By Abby S. Van Voorhees, MD, January 02, 2014In this month’s Acta Eruditorum column, Physician Editor Abby S. Van Voorhees, MD, talks with Erik Stratman, MD, about his recent Journal of the American Academy of Dermatology article, “Maintenance of Certification in dermatology: What we know, what we don’t.”
Dr. Van Voorhees: Tell us about the history of the Maintenance of Certification movement. Where did the idea for this type of program come from? What was the problem with lifetime certificates? Why did the American Board of Medical Specialties not just stick with a qualifying exam for recertification?
Dr. Stratman: Prior to 1991, board-certified dermatologists were issued lifetime certificates. With this model, concern grew that certifying competency at only one moment in time at the beginning of a career was inadequate to assure that a diplomate was remaining clinically competent over the course of a career. That launched the time-limited certification era. Dermatologists who initially certified between 1991 and 2006 were issued time-limited certification, requiring diplomates to take an open-book test at the end of every 10-year cycle after initial certification. Over time, though, the American Board of Medical Specialties (ABMS), the parent board of the American Board of Dermatology (ABD), concluded that once-per-decade medical knowledge examination performance did not guarantee physician competency, and did not really assess other important patient care competencies like patient communication. Also during this time, the Institute of Medicine published a series of white papers concluding that physicians do a poor job of self-stimulated quality improvement. No one, to the best of my knowledge, has refuted the data or conclusions in those publications. It was imperative that the medical profession do something, even if flawed at initiation, to bring physicians along to realize this problem and attempt to correct it. The medical community has a moral obligation to address this huge gap — in knowledge and in practice.
As a result, the ABMS then launched the Maintenance of Certification (MOC) movement. The MOC program by the ABD began in 2006. The purpose of MOC was to provide a more ongoing assessment of clinician competence, as well as an opportunity to help clinicians assess and, when necessary, improve their competencies in areas beyond just medical knowledge. [pagebreak]
Dr. Van Voorhees: Is there any evidence that MOC improves quality of care?
Dr. Stratman: Studies have not been performed in dermatology to investigate whether participation in MOC positively impacts the quality of care dermatology patients receive. In larger fields where MOC has been in place for longer periods of time, studies have been performed and show an association between participation in MOC and improvement on certain patient care quality indicators. The American Academy of Dermatology (AAD) currently houses the largest data source in dermatology for physicians participating in Maintenance of Certification and performance improvement activities for MOC Component 4 credit. I cannot wait to see some type of publication from the AAD that analyzes these findings and communicates to dermatologists what sorts of care improvements have been documented for the population of dermatologists participating in these dermatology quality improvement activities. I predict we will see improvements in acne, psoriasis, and melanoma care. The measures are primarily process measures, not outcomes measures. That means that we are measuring what the dermatologist does in practice to deliver care. We are not quite at the level of measuring patient outcomes through current MOC efforts, with the exception of patient experience outcomes and quality of life outcomes for certain dermatologic diseases. The ABD is committed to study the impact of participating in MOC on quality of care delivered. From my perspective, having now participated in about six quality improvement projects for MOC Component 4 credit, there is no doubt in my mind that, for the individual dermatologist, quality of care delivered can be significantly, positively impacted by participating in good Component 4 activities.
Dr. Van Voorhees: What factors influence the quality of medical care? Is medical knowledge the single most important factor?
Dr. Stratman: There are several factors that influence quality of medical care. The clinician does not necessarily have direct control over all of these factors. However, one of the things we learn is that medical knowledge, while important, is not the sole factor in defining the quality of medical care. In many cases, it’s not even the most important factor. Clinicians can certainly have gaps in knowledge. When these exist, the quality of care can suffer. Education can be planned to improve the medical knowledge of the clinician. That is the underlying purpose of MOC Component 2 (Self-Assessment): to identify our own medical knowledge gaps and then to grow our medical knowledge around issues pertinent to our practice. [pagebreak]
A second factor, though, is gaps in performance. This is very common in practice. This occurs when we know what to do, we have the knowledge, but we do not necessarily know the process to make this happen, or we do know the process but there are significant barriers to getting it done. Perhaps we do not have easy access to get our patient a sentinel lymph node biopsy. Perhaps we do not have access to a lab so we can order the latest tests that might be useful in diagnosing a patient’s problem. These are issues of process, not knowledge. In my experience in participating in quality improvement activities, I think process problems are far more common than knowledge problems, and these significantly impact subsequent quality of care.
Dr. Van Voorhees: Is there any evidence to suggest that the quality of care changes over time? If so, does it increase in the setting of greater experience, or decrease?
Dr. Stratman: This has not been studied in dermatology. There is evidence in other medical specialties that the quality of care delivered declines with years in practice. These findings were one of the strong influencing factors leading to the MOC movement. Newer physicians may perform higher on quality measures for a variety of reasons. It may be that they are more up-to-date on the latest standards of care or are more familiar with assessing and changing current practice habits through quality improvement activities, because these are more often integrated into training in the current era.
Dr. Van Voorhees: What was wrong with the traditional CME-based learning? Why do you feel that this was not so successful? Were we simply not paying attention?
Dr. Stratman: There is strong evidence that traditional CME, during which audience members attend education sessions and passively watch PowerPoint presentations, does not result in the learners taking that information and integrating it into the care they provide patients. Also, as mentioned earlier, many of the care gaps in our practices have nothing to do with medical knowledge deficits; instead, they are process problems, which traditional CME activities rarely impact. [pagebreak]
The American Academy of Dermatology is taking steps to break out of the traditional CME-based learning by hosting sessions that are more case-based and that utilize audience response systems to make the audience more engaged by providing clinical scenarios that make the audience think on the spot, “What would I do in this situation?” For learning to be meaningful, studies in adult education show that the learners need to see the relevance and be able to connect that learning to their own patient care context. That is not to say that lecture-based learning has no value, because it is an excellent way to close knowledge gaps, when they exist. For the other types of gaps, more active learning will best impact the individuals participating.
Dr. Van Voorhees: What value do you see MOC offering dermatologists? Are there limitations that still need to be worked out?
Dr. Stratman: To me, MOC brings improvement-based education to the individual clinician. Component 2 helps the clinician better identify “What areas am I weak in that are relevant to my practice?” rather than the traditional approach of “What is on this list of lecture topics that I find interesting?” While the answers to these two questions may be the same, in many cases the answers may be different.
For example, I do not enjoy managing leg ulcers, yet I see many patients each year with leg ulcers. I feel out of touch with wound care advances. I enjoy listening to the psoriasis mavens teach me about the latest data on biologic therapies, which I am familiar with and prescribe often. Although I might look at the list of lecture topics at an education venue and smile brighter at the thought of listening to the psoriasis mavens, my self-assessment data would steer me toward the session to learn more about ulcer management, because it is a relevant need in my practice. Maintenance of Certification will help clinicians participate in identifying their own knowledge gaps and performance gaps. [pagebreak]
Although it is the most different kind of learning compared to traditional CME, participating in a locally relevant quality improvement activity for MOC credit has been the most valuable source of CME that I have obtained in recent years. By participating in an MOC Component 4 activity, and taking a look at an area where I could identify a need to improve, I have been able to plan actions in a meaningful way that provided better care to my patients. For example, I learned that I wasn’t appropriately prescribing pre-operative antibiotics for patients with artificial heart valves or joint replacements. In addition, I could actually measure the amount of my improvement afterwards to see how much better the care was that I provided. At the end of the day, that is the purpose and goal of MOC and CME: To improve the care that patients receive. This is directly tangible when you perform a practice assessment that is meaningful to your local practice.
There are several limitations that still need to be worked out. The field needs more data to determine the quality benefit of practice assessments. The ABD is committed to undergoing a continuous assessment of its MOC program and to work to improve areas that are more challenging or more confusing or less meaningful for diplomates. The quality of self-assessment activities needs to continue to improve. The cost of participating in MOC needs to be kept in mind so that is not a significant barrier to improving the quality of care. As often as possible, programs should seek to help meet multiple requirements through participation in a single meaningful activity, as opposed to making people have to participate in numerous different meaningless or “check box only” activities. The ABD must make sure that requirements for MOC are clear in explanation, sensible in time commitment, and meaningful to those who participate.
Erik Stratman, MD, is chairman of the department of dermatology and program director for the dermatology residency program at Marshfield Clinic in Marshfield, Wis. His article was published in the Journal of the American Academy of Dermatology; J Am Acad Dermatol 2013;69:1.e1-11. doi:10.1016/j.jaad.2013.03.033.