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The future of the American Board of Internal Medicine Maintenance of Certification (MOC) program is at a crossroads. The current MOC program lacks a clear visible mission, adds to modern health care’s onerous bureaucracy, and thus pulls physicians from the most important humanistic aspects of their profession. The aim of the MOC program should be to promote the best patient care by ensuring certified physicians maintain core skills through continuous education and evaluation. The program should focus on education and be designed with the rigorous obligations of practicing physicians in mind. Moving forward, the American Board of Internal Medicine should cocreate MOC with the physician community and apply innovative adult education techniques. Over time, data-driven methods and member feedback should be used to provide continuous program improvement. This review describes the origins of the current state of MOC, explores its evidence base, provides examples of model programs for the maintenance of complex professional skills, and outlines guiding principles for the future of MOC.

Introduction: The ambulatory continuous ECG monitors can provide a comprehensive cardiac assessment in outpatient settings. Extended cardiac monitoring is often needed by physicians to assess the efficacy of treatment, evaluate symptoms, and to stratify patients at risk. In this study, we compare the impact of outpatient cardiac monitoring between 1-14 days and 15-30 days. Method: A retrospective analysis was done on ECG data collected from 2,679 patients using Zywie ECG monitors (Zywie, Inc., Georgia). These patients were monitored for 14-30 days. We evaluated three arrhythmias in this study: i) Atrial fibrillation (AF) of duration >15s ii) Ventricular tachycardia (VT) consisting of more than 3 heartbeats iii) Pause of duration >3s. We analyzed the first occurrence of arrhythmia episodes in every patient during their monitoring period. We identified at least one episode of AF in 486 patients, VT in 106 patients, and pause in 78 patients. Results: The incidence of the first episode of AF, VT, and pause was observed after 14 days of monitoring in 15.8%, 28.3%, and 23.1% patients, respectively (Figure 1). Furthermore, among the VT episodes, 85.3% episodes had a duration between 1-10s and 14.7% with a duration >10s. Similarly, 76% of identified pauses had a duration between 3-4s, 12% between 4-5s, and 12% with a duration >5s. Conclusion: The results demonstrate the incremental diagnostic yield of critical arrhythmic events when the monitoring is extended beyond 14 days. This study suggests that long-term outpatient monitoring can provide better diagnosis, especially for patients at a higher risk of developing critical arrhythmias.

Background— Complex fractionated atrial electrograms (CFAE) are morphologically more uniform in persistent longstanding as compared with paroxysmal atrial fibrillation (AF). It was hypothesized that this may result from a greater degree of repetitiveness in CFAE patterns at disparate left atrial (LA) sites in longstanding AF. Methods and Results— CFAEs were obtained from recording sites outside the 4 pulmonary vein (PV) ostia and at a posterior and an anterior LA site during paroxysmal and longstanding persistent AF (10 patients each, 120 sequences total). To quantify repetitiveness in CFAE, the dominant frequency was measured from ensemble spectra using 8.4-second sequences, and repetitiveness was calculated by 2 novel techniques: linear prediction and Fourier reconstruction methods. Lower prediction and reconstruction errors were considered indicative of increasing repetitiveness and decreasing randomness. In patients with paroxysmal AF, CFAE pattern repetitiveness was significantly lower (randomness higher) at antral sites outside PV ostia as compared with LA free wall sites ( P P Conclusions— In paroxysmal AF, CFAE repetitiveness is low and randomness high outside the PVs, particularly the left superior PV. As evolution to persistent longstanding AF occurs, CFAE repetitiveness becomes more uniformly distributed at disparate sites, possibly signifying an increasing number of drivers from remote PVs.