ABA Update

he year 2007 was an active one for the American Board of Anesthesiology (ABA). I am pleased to provide an update report to ASA members regarding some of the salient progress points.

MOCA Ongoing Development: ABA is completing the decade-long rollout of the Maintenance of Certification in Anesthesiology (MOCA) program, which began in 2000 with the issuance of time-limited certification, consistent with the mandate from the American Board of Medical Specialties (ABMS) to all of its member boards. The MOCA program has matured to the extent that all ABA diplomates are automatically enrolled or re-enrolled in MOCA immediately upon one of three milestones, which are: becoming certified, becoming recertified (for pre-2000 diplomates with non-time-limited certificates, which is sun-setting in 2009) or upon completing a prior MOCA cycle, either expedited MOCA (one time only for those needing to demonstrate up-to-date certification status) or the normal 10-year MOCA cycle.

The four components of MOCA are now fully defined.

1. Professional Standing Assessment (PS) is conducted by the state medical boards by virtue of their review of physicians’ competency and any actions taken against a physician, as part of the state medical boards’ processes to grant or renew state medical licenses. Satisfactory PS consists of holding at least one active, unrestricted medical license, with any and all other medical licenses similarly being unrestricted.

2. Lifelong Learning and Self-Assessment (LL-SA) is reported to the personal ABA Web site portal of each MOCA participant, either by the MOCA participant him/herself or directly from qualified providers of ACCME-approved continuing medical education (CME) activities. The benefit of an ACCME-approved CME provider directly reporting is that those directly reported LL-SA credits are exempted from periodic ABA audits. Self-reported LL-SA credits are subject to periodic sample audits in which the MOCA participant must supply documentation of participation in the audited LL-SA activity. ASA already has a relationship with ABA for LL-SA reporting, so CME activities completed through ASA will not be audited by ABA.

As a result of this added value to their CME attendees directly reporting LL-SA participation to the ABA (thus avoiding LL-SA audit by ABA), increasing numbers of anesthesiology CME provider organizations are collecting their CME attendees’ ABA I.D. numbers and are developing the requisite relationship with ABA. ASA members can encourage other anesthesiology CME provider organizations to contact the ABA office so they can similarly directly report LL-SA credits for their CME attendees.

3. Cognitive Expertise (CE) assessment is conducted by a secure examination, which may be taken between the seventh and 10th year of the 10-year MOCA cycle. The examination is conducted twice yearly, in January and August, in commercial computer-testing venues across the country. After 2009, the CE examination will no longer be simultaneously offered for recertification of pre-2000 diplomates. The final date for pre-2000 diplomates to register for the August 2009 recertification CE examination is December 31, 2008. The supporting documents deadline for the August 2009 CE examination is March 31, 2009.

4. The Practice Performance Assessment and Improvement (PPAI) requirement, which will replace the current letter-of-reference forms, has been finalized for submission for approval to ABMS, to be phased in starting January 1, 2008. MOCA PPAI will then consist of three activities: 1) case evaluations, 2) patient safety modules and 3) simulation education. The first nine years of a 10-year MOCA cycle will be divided into three 3-year segments. MOCA participants must complete at least one of the three activities in each of the segments of their MOCA cycle. Each type of activity must be completed at least once in the 10-year MOCA cycle.

Each year, ABA will audit a sample of the case evaluations submitted by MOCA participants. The patient safety requirement will be met by a MOCA participant completing 20 hours of ABMS patient safety modules or 20 hours of ASA patient safety modules. ASA has already established a safety module editorial board that has begun the work of developing the ASA safety modules. Similarly, the ASA Committee on Simulation Education has begun accepting applications for ASA approval of simulation education centers. After approval by the ASA simulation committee, those centers can begin to offer simulation education that will be eligible to meet the ABA MOCA PPAI requirement.

New Residency Training Paradigms: The Residency Review Committee (RRC) for Anesthesiology of the ACGME has approved revised training requirements for anesthesiology residency programs effective July 2008, which will: 1) require more specific content for the clinical base year, 2) incorporate more months of training in perioperative medicine and 3) provide more flexibility regarding when research training can take place within a residency.

ABA has responded by reviewing innovative program proposals, on a case-by-case basis, from programs that wish to commit up front at the time of application for residency to train individuals in voluntary five-year schedules that include a clinical base year, a three-year residency, and a fifth year of either an ACGME-accredited fellowship or a fifth year of research. The additional year of research can be flexibly carried out across the CA-1-3 years, provided the requirement for at least six months of satisfactory clinical anesthesiology training has taken place prior to research. However, ABA limits fellowship-level (i.e., consultant-level) training to the CA-3 and CA-4 (PGY-4 and -5 years). The number of fellowship-creditable months in the CA-3 year is limited to no more than three months, with the balance of the fellowship months in the CA-4 year, in order for the individual to be permitted to enter the ABA’s examination systems. All other requirements for residency and fellowship established by the RRC/ACGME and ABA must be met.

Independent Practice Requirement: To clarify confusion regarding when a candidate in any of the ABA certification programs has met all of the requirements to be granted certification status, ABA has inserted more specific wording in all of the applicable sections of its 2008 Booklet of Information (www.theABA.org). The confusion arose because of the misunderstanding that the “passing” of an examination or examinations automatically results in certification. However, the examination is only one of the several requirements for certification, all of which are enumerated and repeated in sections 2.01, 2.04, 3.02, 3.05, 4.02 and 4.03 of the 2008 ABA Booklet of Information.

For this clarification, the following wording is now included in the 2008 ABA Booklet of Information: “At the time of certification by the ABA, the candidate must be capable of performing independently the entire scope of anesthesiology [or subspecialty] practice without accommodation or with reasonable accommodation. Although admission into the ABA examination system and success with the examinations are important steps in the ABA certification process, they do not by themselves guarantee certification. The ABA reserves the right to make the final determination of whether each candidate meets all of the requirements for certification after successful completion of the examinations for certification.” The term “accommodation” in the 2008 ABA Booklet of Information is used in the sense applicable in the Americans with Disabilities Act.

Irregular Examination Behavior: Because the public, patients, colleagues and medical institutions rely upon ABA certification as one indicator, among many, of professional competence, further clarifying language about ABA policy on the issue of irregular examination behavior has been inserted into Section 2.12 of the 2008 ABA Booklet of Information.

Irregular examination behavior is “conduct which may jeopardize the integrity or validity of any ABA examination process or result, including but not limited to copying or reproducing any element of an examination for personal use or the use of a third-party without the explicit and specific written consent of the ABA.” As distinct from copying, reproducing includes, but is not limited to, any electronic means, film or digital photography or reproducing from memory.

ABA considers irregular examination behavior to be a demonstration of unsatisfactory professionalism. For the In-Training Examination, such behavior will not only result in that In-Training Examination being voided, but ABA will require an unsatisfactory rating for that six-month clinical competency report and will not permit the violator to enter the ABA certification examination system for two years beyond when he/she would normally have been able to sit for the part one ABA examination. Similarly, for irregular examination behavior on an ABA examination, that examination will be voided and the candidate will not be permitted to re-apply for the ABA examination system for at least two years. At its discretion, ABA may impose more severe actions or require such an individual to wait even longer than two years to re-apply for an examination.

Alternate Entry Pathway: ABA recently introduced a seven-year pilot program of an “Alternate Entry Pathway” for the purpose of facilitating an increase in the number of basic scientist physicians or qualified clinical research physician faculty as members of anesthesiology academic departments in the United States. International medical graduates with research programs already certified by the national anesthesiology certifying organization in the country where they trained, and who were eligible to practice anesthesiology in the United States, could be eligible by this pathway to enter the ABA examination system for initial certification in anesthesiology after four years of contributions to an academic institution in the United States. The wording of section 5.08 of the 2008 ABA Booklet of Information has been strengthened to emphasize the research purpose of this pilot program and the requisite research qualifications for intended applicants.

ASA — Partner With ABA: ABA continues to work enthusiastically with ASA, through our Joint Council for the Continuous Professional Development of Anesthesiologists, which has helped to develop the MOCA requirements, as well as through the Joint ASA-ABA Council on In-Training Examinations, the ASA Patient Safety Editorial Board and the ASA Committee on Simulation Education. All of these efforts contribute to maintaining the public trust in a high degree of accomplishment of ABA-certified anesthesiologists.

Patricia A. Kapur, M.D., is Professor and Ronald L. Katz, M.D., Chair, Department of Anesthesiology, David Geffen School of Medicine at the University of California-Los Angeles.