ABR White Paper

Maintenance of Certification

This document is prepared by the ABR Maintenance of Certification Coordinating Committee and Executive Director:
John E. Madewell, M.D.; Robert R. Hattery, M.D. (Executive Director); Stephen R. Thomas, Ph.D. (Chair); Larry E. Kun, M.D.; Gary J. Becker, M.D.; Christopher Merritt, M.D.; Lawrence W. Davis, M.D.

Revised and approved by the ABR Board of Trustees on 6 June 2004.

Table of Contents

Executive Summary
Introduction
Vision
Background
Lifetime and Time-Limited Certificates
The Meaning and Value of MOC
The Maintenance of Certification (MOC) Model
Diagnostic Radiology and Subspecialties
Maintaining Primary and Subspecialty Certification
Multiple-Certificate Holders
Radiation Oncology
Radiologic Physics

Executive Summary

PURPOSE
Maintenance of Certification (MOC) recognizes that in addition to medical knowledge, several essential elements involved in delivering quality care must be developed and maintained throughout one's career. The MOC process is designed to facilitate and document the professional development of each ABR diplomate through its focus on the essential elements of quality care in Diagnostic Radiology and its Subspecialties, Radiation Oncology, and Radiologic Physics. The initial elements of the ABR-MOC have been developed in accord with guidelines of The American Board of Medical Specialties (ABMS). Further details will be developed as the process evolves.

MOC and Certification
All diplomates with 10-year, time-limited primary or subspecialty certificates who wish to maintain certification must successfully complete the requirements of the appropriate ABR-MOC program for their specialty or subspecialty. Subspecialists will be required to maintain primary certification in order to retain subspecialty certification. Holders of multiple certificates must meet ABR-MOC requirements specific to the certificates held. Diplomates with lifelong certificates are not required to participate in the MOC, but are strongly encouraged to do so.

MOC Components, Competencies and Requirements
MOC is based on documentation of individual participation in the four components of MOC: 1) professional standing, 2) lifelong learning and self-assessment, 3) cognitive expertise, and 4) performance in practice. Within these components, MOC will address six competencies—medical knowledge, patient care, interpersonal and communication skills, professionalism, practice-based learning and improvement, and systems-based practice.

Professional Standing: For Diagnostic Radiology (DR) and Radiation Oncology (RO) diplomates, documentation of professional standing is based on continuous possession of valid, unrestricted licenses to practice medicine in all states in which the physician is licensed. For Radiologic Physics (RP) diplomates, documentation of professional standing is based on attestation letters, documentation of licensure or other regulatory agency certification for the practice of medical physics (where applicable), and documentation of expertise-based appointments or recognition.

Lifelong Learning and Self-Assessment: Lifelong learning is critical to ensure that new information and knowledge are incorporated into clinical practice. ABR views this as a highly important component of MOC. Requirements for individual diplomates will vary, depending on the type and number of time-limited primary and subspecialty certificates held, and will include a combination of approved continuing medical education (CME) and self-assessment activities.

  • Diagnostic Radiology — 500 approved CME credit hours (at least 250 hours in Category 1) are required over a 10-year cycle, of which at least 70% must be in specialty-specific or related areas. Self-assessment will be accomplished through completion of a minimum of 20 self-assessment modules (SAMs) over the 10-year MOC cycle. SAMs must be approved by the ABR and will consist of instructional content, followed by multiple-choice questions, with feedback from the diplomate. Four of the 20 SAMs will address general content as prescribed by the ABR.
  • Radiation Oncology — 500 CME credit hours are required over the 10-year cycle, at least 250 of which must be in Category 1. Of the 500 hours, 400 (including 200 Category 1 hours) must be related to radiation therapy or oncology. The periodic self-assessment requirement may be satisfied by participation in the equivalent of eight approved educational venues and successful passing of an automated self-assessment program that covers the respective educational materials.
  • Radiologic Physics — Depending on the number of certificates held, from 500 to 700 hours of CME are required over a 10-year cycle, a portion of which are attained through participation in self-directed educational projects (SDEPs).

Cognitive Expertise: Cognitive expertise will be evaluated through a proctored, computer-based examination. In general, the examinations will be tailored to individual practice patterns. Requirements of individual diplomates will vary, depending on the type and number of time-limited primary and subspecialty certificates held. Examination content for Diagnostic Radiology will be drawn from material the diplomate has previously reviewed as a part of that diplomate's selected lifelong learning and self-assessment program. For Radiation Oncology, the examination will cover 13 designated content areas. The Radiologic Physics examination content will be drawn from two areas: fundamental core knowledge and current evolving technologies. The intent of the examinations is to reinforce the process of individual lifelong learning, rather than to serve as recertification examinations.

Assessment of Performance in Practice: Practice performance will focus on practice improvement, and will offer diplomates a choice of ways in which to meet the component. ABR practice performance plans are not finalized, and ABMS approval is not expected until 2005 or early 2006.

Program for Maintenance of Certification

INTRODUCTION
The American Board of Medical Specialties (ABMS) and the American Board of Radiology (ABR), as a member board, have initiated a new process termed Maintenance of Certification. Maintenance of Certification (MOC) recognizes that in addition to medical knowledge, there are several essential elements involved in delivering quality care that must be developed and maintained throughout one's career. Lifelong learning is critical to ensure that new information and knowledge are incorporated into clinical practice. The MOC process is designed to facilitate and document the professional development of each diplomate through its focus on the essential elements of quality care in Diagnostic Radiology and its Subspecialties, Radiation Oncology, and Radiologic Physics.

For several years, the ABR has been evaluating 10-year, time-limited certification, recertification, and programs for physician quality improvement and recognition. The following tables illustrate the years in which the ABR began issuing 10-year, time-limited certificates (TLCs).

Subspecialty Certificates (1)
1994 - Subspecialty certificates in Pediatric Radiology and Vascular and Interventional Radiology

1995 - Subspecialty certificates in Neuroradiology

1999 - Subspecialty certificates in Nuclear Radiology
(1) Formerly Certificates of Added Qualification (CAQs)

Primary Certificates
1995 - Primary certificates in Radiation Oncology

2002 - Primary certificates in Diagnostic Radiology and Radiologic Physics

Communications with diplomates and our specialty and subspecialty societies about the ABR Maintenance of Certification program (ABR-MOC) have been ongoing for several years, initially through small group conferences and society organizational meetings, and later through ABR announcements and presentations by ABR trustees at national specialty and subspecialty society meetings. More recently, the ABR has embarked on an aggressive effort to conduct interactive presentations at meetings of multiple societies. Input from the broad radiology community continues to be sought as development of ABR-MOC progresses. The ABR anticipates a continuing education process for its diplomates as transition is made to the MOC program.

The ABR's deliberations and involvement with its sponsoring societies and other specialty societies have provided valuable information, dialogue and input which have been integrated into the developing program. As ABR-MOC evolves and is implemented, these organizations will be involved in providing Accreditation Council for Continuing Medical Education (ACCME)-approved CME and ABR-accepted self-assessment modules (SAMs), practice performance tools, information networking, and content development for the cognitive expertise examination.

THE VISION

The vision of the ABR is to ensure that its diplomates in Diagnostic Radiology and its Subspecialties, Radiation Oncology, and Radiologic Physics, ". . . possess the knowledge, skills, and experience requisite to the provision of high-quality care." The purpose of ABR-MOC is directly in line with this vision: to create a process that encourages and enables each diplomate to provide evidence to peers and the public that quality of care is maintained throughout that person's career. Such evidence is accumulated over the course of the 10-year certification cycle as activities related to the four components and the six competencies of MOC are completed successfully. All of these activities are designed to improve patient care and to continually enhance professional development. The ABR-MOC certificate is not a guarantee of competence. Rather, it documents that the diplomate has satisfied the requirements of the MOC program, which can be considered a tangible indicator of competence.

The ABR-MOC program includes concepts of quality improvement with an emphasis on active participation in individual educational planning. Included are needs assessments, CME, and practice performance tools. To help with continuous professional development and MOC, the ABR will work cooperatively with the specialty and subspecialty societies to assist each diplomate in creating and implementing individual educational plans and lifelong learning self-assessment programs.

BACKGROUND

The emphasis on quality of healthcare, physician training, and board certification has a nearly 100-year history. In his presidential address to the Academy of Ophthalmology and Otolaryngology in 1908, Dr. Derrick T. Vail included the following comment: ". . . and if he is found competent let him then be permitted and licensed to practice ophthalmology." Subsequently, the American Board of Ophthalmology was organized in 1916.

The American Board of Radiology was formed in 1934. The opening paragraphs in A History of the American Board of Radiology 1934 – 1964 by E. L. Jenkinson, read:
With increasing specialization in medicine, as the nineteenth century gave way to the twentieth, there sprang up across America innumerable groups of "specialists," looking to improve the quality of practice in their respective fields. The American Roentgen Ray Society was organized in 1900, the Radiological Society of North America in 1915, and the American Radium Society in 1916. Just what constituted a "specialist" was, however, open to a variety of interpretations. Any Doctor of Medicine was entitled to a listing in the Directory of the American Medical Association as specializing in the field in which he considered himself best qualified. In other words, he was the judge of his own qualifications.

The situation … posed a problem. The medical profession had, for many years, considered that there should be minimal standards of preparation for the practice of any medical specialty in order to protect the public, the profession in general, and the specialists themselves. [Jenkinson also noted that unless some centralized process was established, each state would develop its own specialty board.] In view of this possibility, it appeared that the practical solution would be for each group to set its own house in order and place its mark of approval on those qualified to practice predominately in that particular field.

In 1934, the purposes of the ABR were stated as follows:

  1. encouraging the study and promoting and regulating the practice of radiology [which was defined as "that branch of knowledge which deals with the diagnostic and therapeutic application of radiant energy including roentgen rays and radium"];
  2. determining the competence of specialists in radiology;
  3. arranging, controlling, and conducting investigations and examinations to test the qualifications of voluntary candidates for certificates issued by the Corporation;
  4. granting and issuing certificates in the field of radiology to such applicants;
  5. serving the public, physicians, hospitals, and medical schools by preparing and furnishing lists of certified practitioners;
  6. protecting the public against irresponsible and unqualified practitioners who profess to be specialists in radiology.

The Advisory Board of Medical Specialists was organized in 1933 – 1934. The ABR became a member of the Advisory Board in 1934 and was recognized by the Council on Medical Education and Hospitals of the AMA. In 1938, the Advisory Board authorized the publication of a Directory of Medical Specialists, which would include specialists of 11 boards, including the ABR. The Articles of Incorporation were amended in 1970, and the ABMS (American Board of Medical Specialties) was formed.

The concept of board certification was inspired by a desire to serve individual patients and the public with a focus on education, skills and quality of care. Currently, all of the 24 member boards of ABMS have elements of their missions that are based on education, standards, cognitive content, skills, knowledge, and an examination process unique and appropriate for the specialty. The ultimate translation of the process of certification is quality patient care. Quality of healthcare, including physician quality, was the focus in the beginning and remains the focus today. The gap in healthcare quality could be defined in the future as the difference between the care that is delivered and the care that could be delivered in the setting of current and evolving medical knowledge and expertise.

Physicians' performance and outcome measurements are of great concern to the profession and are of escalating concern to other organizations, such as the Joint Commission on Accreditation of Healthcare Organizations, the National Committee on Quality Assurance, the National Quality Forum, the Institute for Healthcare Improvement, state licensing boards, the public at large, etc. Lifetime certification has long been accepted by the public and the profession as a good, but imperfect, process. However, questions have been raised as to whether physicians initially certified upon completion of their residency maintain the knowledge, skills, and clinical ability necessary to continue providing quality patient care.

Board certification after completion of training as in the past (i.e., lifetime certification based on an examination at a single point in one's career) is no longer accepted as the benchmark for quality. All of the ABMS Member Boards have debated the merits of primary certification, recertification, time-limited certification and maintenance of certification. The ABR and the other ABMS boards have committed to continuous improvement and continuous professional development models with time-limited certification as the benchmark for the future. In developing its unique, specialty-specific MOC program, each ABMS member board follows an architectural plan that includes the four components and addresses the six MOC competencies developed by the ABMS and the Accreditation Council on Graduate Medical Education (ACGME) and endorsed by all of the boards.

In this context, the ABR is pursuing development of the American Board of Radiology Maintenance of Certification. The ABR-MOC program, which incorporates all of the components and competencies, has an overarching goal of improvement in the quality of patient care via improved outcomes and evidence-based practice of our specialty. The result is a paradigm shift from lifetime certification, based upon one-time successful passing of a cognitive examination, to time-limited certification, based upon a program of continuous professional development.

In the 2004 ABMS President's report, Dr. David L. Nahrwold made the following comment:
"Our profession is becoming increasingly marginalized through the activities of health plans, insurance companies, Medicare, and many other organizations working to determine health policy.(2) Our way out of this problem, as Rosemary Stevens puts it, is 'to convince the public that the profession has different, and perhaps loftier goals, than the other players.(3) A primary goal should be to provide patient-centered, evidence-based medicine." Recent surveys indicate that patients and peers have certain expectations about the examinations physicians take, that board certification is regarded as very important, and that patients focus on some other important concepts: 1. patients and the public expect physicians to stay current with contemporary medicine (lifelong learning and self-assessment); 2. they expect physicians to be evaluated by independent organizations (licensure and certification); and 3. they expect satisfaction surveys to reflect service and the art of medicine. The concept of ABR-MOC contains elements that, over time, will help meet the expectations of patients, the public, and peers. Certification and MOC are processes and competencies embodied in the contemporary physician.

(2) ABMS Executive Committee Minutes 2-10-2004
(3) Public Role for the Medical Profession in the United States: Beyond Theories of Decline and Fall: Rosemary A. Stevens: The Milbank Quarterly: Volume 79, Number 3, 2001.

LIFETIME AND TIME-LIMITED CERTIFICATES Lifetime certificates (time-unlimited certificates) were issued as primary certificates in Radiation Oncology prior to 1995 and in Diagnostic Radiology and Radiologic Physics prior to 2002. Since the above respective dates, primary certificates issued in Diagnostic Radiology, Radiation Oncology and Radiologic Physics have been ten-year, time-limited certificates (TLCs). Subspecialty certificates (formerly CAQs) have always been issued as ten-year certificates. Diplomates who hold lifetime certificates will maintain those certificates, but are strongly encouraged to participate in ABR-MOC. Diplomates with 10-year, time-limited certificates as primary or CAQ/Subspecialty certificates, who wish to maintain certification, must successfully complete the requirements of the ABR-MOC. Participation in ABR-MOC demonstrates an individual's commitment to lifelong learning and continuous professional development. All ABR trustees participate in MOC.

THE MEANING AND VALUE OF MOC

The ABR-MOC program will provide a process for ABR diplomates to document their commitment to lifelong learning and self-assessment in order to continuously improve the quality of their practices and continue their professional development. The ABR will continue to address the MOC components and competencies of its certified diplomates. This process can provide information and documentation to peers and to the public that the Board's diplomates are maintaining a requisite standard of knowledge, skill, and understanding essential to practice.

The ABR is committed to incremental implementation of ABR-MOC, consistent with ABMS guidelines and the distinctive nature of our specialty and subspecialty practices. The ABR will strive to plan, develop, and implement its MOC program as a fair and creditable process that will meet public and professional scrutiny, foster continuous professional development and practice improvement, and take into account the high quality and diversity of our specialty and subspecialty practices.

THE MAINTENANCE OF CERTIFICATION (MOC) MODEL

MOC was developed as an initiative of the ABMS and in response to public and professional interest in enhancing the quality of medicine. An ABMS task force used the framework of the essential components to develop a four-part model of MOC. The ABMS member boards have endorsed and accepted this model and have unanimously agreed to establish MOC programs.

ABR-MOC has four components: professional standing, lifelong learning and periodic self-assessment, cognitive expertise, and practice performance. In the MOC process, the six competencies (below) are evaluated through these four components. The competencies have been developed by the ABMS and the ACGME and are significant elements of the ten-year MOC cycle. The ABR and other boards are developing specialty- and subspecialty-specific definitions based on the following ABMS general competencies:

Medical Knowledge: Know and critically evaluate current general and practice-specific medical information; understand and incorporate evidence-based decision-making.

Patient Care: Improve performance skills, including medical interviews and physical examinations; incorporate a synthesis of clinical data.

Interpersonal and Communication Skills: Communicate effectively with patients and families, other professionals, and team members; maintain comprehensive, legible medical records.

Professionalism: Demonstrate self-awareness and knowledge of limits, high standards of ethical and moral behavior, reliability and responsibility, respect for patient dignity, and autonomy.

Practice-Based Learning and Improvement: Engage in ongoing learning to improve knowledge and skills; analyze one's practice to recognize strengths and deficiencies; seek input to improve practice and quality care.

Systems-Based Practice: Promote patient safety within the system; provide value for patients through cost-effective care; promote health and prevention of disease and injury; demonstrate effective practice management.

Within this overall framework, the individual ABMS boards are designing their MOC programs to reflect their specific approaches to the process. The overriding principles of the ABR-MOC are to evaluate the six basic competencies through implementation of procedures to evaluate the four components. This practice will evolve into a continuous process of lifelong learning and self-assessment which stresses the adult learning concepts of self-direction, knowledge-into-action, practical content, self-discovery and incorporation of knowledge and skills into the practice.

The ABR anticipates the process will continue to evolve as the transition to the MOC program moves forward. Further details of the four components and six competencies will be developed throughout 2004-2005 and beyond. They will continue to progress and mature over the next few years.

DIAGNOSTIC RADIOLOGY AND SUBSPECIALTIES

The four components that form the model for Maintenance of Certification are:

Part One: Professional Standing: This will require valid, unrestricted licenses to practice medicine in all states in which a physician holds license. This licensure requirement will be continuous, meaning that ABR certification may be withdrawn or suspended if a license is revoked or suspended at any time.

Part Two: Lifelong Learning and Self-Assessment:
Lifelong Learning: Requires a minimum of 500 CME credit hours, approved by the Accreditation Council for Continuing Medical Education (ACCME) over the 10-year cycle, with 250 of those 500 hours in Category 1 and the remaining in Category 1 or 2. A minimum of 70% of the 500 hours must be in specialty-specific or related areas, with the remaining 30% being allowed in either nonspecialty specific clinically-related general CME; or relevant topics such as risk assessment, ethics, processes of continuous quality improvement, methodologies of measurements of outcomes, statistics, etc. The diplomate should keep an educational plan which relates the practice profile, local needs assessment, and self-assessment to personal CME activities.
Self-Assessment: Self-assessment will be accomplished through a series of Self-Assessment Modules (SAMs), which are also ACCME CME Category 1-approved activities. To count toward MOC, SAMs must be ABR-accepted and will be classified into two subgroups. One will be General Content, required of all diplomates. A second group, Clinical Content, will consist of SAMs selected by the diplomate from multiple specialty and subspecialty modules. Each SAM will consist of ABR-accepted instructional content followed by multiple-choice questions. Feedback to the diplomate will consist of correct answers, evaluation of performance in the participating group, and relevant references and discussion. Twenty (20) SAMs will be required for completion over the 10-year cycle, with an ideal of two per year. Twenty percent (20%) of SAMs or four (4) over 10 years will be from the General Content category. Eighty percent (80%) of SAMs or sixteen (16) over 10 years will be from the Clinical Content category. SAMs will be accepted by the ABR and developed by Diagnostic Radiology societies, subspecialty societies, and other qualified organizations. SAMs are for individual self-assessment and to direct further CME activities. Individual scores will not be entered into the ABR database, but will remain confidential to the physician. The content of the clinical SAMs selected by the diplomate (and the general SAMs accepted by the ABR) will be related to the diplomate's cognitive expertise examination. The diplomate will be responsible for documenting successful completion of the SAMs during the 10-year period and for validating and recording CME self-assessment data. Eventually, this data may be entered into the electronic repositories of national societies and subspecialty societies, into other repositories that can be made available to the ABR, or directly onto the ABR website. In some instances, data may need to be submitted to the ABR in hardcopy form.

Part Three: Cognitive Expertise. The ABR cognitive MOC examination for maintenance of the primary certificate in the specialty of Diagnostic Radiology will be a computer-based examination. It will be offered initially in 2009, then annually. The ABR's Diagnostic Radiology subspecialty examinations (formerly CAQs) will be offered annually starting in 2004, even as the other ABR-MOC components in the subspecialties are being developed to complete the transition to the new paradigm. The subspecialty examinations will be proctored and secure; these case-based computerized examinations will cover the prescribed knowledge determined by the ABR to be necessary for the practice of the subspecialties.

The cognitive examination in Diagnostic Radiology to be implemented in 2009 will consist of general and clinical content. General Content will be applicable to all diplomates and thus will be part of each diplomate's cognitive examination (not to exceed 20% of the content of the examination). It will be derived from the topic areas of the General Content SAMs. (The CME and SAMs will be produced and made available through the various radiology specialty and subspecialty societies). The Clinical Content SAMs (diplomate-selected, individualized for practice emphasis and needs assessment) will comprise up to 80% of the cognitive examination. These will also be ABR-accepted, but produced and made available through radiology societies.

The ABR cognitive MOC examination for Diagnostic Radiology could cover content areas from one of, or any combination of: Musculoskeletal, Cardio-Pulmonary, Gastrointestinal, Genitourinary, Neuroradiology, Vascular/Interventional, Ultrasound, Pediatrics, Nuclear Radiology, Breast Radiology, Patient Safety, and Socioeconomic Concepts. The subspecialties will cover their specific areas of certification.

Part Four: Assessment of Performance in Practice: Practice performance, still under consideration with input from ABR-sponsoring societies and other societies, will focus on practice improvement, and will offer diplomates a choice of ways in which to meet the component. The ABMS has not as yet approved the ABR practice performance plans; approval may not be finalized until 2005 or early 2006. The following are ABMS guidelines:

  1. A program of practice assessment should be phased in, periodically evaluated for its effectiveness, and systematically improved. Diplomates should be kept informed of the development of practice performance assessment.
  2. The assessment process should reflect the activities of a diplomate relating to patients or patient care.
  3. Standards for measurement of clinical practice performance should be based on evidence-based guidelines, explicit expert consensus, or normative peer comparison.
  4. The assessment process should compare the diplomate's practice performance to evidence-based guidelines or explicit expert consensus, where available, and to the performance of peers. After an initial baseline assessment, diplomates should be asked to develop implementation plans for how they would improve performance. The diplomates should submit follow-up assessments of the effect of their improvement plans. Each board should have a plan for what to do with diplomates whose performance does not meet acceptable expectations.
  5. Initially, each of the six general competencies should be assessed at least once during a board's repeating maintenance-of-certification cycle. It is expected that by the end of the second cycle, this should be a continuous process.
  6. Assessment of patient care should initially focus on a sampling of patients with a key disease or clinical process (such as asthma, diabetes, pregnancy, immunizations, surgical procedure or processes central to that specialty) at least once per cycle. By the end of the second cycle, each board should move to a more continuous sampling of patients that will enable the diplomate to demonstrate, at any point in time, the quality of care given to a defined number of patients or performance in specialty-related key activities.
  7. For assessment and improvement of clinical performance, an effective method for each board to consider is to be a part of a collaborative effort with other practices, using shared databases.
  8. The measurement of practice performance should use proven educational and assessment methodology.
  9. Practice assessment should provide performance feedback, improve workflow, improve efficiency of practice, and should not duplicate other assessment efforts.
  10. Practice assessment should include appropriate collaboration with specialty societies and other organizations with relevant education and assessment expertise.
  11. Boards should develop consistent policies regarding the status of maintenance of certification for diplomates who are not involved in direct patient care.
  12. The assessment of physician performance should begin during residency and continue throughout practice. The board's evaluation of physician performance during residency should be linked to the six general competencies described by the ABMS-ACGME.

Some examples of practice performance modules under consideration include:
· Patient safety
· Reporting, to include turnaround
· Clinical practice guidelines
· Patient and referring physician surveys
· Peer review, to include double reading assessment

Maintaining Primary and Subspecialty Certification: Subspecialists will be required to maintain primary certification in order to maintain subspecialty certification. Maintenance of both certificates will be streamlined via common components, including professional standing, lifelong learning/self-assessment, and the General Content portion of the SAMs and cognitive expertise examination. Multiple-TLC holders with primary and subspecialty TLCs will select six Clinical Content SAMs relative to their specific specialties. These selections, along with the remaining Clinical Content SAMs, will relate to the Clinical Content portion of the cognitive examination. Self-assessment will have an ABR-accepted General Content portion that is required of all diplomates and reflects the common features of specialty and subspecialty practice in the broadest sense.

Multiple-Certificate Holders: In the near-term, holders of multiple certificates will include diplomates with lifetime primary certificates in Diagnostic Radiology and TLCs in one of the subspecialties. The ABR-MOC requirements for these diplomates are specific to the subspecialty. Nevertheless, all are encouraged to participate fully in the MOC process, including voluntary participation in a program to maintain the primary certificate. As is true of the entire ABR-MOC program, the components of subspecialty MOC are being developed and phased in during the transition period. For 1994 and 1995 subspecialty diplomates, the only requirements that must be satisfied for MOC are evidence of professional standing (Part One) and evidence of cognitive expertise (Part Three, or the case-based computerized examination). The cognitive subspecialty examinations are being given in July of 2004, and in January and July of 2005 at test centers in Tucson, Tampa, and Chicago. By the end of 2004/2005, selected SAMs in the subspecialties will be available and the other MOC components will be in a transition phase.

Starting in 2004, diplomates with primary TLCs in Diagnostic Radiology (issued in 2002) could become subspecialty certified. These multiple-TLC holders will be the first group required to fully participate in ABR-MOC in order to maintain each of their certificates. Their certification will be accomplished through the same process used by the single-certificate holders, except these diplomates' Clinical Content SAMs will need to reflect their specific practice profiles and subspecialty SAM requirements. To address both the needs of the diplomates and the requirements of the ABMS guidelines for development of MOC programs, the ABR fashioned its ABR-MOC to recognize that practices are highly individualized, particularly as regards clinical responsibilities and subspecialty emphasis. Through ABR-MOC, diplomates will integrate their lifelong learning activities (directed by self-assessment, general and selected Clinical Content SAMs, cognitive expertise examination, and practice performance tools) to successfully complete multiple certificates.

Part One: Professional Standing - This component requires all medical licenses to be verified as valid and unrestricted. This verification applies to all certificates held by a diplomate.

Part Two: Lifelong Learning and Self-Assessment - Multiple-TLC holders have the same requirement of 500 CME credit hours over the 10-year period. Moreover, the ideal number of SAMs remains two per year (20 per 10-year MOC cycle, consisting of four general content and 16 clinical content SAMs). However, the diplomate will be expected to take at least six of the required number of Clinical Content SAMs (six of 16) in the area of the subspecialty certification. If a multiple-TLC holder has a practice emphasis that is completely (or nearly completely) dedicated to a subspecialty discipline, the diplomate should choose additional SAMs (above the six required) from the subspecialty field or from other topic areas altogether.

Part Three: Cognitive Expertise - Multiple-TLC holders will be expected to take only one examination—not two—to maintain primary and subspecialty certificates. The examination will be predominately case-based and computerized. It will comprise 20% general content (to be accepted by the ABR) and 80% clinical content (from SAMs, the composition of which will be patterned after the practice profile or through the emphasis that the diplomate determines through an individual educational program of lifelong learning/self assessment and selection of SAMs). Finally, for multiple-TLC holders with four or more TLCs, the ABR will individualize the requirements while maintaining the basic precepts of MOC.

Part Four: Assessment of Performance in Practice - This component is still in development. There are going to be differences between the Part Four programs eventually developed for Diagnostic Radiology and its Subspecialties, Radiation Oncology, and Radiologic Physics. Similarly, there could be differences between Part Four programs developed for Neuroradiology, Pediatric Radiology, Nuclear Radiology, and Vascular Interventional Radiology. There is ample common ground among these specialties and subspecialties, offering the opportunity to positively impact practice quality in a number of major ways. These include the judicious use of contrast materials, management of contrast reactions, minimization of exposure to ionizing radiation, adoption and implementation of wrong-site/wrong-procedure/wrong-patient measures, timely and efficient reporting, participation in quality assessment/quality improvement programs, and many more.

RADIATION ONCOLOGY

The four components that form the model for Maintenance of Certification are:
Part One: Professional Standing - Diplomates are required to maintain active, current, valid, unrestricted, and unqualified licenses relevant to all locations of practice. All current licenses will be checked at the time the diplomate registers for the cognitive expertise examination. Beginning in 2004, the American Board of Radiology will regularly conduct random sample checks of licensure status amongst diplomates with time-limited certificates.

Part Two: Lifelong Learning and Self-Assessment -
Lifelong Learning: A minimum of 500 CME credit hours, approved by the Accreditation Council for Continuing Medical Education (ACCME), are required over the 10-year cycle, at least 250 of which must be in Category 1. Of the 500 hours, 400 (including 200 Category 1 hours) must be related to radiation therapy or oncology.
Self-Assessment: The periodic self-assessment requirement may be satisfied by participation in educational venues (e.g., refresher courses, workshops, reading assignments, etc.) that meet ABR-announced standards and are accepted by the ABR. As part of the self-assessment module, the diplomate will need to successfully pass an automated self-assessment program covering the respective educational materials. Feedback to the diplomate is expected to provide input of value in selecting future lifelong learning and self-assessment opportunities.
The lifelong learning and periodic self-assessment components will initially include the efforts of the ABR and the Radiation Oncology educational and specialty societies. Radiation Oncology refresher courses are currently offered by several of the societies in conjunction with a periodic self-assessment program that includes a self-administered examination. Documentation that the diplomate has successfully completed an examination of this type, related to a refresher course or similar self-assessment program, shall represent one unit of self-assessment. The diplomate will be responsible for documenting successful completion of the equivalent of eight or more self-assessment units during the 10-year period.

Part Three: Cognitive Expertise - The diplomate is expected to maintain the essentials of core knowledge fundamental to the practice of Radiation Oncology. Documentation of cognitive expertise requires completion of a computer-based examination during the 10-year MOC cycle, which is offered by the ABR at least once a year. The examination, derived from the recertification exam offered since 1999, is a comprehensive test covering the knowledge base required for the practice of Radiation Oncology. The proctored examination is currently administered in three computer-based testing centers (i.e., the American Board of Radiology, Tucson, AZ, the American Board of Pathology, Tampa, FL, and the American Board of Psychiatry and Neurology, Chicago, IL); the venues may change in the future. On the day of the examination, the identity of the candidate (as the person scheduled to participate in the examination, according to ABR records) will be confirmed.

The ABR Cognitive Expertise examination in Radiation Oncology covers 13 content areas:
gastrointestinal cancers, genitourinary cancers, gynecological cancers, breast cancer, lymphomas and leukemias, head and neck cancers, pediatric cancers, central nervous system tumors, sarcomas, thoracic malignancies, palliation, radiation and cancer biology, and physics.

Part Four: Assessment of Performance in Practice - Each diplomate is expected to maintain active professional involvement in Radiation Oncology. The final configuration and components for practice performance evaluation as applied to Radiation Oncology are under discussion. The following two documents are being reviewed for potential guidance for this aspect of ABR-MOC:
1. ABMS White Paper (04/08/03): The Argument for Why Every ABMS Board Should Accept, Develop and Promote the Concept of Maintenance of Certification. Included is the concept of assessment of practice performance based on an improvement approach rather than an inspection approach;
2. ABMS Blueprint for Part IV: Assessment of Practice Performance.

The following are ABMS Guidelines:
A) A program of practice assessment should be phased in, periodically evaluated for its effectiveness, and systematically improved. Diplomates should be kept informed of the development of practice performance assessment.

B) The assessment process should reflect the activities of a diplomate relative to patient care.

C) Standards for measurement of clinical practice performance should be based on evidence-based guidelines, explicit expert consensus, or normative peer comparison.

D) The assessment process should compare the diplomate's practice performance to evidence-based guidelines or explicit expert consensus (where available) and to the performance of peers. After an initial baseline assessment, the diplomate should be asked to develop a plan to implement improved performance. The diplomate should submit a follow-up assessment of the effect of the improvement plan. Each board should have a plan for what to do with diplomates whose performance does not meet acceptable expectations.

E) Initially, each of the six general competencies should be assessed at least once during a board's repeating maintenance-of-certification cycle. It is expected that by the end of the second cycle, this should be a continuous process.

F) Assessment of patient care should initially focus on a sampling of patients with a key disease or clinical process at least once per cycle. By the end of the second cycle, each board should move to a more continuous sampling of patients that will enable diplomates to demonstrate, at any point in time, the quality of care given to a defined number of patients, or performance in specialty-related key activities.

G) For assessment and improvement of clinical performance, an effective method for each board to consider is to be a part of a collaborative effort with other practices, using shared databases.

H) The measurement of practice performance should use proven educational and assessment methodology.

I) Practice assessment should provide performance feedback, improve workflow, improve efficiency of practice, and should not duplicate other assessment efforts. J) Practice assessment should include appropriate collaboration with specialty societies and other organizations with relevant education and assessment expertise.

K) Boards should develop consistent policies regarding the status of maintenance of certification for diplomates who are not involved in direct patient care.

L) The assessment of physician performance should begin during residency and continue throughout practice. The board's evaluation of physician performance during residency should be linked to the six general competencies described by the ABMS-ACGME.

Initial considerations regarding assessment of practice performance have ranged from identification of a physician-specific, on-site accreditation, to computerized programs evaluating submitted patient and management materials. Opportunities to incorporate aspects of ongoing physician practice assessment, such as regular chart rounds that involve documented peer review, are also being considered as part of this component of MOC. As specialty-related standards are further developed, it is anticipated that societies and organizations will submit proposals for consideration. Each practice performance program will need to be approved by the ABR prior to incorporation into the MOC process.

RADIOLOGIC PHYSICS

The four components that form the model for Maintenance of Certification are:

Part One: Professional Standing - This will be evaluated through three mechanisms:

  1. Letters of attestation from an ABR-certified Radiologic Physicist and an ABR-certified Radiologist or Radiation Oncologist. The requested statements will attest to the candidate's active involvement in the discipline of Radiologic Physics with specific focus on four areas of performance: patient care, scientific knowledge, interpersonal/communication skills, and professionalism.
  2. Documentation of licensure or other regulatory agency certification for the practice of medical physics (where applicable).
  3. Documentation of expertise-based appointments or recognition. This will entail a listing of recognition by professional organizations or peer groups as to specific expertise and/or resource capabilities of the candidate. Examples of such activity include appointment to a national/international committee such as the NCRP, ICRP, etc.; membership in an NIH Study Section; invitations, such as a special lecturer, Visiting Professor, etc.

Part Two: Lifelong Learning and Self-Assessment - Lifelong learning requirements may be satisfied through 1) attainment of approved continuing education credits (Category 1 equivalent), and 2) completion of Self-Directed Educational Projects (SDEPs). Continuing Education (CE) credits would be for educational functions approved by the Commission on Accreditation of Medical Physics Education Programs (CAMPEP) or other recognized accrediting organizations. For SDEPs, the candidate must identify areas in which professional improvement and/or educational augmentation is needed. The approach to each project is prospective and must be defined in advance. The components of the SDEP include: a) a statement of the educational need, b) a list of activities designated to address the need, c) documentation of achievement, and d) an outcome statement.

Total number of credits required over the 10-year period:
A) Single time-limited certificate (TLC) holder: Must equal or exceed 500 credit hours with a minimum of 200 in each of Category 1 and SDEPs.

B)Two-certificate TLC holder: Must equal or exceed 600 credit hours with a minimum of 250 in each of Category 1 and SDEPs.

C)Three-certificate TLC holder: Must equal or exceed 700 credit hours with a minimum of 300 in each of Category 1 and SDEPs.

Self-assessment as a global process is intended to bring all facets of essential professional development into focus. At three time points within the 10-year cycle, the candidate will be required to perform a self-assessment as to overall progress in completing the requirements of the MOC process. Through this cumulative assessment, the diplomates will evaluate their level of performance in fulfilling the four components. In accordance with given guidelines, the diplomate will provide an assessment of the degree to which requirements have been satisfied, in correlation with a personal schedule for completion and submission of the MOC application.

Part Three: Cognitive Expertise - Diplomates are expected to maintain the essentials of core knowledge fundamental to the practice of Radiologic Physics, and to remain up-to-date on evolving technologies, protocols, procedures and techniques involving applications of physics in medicine. Fulfillment of these expectations will occur by evaluation of cognitive expertise utilizing a proctored, timed, web-based examination that will be administered in three parts for completion over the 10-year period. The examination format will be open book, and the exam will consist of multiple-choice questions with content based on 1) core knowledge (approximately 30%), and 2) current evolving technologies (approximately 70%). To accommodate the annual class of diplomates, new cognitive exam modules will be available on a yearly basis. A diplomate who fails an exam will have the opportunity to retake the examination, offered in the next year. The three exam components must be successfully completed over the 10-year cycle. Multiple-TLC holders must complete the three exam components for each of the disciplines for which they hold certificates.

Part Four: Assessment of Performance in Practice - Diplomates are expected to maintain active, professional involvement in the discipline of Radiologic Physics. Diplomates must provide information regarding their participation in the profession of Radiologic Physics over the 10-year period, including evidence that they are currently active within the field. They must submit information on their current employment status, their associated medical physics responsibilities, and any additional activities or processes that reflect involvement in and contribution to the profession of medical physics.

The final configuration of and components for practice performance evaluation as applied to Radiologic Physics are under discussion. Input is being solicited from associated specialty societies.