additional qualifications as to the type of points a diplomate would need and the time frame in which they had to be earned. The 2014 release included the previous requirement of at least 20 points earned in Medical Knowledge (also referred to as Part 2) and at least 20 points in Practice Assessments (Part 4) and added a new, undefined number of points covering the topics of Patient Safety and Patient Voice to reach the 100-point total (Table 2). Many in the physician community provided quick and strong feedback on the updated MOC process.6Teirstein P.S. Boarded to death: why maintenance of certification is bad for doctors and patients.N Engl J Med. 2015; 372: 106-108Crossref PubMed Scopus (76) Google Scholar Complaints included the cumbersome nature of many Practice Improvement Modules (PIMs) and a lack of availability of Patient Safety and Patient Voice MOC credits. In response to this pushback, the ABIM made updates in 2015, including at least a 2-year suspension on requiring Practice Assessment, Patient Safety, and Patient Voice MOC (Table 3).Table 2Parts of the Current ABIM MOC ProgramPart 1Possess a valid and unrestricted license to practice medicineAssumes initial certification examinationPart 2Self-evaluation of medical knowledgePart 3Secure recertification examinationPart 4Self-evaluation of practice performance—PIMs Open table in a new tab Table 3ABIM MOC Requirements in 2014 and 20152014 requirements2015 requirementsSecure examination every 10 yearsSecure examination every 10 years; examination to become “reflective of practice”Some MOC points every 2 yearsSome MOC points every 2 years100 MOC points every 5 years100 MOC points every 5 yearsCME does not qualify for MOCDesignated CME will qualify for MOCWebsite reporting: “Meeting MOC Requirements”Website reporting: “Participating in MOC”Required:Suspended for 2 years: Practice Assessment Practice Assessment Patient Voice Patient Voice Patient Safety Patient SafetyFees not cappedFees capped through 2017 Open table in a new tab As of this writing, all time-limited diplomates are required to earn 100 MOC points in 5-year cycles. At least some MOC activity must be completed every 2 years, with the first deadline for completion set for December 31, 2015. The type of MOC activity completed is at the discretion of the individual diplomate until further guidance is provided by the ABIM for 2017 and beyond. There are many concerns about recertification and the implications of participating or not participating in MOC, particularly for those with time-unlimited certificates, as to how this might affect licensure, hospital privileges, or even reimbursements for specialty services. Although not developed as a criterion for employment, an unintended consequence of board certification has been to accept the designation of this achievement as a surrogate marker of competence and quality.7Kuemmerle J. ABIM maintenance of certification 2014: navigating the challenges to find opportunities for success.Gastroenterology. 2014; 147: 260-263Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar What was once a mark of distinction has now increasingly become a minimally acceptable level of accomplishment to receive and maintain privileges as a practicing gastroenterologist at some health care facilities, to be paneled as a gastroenterology specialist provider by third-party insurers, and to receive recognition as a specialist from professional liability insurers, thus rendering board certification a high-stakes endeavor. Failure to participate in MOC has the potential to tarnish the hard-earned credential of board certification and might eventually lead to loss of the credential for those diplomates with a time-limited certificate. The impact of these changes on workforce and practice issues is not yet known but is reasonably anticipated to be negative. From an idealized perspective, the MOC program was intended to be a mechanism to ensure physician participation in lifelong learning and assessment and to publicly demonstrate and confirm an accounting of the value of the credential. However, in execution, even the ABIM has now admitted the process to be flawed and is working with the medical societies to recalibrate and revalue the process.8American Board of Internal Medicine. ABIM announces immediate changes to MOC program. http://www.abim.org/news/abim-announces-immediate-changes-to-moc-program.aspx. Accessed June 29, 2015.Google Scholar The AGA has taken the position that it will continue to provide whatever resources are necessary for its members who choose to maintain ABIM certification. The AGA is also able to act as an intermediary between AGA members and the ABIM. To ensure the AGA was appropriately representing its membership, a survey was distributed in September 2014. The survey was sent to a relevant subset of the US AGA membership; there were 1168 responses for a 34.4% response rate, with a 99% confidence level and ±3.06 margin of error. The survey showed that the majority (77.2%) of diplomates intended to enroll in MOC. This held true for both those holding time-limited (88.4%) and time-unlimited certificates (57.7%). However, when those holding time-limited certifications were asked to choose the single best statement that reflected their attitude about MOC, the majority of respondents (53.1%) said they valued the credential but resented the increased demands of the new changes to MOC. Forty-two percent said they did not particularly value the process but would participate to avoid tarnishing the credential in any way. Only 4.8% believed the MOC process added value to board certification. Eighty-two survey respondents indicated they would elect not to participate in MOC. When asked to choose the single best reason why, 45.9% did not believe MOC held any professional or personal value for them, 28.2% responded that time and aggravation were the main issues, 17.7% responded that the process was too complicated/the rules hard to comprehend, 7.1% noted they were too close to retirement for this to matter, and 1.2% thought the cost was prohibitive. To support the AGA members, several initiatives are under way. The AGA is helping members navigate the ABIM changes with a comprehensive communication plan, including e-mail messages and informational tools on the AGA’s website. The AGA participated in an American College of Physicians–formed alliance to provide feedback and guidance to the ABIM and advocate for changes to the MOC program to reduce the burden on the physician diplomates. Additionally, for members who choose to participate in MOC, the AGA more than doubled the number of MOC offerings to meet the increased requirements. Finally, the AGA created a task force (represented by the authors of this report) with the charge to conduct a scholarly review of educational principles and determine the ideal pathway for recertification of gastroenterologists. The task force seriously considered the role of accountability in the development of any certification process. The authors of one paper linking professionalism and accountability with the role of certification note that the true constituency of the certification boards is the public. Furthermore, they state that board certification has the potential for leadership in advancing quality practice with transparency and public accountability.9Cassel C.K. Holmboe E.S. Professionalism and accountability: the role of specialty board certification.Trans Am Clin Climatol Assoc. 2008; 119: 295-304PubMed Google Scholar Physicians are regarded as professionals both by the public and by their peers, and they remain a most trusted profession among the public. Individually, some physicians may fall short of the mark, but the overwhelming majority of members of the profession live up to the ideals of their vocation. According to the Royal College of Physicians report of a working party on professionalism in a changing world, medical professionalism was defined as “A set of values, behaviors and relationships that underpins the trust the public has in doctors.”10Royal College of Physicians. Doctors in society: medical professionalism in a changing world. https://www.rcplondon.ac.uk/sites/default/files/documents/doctors_in_society_reportweb.pdf. 2005. Accessed June 22, 2015.Google Scholar This report concludes that “in their day to day practice, doctors are committed to: integrity, compassion, altruism, continuous improvement, excellence and working in partnership with members of the wider healthcare team.” A goal of MOC is to reassure the public that a practitioner continues professional development and education after training. Does the current MOC process actually meet this goal, and does this program help physicians keep skills and knowledge current in a changing health care environment? It would be important to determine if enrollment in MOC allows the public to know which providers are using best practices and evidence-based standards. In other words, does enrollment in MOC make a practitioner a “good doctor”? The task force could find no evidence of reassurances to verify this, particularly in the context of an explosion of scientific information, rapid advances in technology, and a changing health care environment. Accountability is a major issue in health care, encompassing the procedures and processes by which one party justifies and takes responsibility for its activities.11Emanuel E.J. Emanuel L.L. What is accountability in health care?.Ann Intern Med. 1996; 124: 229-239Crossref PubMed Scopus (204) Google Scholar There are several models of accountability in health care: professional, economic, and political. The traditional model of accountability has been the professional model, in which the physician’s actions are directed toward the patient’s health or well-being. This professional model of accountability consists of 2 areas of accountability: (1) physicians to their professional colleagues and organizations and (2) physicians to their individual patients. The medical profession is moving from a “golden age” in which physicians are completely trusted by their patients with a great deal of autonomy in how they practice medicine to an era of assessment and accountability. Should accountability be the responsibility of our GI professional societies, or should this important issue be left to other medical boards? This is a difficult question and one the task force did not directly address, placing its focus instead on the charge of determining the ideal pathway for what we now believe should be termed “continuous professional development” rather than “recertification.” However, the topic of who would administer a program of continuous professional development was raised, and it was noted that one of the key roles of a professional society is to safeguard the public interest and to provide peer review and support. We concluded that it is important for practitioners to participate fully to co-create a process that will ensure public accountability and provide information and accountability relative to the question of whether an individual practitioner is a “good doctor.”12Holmboe E.S. Batalden P. Achieving the desired transformation: thoughts on next steps for outcomes-based medical education.Acad Med. 2015; 90: 1215-1223Crossref PubMed Scopus (46) Google Scholar Health care and medical education are evolving at a rapid pace; therefore, the task force recognized the need for an update on these issues to meet the charge of identifying the ideal pathway for recertification. MOC and assessment of competencies for physician practice must reflect and be sensitive to these changes. In this section, we briefly consider factors that inform assessment of competence for practicing physicians: diversity in the GI workforce, changing paradigms in health care, quality improvement, patient safety, and value, technology, and the evolving workplace (Figure 2). The current GI workforce is more diverse now than ever, continuing to reflect the communities that physicians serve. As physicians live and work longer than in years past, our workforce will have a large degree of generational diversity that will include 4 generations of physicians: Traditionalists (born 1900–1945), Baby Boomers (born 1946–1964), Generation X (born 1965–1980), and Millennials (born 1981–1994). The majority of the workforce will be composed of Baby Boomers and Generation X. Each generation has its own sense of work ethic, values on education and training, preferences for learning, and level of engagement with technology.13Twenge J. Campbell S. Hoffman B. et al.Generational differences in work values. Leisure and extrinsic values increasing, social and intrinsic values decreasing.J Manage. 2010; 36: 1117-1142Crossref Scopus (708) Google Scholar As medical science and technology have advanced, gastroenterologists have subspecialized as well, either formally or informally. There are formal non–ACGME-accredited programs in some areas and an ACGME-accredited transplant hepatology fellowship with a formal examination and standards for training.14Accreditation Council for Graduate Medical Education. Frequently asked questions: transplant hepatology. http://www.acgme.org/acgmeweb/portals/0/pdfs/faq/158_transplanthepatology_faqs.pdf. Accessed June 29, 2015.Google Scholar The development of niche practices can fulfill a need in a region, hospital, or practice. Examples of subspecialization include the fields of inflammatory bowel disease (IBD), transplant hepatology, motility, nutrition, and advanced endoscopy. At the same time, general gastroenterologists may choose to narrow their scope of procedure and practice in response to a variety of personal and health care environment factors. Gastroenterologists continue to hold roles in research, education, and administration, which can decrease clinical responsibilities as these other roles grow. Assessment and recertification should reflect current practice and be sensitive to the needs of the diverse workforce. The changes in health care delivery can be conceptualized as they affect the individual, the micro system of care, and the macro level of care. There is a growing shortage of primary care providers, which has led to the introduction of nurse practitioners and physician assistants in practices. A similar shortage is projected in gastroenterology by 2020.15Dall T, Sen N, Zhang Y, et al. The impact of improved colorectal cancer screening rates on adequacy of future supply of gastroenterologists. Prepared for Olympus America Inc., January 7, 2009.Google Scholar Gastroenterology care is evolving to incorporate greater diversity of team members to care for chronically ill patients with GI and liver conditions, such as IBD and end-stage liver disease, and to manage this increasing demand at the micro level. Health care organizations are being reconfigured into new clinical and business relationships that move beyond the individual or small group practice.16Umansky B. The field guide to hospital partnership and affiliation models. The Advisory Group. October 23, 2014. https://www.advisory.com/research/health-care-advisory-board/resources/2014/posters/the-field-guide-to-partnerships-and-affiliations. Access