The survey report by Dave Yousem in this issue of the American Journal of Neuroradiology is a helpful window into the current level of understanding and acceptance of Maintenance of Certification (MOC) by members of the American Society of Neuroradiology (ASNR). We appreciate the invitation from the editors to provide additional perspective.
Most neuroradiologists understand that MOC was not created by the American Board of Radiology (ABR). The American Board of Medical Specialties now requires all member boards to administer a process of MOC, responding to the concerns and expectations of patients, payers, and governments for monitoring and assurance of quality and safety in health care. Our colleagues in all specialties of medicine are adapting to new MOC requirements that have the same components as the MOC program sponsored by the ABR.
Considering the natural reaction of most people to a process that will consume time and money, we view the overall acceptance of MOC by neuroradiologists as encouragingly professional. Some of the survey comments about MOC were quite positive. As Dr. Yousem notes, 115 respondents offered comments characterized as “negative,” a relatively small proportion of the 2662 surveyed and 1020 responding.
More importantly, a large proportion of eligible neuroradiologists are, in fact, engaged in MOC. Of the cohort of neuroradiologists that was subspecialty certified in 1995, when the examination was first offered, more than 80% of those aged 60 years or younger have taken the recertification examination and are enrolled in ongoing MOC. For the 1996 cohort, the percentage is about 70%. These numbers will likely increase, because each diplomate has a 3-year grace period during which an expired subspecialty certificate can be reinstated simply by passing the MOC examination.
Objective evidence that most neuroradiologists engage in MOC is solid, but the negative comments registered in Dr. Yousem’s survey are important and merit a response. Several respondents criticized the inconvenience and cost of traveling to take the MOC examination. The ABR is very aware of these concerns and has been working for several years to increase the geographic availability of MOC testing. The MOC examination for neuroradiology is now given at the annual meetings of the Radiological Society of North America and the ASNR. (Approximately 60 neuroradiologists completed the test at the most recent meetings of each of these societies.) The ABR is also working with national testing centers to enable the administration of MOC examinations with high-image quality that are geographically closer to the homes of most diplomates.
Another frequent complaint is the cost of enrolling in MOC. The ABR has carefully studied the anticipated expense of information technology and personnel needed to administer the MOC process. Fees are determined accordingly and will be adjusted as actual expenses are defined more clearly. The annual fee is not primarily a prepayment of the examination fee, or an administrative fee for registering CME credits. It is mainly the assessment necessary to fund the ongoing development and maintenance of an MOC infrastructure. No separate examination fee will be charged. It may be reassuring to radiologists to know that the MOC fee of the ABR is in the middle of the range of fees in all specialties.
Confusion about self-assessment modules (SAMs) seems to be decreasing as subspecialty societies offer more of them at meetings and on-line. The ASNR is doing an excellent job in this regard. It is not surprising that practice quality improvement (PQI), the ABR’s program for Component 4 of MOC and the last to be introduced, is now engendering the most confusion. However, as with the initial apprehension about SAMs, this confusion will almost certainly diminish as our professional organizations become engaged in supporting PQI for their members.
The MOC examination itself is continually reviewed and adjusted. Cases with relatively poor statistics or suboptimum image quality are noted and replaced. All new cases and questions are reviewed by a group of neuroradiology raters before being added to the examination pool. The ABR also conducts routine exit surveys of test takers. On a consistent basis, 70% to 75% of candidates rate the appropriateness, clarity, and image quality of the neuroradiology MOC examination at the 2 highest levels (of 5); fewer than 10% rate these features of the examination at the 2 lowest levels.
Beginning in 2010, neuroradiologists who wish to renew both their subspecialty certification and their time-limited general certification in diagnostic radiology will be able to do so by taking a single examination. This test will have content modules that are matched to the largest components of the neuroradiologists’ practice. A minimum of 50% of the clinical content of the examination will be required to be in the subspecialty area for which the diplomate wishes to maintain certification. (There will be special policies and procedures for participants renewing more than 1 subspecialty certificate.) As of 2010, 20% of the MOC examination for every radiologist will cover general topics, such as radiation safety and treatment of reactions from contrast material.
As neuroradiologists come to understand that the subspecialty MOC process is an integrated route to maintenance of both subspecialty and general diagnostic radiology certification, the number of radiologists who register for the initial subspecialty examination (formerly called the Certificate of Added Qualifications examination) is increasing. From 2003 to 2005, approximately 80 candidates took the initial subspecialty examination in neuroradiology. In 2006, the number jumped to 134, and 160 candidates are registered for 2007. These numbers indicate further evidence of increasing engagement by neuroradiologists in the MOC process.
The Executive Committee of the ASNR deserves credit for working diligently to help members understand MOC and meet the requirements. To this end, the ABR welcomes continued dialogue and partnership with the ASNR.
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