Many surgeons let out a collective cheer recently when the American Board of Surgeons announced that, as of 2018, they will no longer have to take a high-stakes, pass-fail exam every 10 years to maintain certification.

The Board also announced, effective immediately, that it’s extending its continuing medical education (CME) reporting cycle from 3 to 5 years and reducing the number of required self-assessment CMEs – lectures and articles with a short quiz at the end – by a third. Surgeons now have to report 150 credits over 5 years, 50 from self-assessment CMEs. Under the old system, it was 90 credits over 3 years, 60 of which had to include self-assessment.

Surgeons have been telling ABS that the 3-year cycle was too short and that it was difficult to find meaningful CMEs with self assessment. The Board plans additional steps to make maintenance of certification (MOC) less burdensome and more relevant. “This is very positive. People are very encouraged that the Board is listening and trying to be more responsive,” said David Hoyt, MD, FACS , executive director of the American College of Surgeons (ACS).

Alternative evaluation options

What’s on the minds of many, though, is what the alternatives to the 10-year exam will be. “That’s the $64,000 question,” said Emery Chen, MD, FACS, a general surgeon in private practice in Lancaster, Calif.

ABS is considering models that have worked well for other medical boards and hopes to roll out the alternative pathways at its winter meeting in January 2018, according to ABS Executive Director Frank Lewis, MD, FACS .

At this point, it looks like surgeons will be able to take more frequent and convenient shorter tests that are better focused on their particular branch of general surgery, with opportunities to brush up on weak spots and take the tests again if needed. There are several options for how the new system could be structured.

“I think it will probably be less stressful. People worry about the high-stakes exam. They don’t know what’s going to be on it, and they worry that failing could result in losing their staff privileges. We don’t think that’s particularly useful. The purpose is not to either pass or fail you but for you to learn the material,” Dr. Lewis said.

Meanwhile, surgeons who want to take the 10-year exam will still have the option.

Among the many options, surgeons could be given the two dozen journal articles deemed by experts to be the most cutting-edge for a given period, and quizzed on the material, with a chance to be re-quizzed as needed. There could be CME mini-courses or open-book exams on the areas most relevant to a surgeon’s practice and opportunities to relearn what might have been forgotten. Questions could be pushed out by smart phone to assess surgeons’ knowledge, with follow-up review material for incorrect answers and additional questions until the material is aced.

“Everything’s on the table,” said ABS at-large Board Member Tyler G. Hughes, MD, FACS, clinical faculty member at Kansas University, Salina.

A changing world

Like the country’s many other medical boards, ABS has been under pressure to make its MOC process less burdensome and more useful. A major problem is that general surgery isn’t very general anymore; it covers everything from transplants and bariatrics to trauma, endocrine, and vascular operations and more. Surgeons who have specialized have chafed at being examined every 10 years on areas that are no longer part of their practice and at questions about rare diseases such as multiple endocrine neoplasia I and II.

“They remember that one question that kind of stuck in their craw,” said Carol Scott-Conner, MD , FACS, emeritus professor and former head of surgery at the University of Iowa, Iowa City. At one point in her career, Dr. Scott-Conner helped write questions for the exam. “It wasn’t designed to be tricky, but, if you were not practicing in all these fields,” it was tough. “What you’re tested on should be relevant to your practice and help you get better at what you are doing. I think it’s a good change,” she said.

Controversy a few years ago about how the American Board of Internal Medicine (ABIM) ran its MOC program and spent its money also turned up the heat on medical boards, and some physicians have turned to state legislatures to do away with certification altogether as a prerequisite for hospital privileges, among other things. ABIM and many other boards have already made changes to make MOC smoother.

ABS has taken note. “There are a whole variety of things targeted at ways of maintaining longitudinal learning and providing some demonstration of it. We haven’t settled on any one of those. In fact, we may have more than one. We aim to get a good deal of feedback and see what our diplomates feel would be most helpful for them. It’s going to require a lot more detail, but hopefully it’s going to be more effective and more useful.” Dr. Lewis said.

The group will be at national and regional medical meetings this summer and fall to ask surgeons, in person, what they want their MOC system to be. There might be surveys as well, and ABS plans to be at the ACS Clinical Congress in October to solicit input.

The Board is looking to help surgeons with multiple certificates, whether from ABS or other boards, as well. “If we can create a more flexible assessment program that helps them maintain all their certifications, that’s what we want to do. We are looking at options to make it easier for them,” said ABS Director of Communications and Public Affairs Christine Shiffer, who noted that ABS will still likely require a 12-month case log every 10 years, even if surgeons opt out of the 10-year exam.

Will the new system have a negative impact on patient outcomes? After all, even specialized surgeons take night call sometimes. “ABS is responsible to surgeons but also the American public. If we say somebody is certified, it has to mean something. People would argue that there’s no real evidence that the recertification process improves surgical competence. Time will tell,” Dr. Scott-Conner said.

Dr. Lewis said he doesn’t know if the changes will save any money on MOC but noted that, instead of one $1,600 fee every 10 years, there’ll be an option to spread payments out.

Dr. Hughes is on the editorial advisory board of this publication.


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