HPM Maintenance of Certification: Why It's Important, How to Prepare
Lana Christian, MS
Board certification is the gold standard that demonstrates a physician’s knowledge and expertise in a particular specialty or subspecialty. It may also be required for many positions, such as being on hospital staff or on a panel for an insurance company. With the first cohorts of ABMS- and AOA-certified Hospice and Palliative Medicine (HPM) subspecialists quickly approaching the end of their initial certifications, anxiety may be running high about maintaining this certification.
The evolving changes in the Maintenance of Certification (MOC)/Osteopathic Continuous Certification (OCC) process can seem chimeric, which poses challenges to those navigating the MOC waters. In addition, certain barriers frustrate many physicians as they work through the MOC program, including changing requirements, high costs, and increasing demands on their time. Why is MOC important for the field of hospice and palliative medicine, and what can HPM subspecialists preparing for their MOC/OCC Part III exam do now to ensure they are ready and eligible?
Maintenance of Certification Process
MOC and OCC are the processes by which all ABMS and AOA boards ensure physicians’ continuous professional development. Using ABMS and ACGME core competencies as its foundation, MOC and OCC establish broad requirements for all primary boards. MOC and OCC consist of several parts (Table 1), which reflect the boards’ focus on continuous professional development.
Rather than being a single event, certification is now a continuous, lifelong commitment to professional development. Certification and maintenance of certification are highly visible indicators that physicians know current standards of practice and are committed to providing quality patient care.
Importance of Subspecialty Certification in HPM
More than 70% of all hospitals have a palliative care program in place, and increasing numbers of other provider organizations are offering palliative care programs, as well. The challenge is to staff them with enough qualified physicians.1
Certification is widely considered the gold standard of expertise in medicine because of its unique physician-directed approach for assessing qualifications. While medical licensure sets the minimum competency requirements to diagnose and treat patients, it is not specialty specific. Board certification demonstrates a physician’s exceptional understanding of a particular specialty and/or subspecialty. Although certification is voluntary, the government, healthcare systems, insurers, and patients recognize it as an essential measure of the physician’s knowledge, experience, and skills to provide quality health care within a given specialty or subspecialty.
The National Priorities Partnership names palliative and end-of-life care as one of six national health priorities that can create lasting change across the healthcare system,2 and the Institute of Medicine recommends “expanding training opportunities to ensure clinicians across disciplines and specialties who care for people with serious illness are competent in basic palliative care.”3
Despite these prominent recommendations, a shortage of qualified HPM physicians—and current pathways to subspecialty certification—exist.1,4 A study published in 2010 in the Journal of Pain and Symptom Management calculated that more than 6,000 full-time equivalents (FTEs)—or 8,000 to 10,000 physicians—were needed to meet the needs of hospice and palliative care programs at that time. Up to 18,000 physicians were needed if all hospices and palliative care programs used exemplary staffing models.4 Today population growth, aging, and broadened palliative care services have pushed that number higher.
How to Prepare Now to Maintain Your HPM Certification
AAHPM, ABMS, and ABIM offer many resources to help you find MOC-approved activities and earn MOC points:
- AAHPM's UNIPACs are approved by ABIM for MOC Part II (life-long learning and self-assessment) points.
- HPM PASS, 3rd edition, HPM FAST (four modules produced by AAHPM), and HMD PREP are approved for MOC points by six ABMS boards: internal medicine, family medicine, anesthesiology, psychiatry and neurology, and radiology.
- For additional MOC activities, search the ABMS MOC Directory (https://www.mededportal.org/abmsmoc/continuingeducation/) or the ABIM Directory (http://www.accme.org/MOClist) hosted by the Accreditation Council for Continuing Medical Education.
- Osteopathic physicians are encouraged to request approval of MOC points with their Osteopathic Board for any activities that have MOC approval.
- Visit ABIM’s website to obtain the HPM exam blueprint. This is available to all physicians, regardless of their board specialty. AOA’s website has a similar blueprint available to all osteopathic physicians.
To dialog about about MOC, visit AAHPM Connect (http://connect.aahpm.org/home), participate in the online communities discussion, and read late-breaking news on AAHPMblog.org.
Currently nearly 7,000 certified HPM physicians are in practice at least part time in the field. Many were initially certified during a grandfathering period when previous certification by the American Board of Hospice and Palliative Medicine and/or practice hours could serve as a prerequisite for HPM certification.
Since 2012, however, the pipeline for newly certified HPM subspecialists has narrowed, limited by the new requirement that physicians complete a 12-month fellowship before they are eligible to sit for initial subspecialty certification. Moreover, with fellowship slots in short supply—approximately 300 per year— the maximum potential to counteract natural attrition while continuing to grow the workforce is a little more than 600 HPM physicians per recertification cycle (see Table 2). “With this potential for newly certified specialists being much smaller, maintaining HPM certification is more important than ever,” said Dawn Levreau, AAHPM’s director of workforce and leadership.
It is important to recognize that part of the strategy for managing the workforce is the growing number of advanced practice nurses and physician assistants practicing in hospice and palliative care. A variety of certifications in hospice and palliative care for nurses at various practice levels are available through the Hospice and Palliative Certification Center.
Updated Standards in Flux
In 2015 ABMS standards were updated to place greater emphasis on practical application, including patient safety, performance improvement, working with teams, and incorporating judgment into examinations.5 As individual boards tackle how to translate those goals into MOC activities, the ultimate silver lining will be a more relevant, accessible, useful program. In the interim, the state of flux may offer some serendipities.
For example, ABIM has temporarily suspended the MOC Quality Improvement requirement (Part IV)— which involves a practice assessment—until a broader array of more accessible activities is available. That means if you are an internal medicine physician who is due for HPM recertification in 2018, you can earn all 100 MOC points as medical knowledge points between now and December 2018, according to Furman McDonald, MD MPH, senior vice president for academic and medical affairs at ABIM. A plus for all physicians is that most boards now recognize a much wider array of activities that can count toward MOC points.
If you are a dual-boarded diplomate, your selfevaluation requirement may be waived so that you are required only to complete it for one member board in order to receive credit. If this is true for your boards, you need only to attest that you are current and participating in the other board’s MOC program before you take the HPM MOC exam.
Disparities in Requirements
Primary boards have the freedom to tailor specific MOC requirements to their specialty. So, despite the fact that ABIM and AOBIM administers the HPM exams to all qualified candidates, activities that can fulfill each part of MOC differ by specialty. This, plus MOC’s continuing evolution, have created some confusion and challenges for physicians approaching their HPM recertification date.
The good news is that the boards have broadened the activities eligible for Part II MOC points, and the American Board of Medical Specialties has created an MOC directory where diplomates from across specialties can find activities relevant to their practice. There is no parallel directory for osteopathic physicians.
One way to approach this shift to a model of lifelong learning is to engage in some MOC activities every 2 years to show you’re participating in MOC and review your board’s MOC requirements every 2 years to make sure you are on target to meet those requirements.
Time and Money
involves substantial time and financial investments. Some may feel the purse strings ease a bit because now half of the primary boards that grant HPM as a subspecialty certificate do not require MOC for both the primary and subspecialty boards (see Figure 1). For osteopathic physicians, only those whose primary specialty certification is family medicine need to complete both primary and subspecialty OCC.
Growing and sustaining the hospice and palliative care workforce is one of the five strategic objectives of the Academy. Julie Bruno, MSW LCSW, director, education and training for the Academy, states, “Our goal is to make sure everyone understands the process and timelines for MOC, OCC, and the exams. Subspecialty certification is critical to the field.”
Depending on when your initial certification expires, you have more or less time to ensure that you have sufficient MOC points and prepare for the exam. This underscores the importance of planning.
Lois Nora, MD JD MBA, president and CEO of ABMS, recently completed her MOC and sat for her neurology board. She said, “I don’t think any of us look forward to taking an exam. But I’ve been impressed over time with the number of people who have told me retrospectively that preparing for the exam and taking the exam were meaningful to them. This rigorous process is a very important component of us demonstrating to the public who we are as specialists and how we continue to grow and learn.”
The ABIM 2020 Assessment and Innovations in Progress
Although the ABIM 2020 report was tasked separately from the MOC program in general, its recommendations will affect MOC in the future. The goal of this report was to ascertain how to make the certification process more relevant, accessible, adaptable, affordable, engaging, and efficient.
Three overarching recommendations came from that report:
- Replace the 10-year MOC exam with shorter, more frequent exams.
- Focus assessments on cognitive and technical skills (to ensure application of knowledge).
- Recognize specialization (so that maintaining a subspecialty can stand on its own for MOC without requiring underlying certification).
Although the report’s recommendations are still just that, some recommendations are already on the drawing table. Exams will become more user-friendly, as at least some of them move from testing centers to the workplace or home with remote proctoring. Continuous quality improvement (quality activities that physicians are doing within their own practices and health systems) will be integrated into MOC. Activities that integrate HPM into medical care within a hospital community will likely be awarded MOC points. Such innovations should start appearing in the next few years. Recognizing specialization without requiring underlying certification is already a reality in five of the 10 ABMS boards that offer HPM certification.
An ongoing survey of diplomates is providing valuable input on these and other tangible ways to improve MOC. How the survey and report results might affect future credentialing is yet to be determined, so continue to check with your primary board to learn the latest developments.
- Punke H. Workforce Shortage Threatens Future of Palliative Care. Becker Hospital Review. November 05, 2013. http:// www.beckershospitalreview.com/hospital-physicianrelationships/ workforce-shortage-threatens-future-ofpalliative- care.html. Accessed February 9, 2016.
- National Quality Forum. Input to the Secretary of Health and Human Services on priorities for the 2011 National Quality Strategy. October 15, 2010.
- Meghani SH, Hinds PS. Policy brief: The Institute of Medicine report Dying in America: Improving quality and honoring individual preferences near the end of life. Nurs Outlook. 2015;63:51-59.
- Lupu D. Estimate of current hospice and palliative medicine physician workforce shortage. J Pain Symptom Manage. 2010;40(6):899-911.
- American Board of Medical Specialties website. ABMS specialty and subspecialty certificates. http://www.abms. org/member-boards/specialty-subspecialty-certificates/. Accessed January 11, 2016.
ABIM Assessment 2020 task force. Recommendations to the American Board of Internal Medicine (ABIM): A vision for certification in internal medicine in 2020. http:// transforming.abim.org/assessment-2020-report/. Published September 2015. Accessed April 11, 2016.
Rosenbluth G, Tabas JA, Baron RB. What’s in it for me? Maintenance of certification as an incentive for faculty supervision of resident quality improvement projects. Acad Med. 2016;91(1):56-59.
Sklar DP. What happens after medical school? Current controversies about licensure, maintenance of certification, and continuing professional development. Acad Med. 2016;91:1-3.
Lana Christian, MS, is a freelance medical writer baseed in Texas. Learn more and contact Ms. Christian at http://createwriteinc.com.