AANS Neurosurgeon | Volume 29, Number 2, 2020


From MOC to CC: A Paradigm Shift

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The rapid evolution of knowledge and technology, along with public criticism, has led to a new perspective on how to best assess physician competence to practice. Within neurosurgery, a major shift in this realm occurred in 1998, when the specialty became the final medical specialty society to adopt the change from lifetime Board certification to a time-limited certification that required a process of Maintenance of Certification (MOC). For MOC, diplomates are expected to participate in a lifelong learning process to keep their professional knowledge up-to-date. Then, once every ten years proficiency is assessed through a high-stakes written examination in which failure could potentially result in loss of Board certification. Since that time, those ABNS diplomates with lifetime certificates have mostly aged out of practice and been replaced by those participating in MOC. 

Since that time, the field of neurological surgery has continued to evolve at an ever-accelerating pace such that both newly acquired knowledge and advances in technology now make our textbooks outdated by the time they reach press. Younger neurosurgeons have come to rely upon internet-based information and more rapid means of staying updated to maintain current practice standards. At the same time, both public scrutiny of physician practice and governmental regulations have required modern neurosurgeons to constantly evaluate their competency to minimize complications and improve quality of care. 

With equally as high stakes as in the world of medicine, the airline industry has moved towards lifelong learning and continuous education of their pilots in an effort to reduce errors and save lives. Pilots now are required to spend time in flight simulators, participate in regular online educational courses and continuously demonstrate proficiency, if they are going to be responsible for the lives of their passengers.

Given this example, perhaps a new paradigm is needed, as the thought of assessing competency once per decade is no longer tenable. Medicine has recently embraced a similar mindset with the American Board of Medical Specialties (ABMS) requiring member boards to sunset their MOC programs in favor of Continuous Certification (CC). As of this year, all member Boards have rolled out programs in which individual members are now required to participate in online offerings and to demonstrate proficiency. Some of the larger societies now require member physicians to complete educational modules on a monthly or quarterly basis. Neurosurgery complies by moving towards an annual process. Recognizing that this change increases the workload of our diplomates, the change has also evolved to an online process that diplomates can complete from their home or office. The high-stakes process by which participation could potentially jeopardize a diplomate’s ability to practice has ceased and is replaced by a new online adaptive learning tool. This tool is designed to provide all neurosurgeons with updated knowledge centered around:

What you need to know to cover your partner’s practice during a weekend on call.

Recognizing that few of us practice the full spectrum of neurosurgery, the adaptive learning tool intends to provide diplomates with current knowledge in areas of commonality based upon recently published Level I or II randomized controlled trials (RCTs). 

The new adaptive learning tool has a number of advantages. By keeping some of these core principles available from one year to the next, we hope to be able to track and reinforce knowledge in important areas and ensure that all diplomate’s practice standards remain cutting-edge, even years after residency. Secondly, in a time when states and institutions are requiring minimum numbers of specific Continuing Medical Education (CME) credits (trauma, opioid prescribing, subspecialty) by participating in the new CC process, diplomates may now satisfy the annual American College of Surgeons trauma requirements as well as receive specific CME credits by completing various components of the new adaptive learning tool.

As of 2019, all ABNS diplomates with time-limited certificates will be required to participate in the four components of CC. Those with lifetime certificates will be encouraged, but not required, to participate as a way of maintaining current practice knowledge. Although not required to participate, lifetime certificate holders will be listed on the ABNS website as either “Certified – Participating in Continuous Certification” or as “Certified – Not Participating.”

The annual CC process consists of four components, which, as mentioned, can be completed annually online: 

Part I: Online attestation by an independent observer, such as your hospital’s chief medical officer, employer or senior partner that the diplomate holds an unencumbered license and is in good standing with his hospital and state medical board.

Part II: Verification of a minimum of 20 credits per year of AMA PRA Category I CreditsTM in neurosurgery. The AANS is working on a new self-reporting system to make it easier for the diplomate to report CMEs.

Part III: Annual completion of online adaptive learning tool.

Part IV: Requirement that all diplomates participate in an evaluation of their personal outcomes and complication rates through either participation in a regular Morbidity and Mortality (M&M) conference, enrollment of patients in the national Quality Outcomes Database (QOD) or by participating in national courses in which they are required to evaluate their own cases in a reflective forum. 

The basic learning tool, which covers general neurosurgery, can typically be completed in 2-3 hours at one’s leisure. With the development of three subspecialty areas within neurosurgery – pediatric neurosurgery, endovascular neurosurgery and neuro-critical care – holders of those subspecialty documents of “Recognition of Focused Practice” (RFP) will be required to complete the general adaptive learning tool as well as the learning tool for their subspecialty area on an annual basis to maintain their ABNS certificate and their RFP credential. For those in general practice, the subspecialty learning modules will also be available as additional knowledge updates. For example, one may take the basic adaptive learning tool, plus the neuro-critical care adaptive learning tool, the pediatric learning tool or the vascular/endovascular learning tool, for which they may receive additional subspecialty CME credits.

Details of enrollment and participation in the Continuous Certification process are available online through the ABNS website. Penalties and consequences of failure to participate will also be listed there. Obviously, by moving from a 10-year process to an annual process, there will be increased costs to diplomates in order to comply with the new ABMS directives; however, neurosurgery, as a smaller specialty, benefits from having a Board that is revenue neutral, thrives on volunteerism and has worked hard to keep costs as low as possible. These newborn costs are hopefully offset by the CME credits gained and the increased benefit to our patients gained by maintaining best practice standards. As our specialty moves forward, we hope to hear from diplomates suggestions as to how we might improve the process. We are already receiving requests from medical students, residents and neurosurgeons outside of North America for access to the new adaptive learning modules as a way of gaining access to online educational studies and practice standards to which they may not currently subscribe.


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Greg Yost, MD | May 13, 2019 at 10:10 am

Real reform is “Lifetime Certification”. Ive certified 3 times in my career. That’s enough.