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BACKGROUND AND OBJECTIVES: In 2016, the American Board of Medical Specialties (ABMS) approved pediatric hospital medicine (PHM) as the newest pediatric subspecialty. To characterize development of the field, this article aims to: (1) describe the responsibilities and practice settings of US pediatricians self-identifying as hospitalists; and (2) determine how exclusive PHM practice, compared with PHM practice in combination with general or subspecialty care, was associated with professional development interests. METHODS: Pediatricians enrolling in the 2017-2018 American Board of Pediatrics (ABP) Maintenance of Certification program were offered a voluntary survey about their responsibilities, interests, and practice settings. Logistic regression was employed to characterize associations between exclusive PHM practice and: (1) interest in quality improvement (QI) leadership; (2) intention to take the PHM certifying exam; (3) satisfaction with allocation of professional time; and (4) intention to maintain more than one ABP certification. RESULTS: The survey response rate was 70.0%; 1662 (13.1%) self-reported PHM practice. Four-hundred ninety-one (29.5%) practiced PHM exclusively, 518 (31.1%) practiced PHM and general pediatrics, and 653 (39.3%) practiced PHM and one or more subspecialties. Respondents reporting exclusive PHM practice were significantly more likely to report interest in QI leadership or consultation (adjusted odds ratio [OR], 1.39; 95% CI, 1.09-1.79), PHM exam certification (adjusted OR, 7.10; 95% CI, 5.45-9.25), and maintenance of more than one ABP certification (adjusted OR, 2.64; 95% CI, 1.89-3.68). CONCLUSIONS: Hospitalists reported diverse clinical and nonclinical responsibilities. Those practicing PHM exclusively expressed high levels of interest in board certification and QI leadership. Ongoing monitoring of PHM responsibilities and practice settings will be important to support the professional development of the PHM workforce.

Objectives In the vast majority of Children's Hospitals, the critically ill patient can be found in one of three locations: the PICU, the neonatal ICU, and the cardiac ICU. Training, certification, and maintenance of certification for neonatology and critical care medicine are over seen by the Accreditation Council for Graduate Medical Education and American Board of Pediatrics. There is no standardization of training or oversight of certification and maintenance of certification for pediatric cardiac critical care. Data sources The curricula from the twenty 4th year pediatric cardiac critical care training programs were collated, along with the learning objectives from the Pediatric Cardiac Intensive Care Society published "Curriculum for Pediatric Cardiac Critical Care Medicine." Study selection This initiative is endorsed by the Pediatric Cardiac Intensive Care Society as a first step toward Accreditation Council for Graduate Medical Education oversight of training and American Board of Pediatrics oversight of maintenance of certification. Data extraction A taskforce was established of cardiac intensivists, including the directors of all 4th year pediatric cardiac critical care training programs. Data synthesis Using modified Delphi methodology, learning objectives, rotational requirements, and institutional requirements for providing training were developed. Conclusions In the current era of increasing specialized care in pediatric cardiac critical care, standardized training for pediatric cardiac critical care is paramount to optimizing outcomes.

Upon completion of this activity, participants will: In support of improving patient care, this activity has been planned and implemented by Medscape, LLC and Springer Nature. Medscape, LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. Medscape, LLC designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 1.0 MOC points in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit. 1.0 Expiration date: Release date: Post-test link: https://medscape.org/eye/posttest949866 Sobha Sivaprasad, MD, has disclosed the following relevant financial relationships: Served as an advisor or consultant for: Allergan, Inc.; Apellis Pharmaceuticals; Bayer AG; Boehringer Ingelheim Pharmaceuticals, Inc.; Heidelberg Pharma GmbH; Novartis Pharmaceuticals Corporation; Oculis; Optos; Oxurion NV; Roche. Served as a speaker or a member of a speakers bureau for: Allergan, Inc.; Bayer AG; Novartis Pharmaceuticals Corporation; Optos. Received grants for clinical research from: Allergan, Inc.; Bayer AG; Boehringer Ingelheim Pharmaceuticals, Inc.; Novartis Pharmaceuticals Corporation; Optos. Parya Abdolalizadeh, MD, MPH, disclosed has no relevant financial relationships. Samira Chaibakhsh, PhD, disclosed has no relevant financial relationships. Khalil Ghasemi Falavarjani, MD, disclosed has no relevant financial relationships. To assess the trend of paediatric visual impairment and its disparities by year, sex, age and national socioeconomic levels using disability-adjusted life years (DALYs). It is a retrospective analysis of data from the Global Burden of Disease (GBD) 2017. Global and national DALY numbers and rates of vision impairment in three paediatric age groups of 1–4 (preschool children), 5–9 (school children) and 10–14 years (teenagers) years were obtained from the GBD 2017 database. The socioeconomic indices for 195 countries were derived from international open databases. Main outcome measures were comparison of DALYs due to paediatric vision impairment in different age groups by socioeconomic indicators in 2017 and analysis of the trend from 1990. The global prevalence of distance and/or near vision impairment for 1–14 years was 2.8% (95% uncertainty interval (UI): 2.5–3.1) in 2017. The highest DALYs for distance and/or near vision impairment [number=589.93 thousands (95%UI: 367.71–933.29), rate = 92.72 (95%UI: 57.79–146.68)] were observed in teenagers. DALY rate of distance and/or near vision impairment was not associated with socioeconomic indicators, however, DALY rate of refractive disorders had positive correlation with national socioeconomic development. The global trends of DALY numbers in distance and/or near vision impairment as well as refractive and other causes remained stable from 1990 to 2015 (0.128 ≤ P ≤ 0.738), however, DALY rates had a statistically significant trend of reduction in all paediatric age groups (0.003 ≤ P ≤ 0.024). The global health burden of paediatric vision impairment decreased from 1990. Refractive, near vision impairment and other causes were associated with socioeconomic development.

BACKGROUND From 2005 to 2020, the American Board of Plastic Surgery collected data on 20 common plastic surgery operations as part of the Maintenance of Certification process. These data allow the authors to examine national trends in zygomatico-orbital fracture repair over a 15-year period. METHODS Tracer data for zygomatico-orbital fracture repair were reviewed in cohorts from 2005 to 2013 and 2014 to 2020. Results were categorized based on their presence in evidence-based medicine articles published during this period. Differences between years were assessed using the t test or chi-square test as appropriate. RESULTS Four hundred thirty patients were included as of March of 2020. Average age was 37 years (range, 6 to 85 years), and 76 percent were male. Operations took place on average 10 days from injury. There were significant decreases in the use of subciliary (31.9 percent versus 10.0 percent; p < 0.001), gingival buccal (84.3 percent versus 56.4 percent; p < 0.001), and lateral brow (45.2 percent versus 22.3 percent; p < 0.001) incisions, with an increase in lower lid external incisions (15.2 percent versus 30.9 percent; p < 0.001); 2.7 percent of patients had a complication requiring readmission and 4.5 percent required reoperation. The incidence of postoperative diplopia was 7.7 percent, and the infection rate was 1.7 percent. CONCLUSIONS This article reviews the American Board of Plastic Surgery tracer data for zygomatico-orbital fracture repair. The Maintenance of Certification tracer data provide a national database with longer follow-up and more specific information than comparable databases. Analysis of these data over time enables the authors to describe practice trends and gives surgeons the opportunity to compare their outcomes to national norms.

PURPOSE The Trial of Aggregate Data Exchange for Maintenance of Certification and Raising Quality was a randomized controlled trial which first had to test whether quality reporting could be a by-product of clinical care. We report on the initial descriptive study of the capacity for and quality of exchange of whole-panel, standardized quality measures from health systems. METHODS Family physicians were recruited from 4 health systems with mature quality measurement programs and agreed to submit standardized, physician-level quality measures for consenting physicians. Identified measure or transfer errors were captured and evaluated for root-cause problems. RESULTS The health systems varied considerably by patient demographics and payer mix. From the 4 systems, 256 family physicians elected to participate. Of 19 measures negotiated for use, 5 were used by all systems. There were more than 15 types of identified errors including breaks in data delivery, changes in measures, and nonsensical measure results. Only 1 system had no identified errors. CONCLUSIONS The secure transfer of standardized, physician-level quality measures from 4 health systems with mature measure processes proved difficult. There were many errors that required human intervention and manual repair, precluding full automation. This study reconfirms an important problem, namely, that despite widespread health information technology adoption and federal meaningful use policies, we remain far from goals to make clinical quality reporting a reliable by-product of care.

Objective Emergency department (ED) physicians frequently provide critical care (CC) but document inconsistently. Variability in documentation can result in underbilling and is inconsistent with financial stewardship. We used admissions to the intensive care unit (ICU) as a proxy for CC provision. At baseline, CC notes were correctly documented for 20% of eligible visits, with potential missed charges of $1.8 million per year.Our objective was to increase CC note placement for eligible patients from 20% to 60% over 2 years. Additionally, we measured CC notes and the number of ICU admissions per 1000 ED visits, and change in facility fees. Methods We performed this project at a midwestern quaternary children's hospital with 2 EDs (combined volume 120,000 visits/year). We surveyed the ED physicians to inform our interventions. We used maintenance of certification points and financial incentives for quality improvement work to obtain buy-in. We used serial interventions with plan-do-study-act cycles: (1) CC note simplification, (2) education, (3) follow-up surveys, (4) additional location for CC note, and (5) timely reminders. We reviewed sample charts and used χ2 test and control charts for analysis. Results Critical care note placement for ICU admissions increased from 20% to 60% in 8 months, and further to greater than 75%. The CC notes increased from 4 to 16 per 1000 ED visits. Intensive care unit admissions increased but remained appropriate. The billed facility fee for CC increased by 263%. Conclusions This project resulted in significant and sustained improvements in CC note completion. We believe providing education, simplifying the documentation process, automating reminders, and incentivizing optimal documentation were vital to success.

This study evaluated Women Physiatry Facebook group members' perceptions of the value of an online community. The authors hypothesized members would find the group protective against burnout, and early career participants would be more likely to utilize the group for education and networking. This was a cross-sectional survey study of women physicians in the field of physical medicine and rehabilitation (PM&R) primarily in the United States (U.S.). The survey consisted of 51 questions covering demographic information, work/life satisfaction, and physician burnout.There were 310 respondents. Those at an earlier career stage accessed the Women Physiatrists Facebook page significantly more often (p=0.038). Most respondents were neutral regarding the group reducing burnout. Across all career stages, the group was most often utilized as an educational tool to review patient cases (82.2%). Mid to late-career members were more likely to use the group to learn about maintenance of certification (MOC) or continuing medical education (CME) requirements (p=0.019) and searching for a physiatrist in another part of the county (p=0.016). This study suggests closed Facebook groups can be useful educational tools across career stages.

SUMMARY The American Society of Plastic Surgeons, the American Academy of Otolaryngology-Head and Neck Surgery, and the American Academy of Facial Plastic and Reconstructive Surgery commissioned the multidisciplinary Rhinoplasty Performance Measure Development Work Group to identify and draft quality measures for the care of patients undergoing both functional and aesthetic rhinoplasty. One outcome measure and three process measures were identified. The outcome looked at patient satisfaction with rhinoplasty procedures. The process measures look at motivations and expectations of the procedure, airway assessment, and nonnarcotic shared decision-making strategies for pain management. All measures in this report were approved by the American Society of Plastic Surgeons Quality and Performance Measures Work Group and Executive Committee, and the American Academy of Otolaryngology-Head and Neck Surgery Foundation, the American Academy of Facial Plastic and Reconstructive Surgery, The Rhinoplasty Society, and the American Association of Oral and Maxillofacial Surgeons. The Work Group recommends the use of these measures for quality initiatives, Continuing Medical Education, Maintenance of Certification, Qualified Clinical Data Registry reporting, and national quality reporting programs.

The American Board of Medical Specialties (ABMS) implemented the Maintenance of Certification Program as a way to provide a comprehensive approach to lifelong learning, self-assessment, and quality improvement for physicians in all specialties.[1][1] As demonstrated in a systematic review of 62

Phenomenon: Internal medicine physicians in the United States must pass the American Board of Internal Medicine Internal Medicine Maintenance of Certification (ABIM IM-MOC) examination as part of t...

American Boards of Medical Specialties have emphasized single point in time testing for summative assessment of cognitive expertise necessary for board certification. In 2016, the American Board of Anesthesiology introduced Maintenance of Certification in Anesthesiology (MOCA), a longitudinal assessment platform that provides diplomates formative feedback with continuous questions over time and adapts questions to areas of knowledge weaknesses over time. This paper describes the rationale, history, and early results of the American Board of Anesthesiology MOCA platform.

In the 50 years since the American Board of Family Medicine (ABFM) was established, the United States has gone from a shared perspective that high-quality care was being routinely delivered to becoming aware of the significant and pervasive problems with quality. Efforts to stimulate improved quality have included public reporting, pay for performance, and value-based purchasing. In addition, maintenance of certification, systematic reviews of research, practice guidelines, electronic health records, and quality improvement programs have offered support for different dimensions of quality. Despite these programs and infrastructure, there is little evidence that quality has improved systematically in the United States. There are areas in which quality is better but many other areas in which quality has remained the same or even worsened. The focus on financial incentives as a primary tool for motivating improvement may not be productive and there is little evidence from research that quality varies with payment or incentives. Quality is a systems issue and requires system solutions. The ABFM has had a long commitment to assessing quality and has an opportunity to lead the way in reimagining quality measurement and assessment.

Junior radiologists in nonacademic settings currently face multiple challenges, including clinical productivity, climbing the ladder to partnership, maintenance of certification, and administrative requirements. Mentorship of junior radiologists in nonacademic settings can ease their transition into nonacademic practice, foster comradery, increase radiologist retention, and support career growth. Strategies to implement and sustain effective mentorship in nonacademic radiology practice settings are described. SUMMARY: Strategies to implement and sustain mentorship in nonacademic radiology practice settings are described.

OBJECTIVE The aim of the study was to evaluate a longitudinal assessment program for physical medicine and rehabilitation (LA-PM&R) as a replacement for the American Board of Physical Medicine and Rehabilitation maintenance of certification examination. DESIGN In this quality improvement study, randomly selected American Board of Physical Medicine and Rehabilitation diplomates were invited to participate in the LA-PM&R. Participants' maintenance of certification scaled scores were compared with LA-PM&R nonparticipants. We examined the association between LA-PM&R scores and maintenance of certification scaled scores and performance on clone items placed on both examinations. RESULTS There were 2222 American Board of Physical Medicine and Rehabilitation diplomates eligible to take the maintenance of certification examination from February 2018 to February 2019. Invitations were sent to 1050 randomly selected diplomates, of whom 448 initially agreed. Three hundred eighteen individuals completed more than two quarters of LA-PM&R participation and took the maintenance of certification examination. Two hundred sixty-six diplomates took the maintenance of certification examination in the same period who did not participate in LA-PM&R. The LA-PM&R group scored higher on the maintenance of certification examination than the control group (P < 0.05). Performance on the two examinations were highly correlated, r = .50, P < 0.0001. On clone items, LA-PM&R participants had 74% correct on the LA-PM&R but 86% correct on the maintenance of certification examination (P < 0.01). CONCLUSIONS The LA-PM&R program leads to better learning and retention of information than the 10-yr maintenance of certification examination.

Background Physician health and wellness can be negatively impacted by burnout, which, in turn, can lead to medical errors and early retirement. Burnout issues can start in medical school and progress during residency, fellowship, and throughout a physician's career. Previous studies have reported burnout rates between 45% and 54% for US physicians in general. However, there is currently little data regarding health and wellness specifically in the field of allergy and immunology. Objective This workgroup report was developed to assess health and wellness in our specialty. Methods The American Academy of Allergy, Asthma, and Immunology (AAAAI) electronically distributed an anonymous questionnaire using the validated mini-Z survey to a random sample of 1035 fellows and members. In addition to the mini-Z items, the survey queried personal and professional demographic characteristics, and included open-ended wellness questions. Results A total of 138 fellows and members of the AAAAI completed the survey, yielding a 13% response rate. The burnout rate was 35%, which is lower than the national average among US physicians, and is overall encouraging. However, there is room for improvement. Limitations of the study include a small sample size as well as evolving definitions of burnout. Conclusions Our results identify specialty specific concerns and can be used to inform the development of tailored interventions to improve wellness and minimize burnout. However, future surveys with a larger sample size are needed to obtain a more robust data set on allergy and immunology specific wellness challenges.

Objective Recent estimates indicate that most pediatricians do not consistently meet the American Academy of Pediatrics developmental screening guidelines, contributing to the delay of vital evaluations and interventions for autism spectrum disorder (ASD). Our objective was to evaluate the utility of Maintenance of Certification (MOC) Quality Improvement (QI) training designed to improve developmental screening rates in underserved, rural primary care practices. Trainings on best screening practices were disseminated to primary care providers (PCPs) through Extension for Community Healthcare Outcomes (ECHO) Autism, a virtual learning network. Method Across 2 cohorts, 24 PCPs were enrolled in MOC Part 4 training modules delivered through the ECHO Autism QI Learning Network. Throughout the 12 months of enrollment, PCPs reported information on general and ASD-specific developmental screenings conducted at 18- and 24-month well-child visits. A 1-year follow-up was conducted to assess the maintenance of screening rates. Results Baseline rates for general and ASD-specific developmental screenings were 53.3% and 68.3%, respectively. By the end of the 12-month learning module, screening rates increased significantly for general development (88.6%) and ASD-specific screenings (99.0%). At the 1-year follow-up, the rate for general developmental screening was 96.7% and for ASD-specific screening was 97.1%. Conclusion Maintenance of Certification Part 4 training delivered through the ECHO Autism QI Learning Network was found to be incentivizing and highly effective in shaping and maintaining PCP developmental screening practices. Improved screening rates show promise in decreasing time to critical developmental evaluations, interventions, and resources. Our methodology is likely transferable to other ECHO communities and may facilitate expedient implementation of best practice standards in primary care.

Objectives To describe the practice analysis undertaken by a task force convened by the American Board of Pediatrics Pediatric Critical Care Medicine Sub-board to create a comprehensive document to guide learning and assessment within Pediatric Critical Care Medicine. Design An in-depth practice analysis with a mixed-methods design involving a descriptive review of practice, a modified Delphi process, and a survey. Setting Not applicable. Subjects Seventy-five Pediatric Critical Care Medicine program directors and 2,535 American Board of Pediatrics Pediatric Critical Care Medicine diplomates. Interventions A practice analysis document, which identifies the full breadth of knowledge and skill required for the practice of Pediatric Critical Care Medicine, was developed by a task force made up of seven pediatric intensivists and a psychometrician. The document was circulated to all 75 Pediatric Critical Care Medicine fellowship program directors for review and comment and their feedback informed modifications to the draft document. Concurrently, data from creation of the practice analysis draft document were also used to update the Pediatric Critical Care Medicine, was developed by a task force made up of seven pediatric intensivists and a psychometrician. The document was circulated to all 75 Pediatrics Pediatric Critical Care Medicine fellowship program directors for review and comment and their feedback informed modifications to the draft document. Concurrently, data from creation of the practice analysis draft document were also used to update the Pediatric Critical Care Medicine content outline, which was sent to all 2,535 American Board of Pediatrics Pediatric Critical Care Medicine diplomates for review during an open-comment period between January 2019 and February 2019, and diplomate feedback was used to make updates to both the content outline and the practice analysis document. Measurements and main results After review and comment by 25 Pediatric Critical Care Medicine program directors (33.3%) and 619 board-certified diplomates (24.4%), a comprehensive practice analysis document was created through a two-stage process. The final practice analysis includes 10 performance domains which parallel previously published Entrustable Professional Activities in Pediatric Critical Care Medicine. These performance domains are made up of between three and eight specific tasks, with each task including the critical knowledge and skills that are necessary for successful completion. The final practice analysis document was also used by the American Board of Pediatrics Pediatric Critical Care Medicine Sub-board to update the Pediatric Critical Care Medicine content outline. Conclusions A systematic approach to practice analysis, with stakeholder engagement, is essential for an accurate definition of Pediatric Critical Care Medicine practice in its totality. This collaborative process resulted in a dynamic document useful in guiding curriculum development for training programs, maintenance of certification, and lifetime professional development to enable safe and efficient patient care.

In the earlier part of the 20th century, the American Board of Internal Medicine (ABIM) was created as a physician-led, nonprofit, independent evaluation organization with the purpose of establishing uniform standards and helping the public obtain evidence-based care by qualified physicians. In 1936

OBJECTIVE. The objective of this study was to assess clinical practice characteristics of radiologists on the basis of American Board of Radiology (ABR) interventional radiology (IR) certification status. MATERIALS AND METHODS. Medicare-participating radiologists were linked with ABR diplomates using the ABR's public search engine. Radiologists with an interventional radiology/diagnostic radiology (IR/DR) certificate (offered since 2017) were deemed currently IR-certified (n = 2840), and those assigned a vascular and interventional radiology subspecialty certificate (now defunct by the ABR) were deemed previously IR-certified (n = 900). Physician characteristics were obtained from Centers for Medicare & Medicaid Services (CMS) data. RESULTS. Overall, the mean percentage work effort in IR was higher for radiologists currently IR-certified than it was for radiologists who were previously IR-certified (65.9% vs 30.6%). Although 41.2% of currently IR-certified diplomates had more than 90% IR work effort, 35.7% had 50% or less IR work effort. Radiologists with current IR certification versus those with previous IR certification were more likely to be in an academic practice (25.1% vs 8.4%), a larger practice (in a practice with ≥ 100 members, 41.2% vs 22.4%), and earlier career stages (≤ 20 years in practice, 46.5% vs 0.6%). Of the 10 services most commonly billed by currently versus previously IR-certified radiologists, two and zero, respectively, were invasive procedures. Of identified CMS-participating radiologists with more than 50% IR effort, 27.2% (727/2670) were neither previously nor currently IR-certified. CONCLUSION. Although radiologists maintaining IR certification have higher IR work effort than those whose IR certification has lapsed, they are heterogeneous with overall sizable noninvasive diagnostic imaging practices. Approximately one-quarter of radiologists with predominant IR practices have never obtained IR certification. Because current IR/DR maintenance of certification testing exclusively addresses IR practice, attention is warranted to ensure certification is relevant to all IR diplomates.

OBJECTIVE. Physicians across specialties have expressed concerns about Maintenance of Certification (MOC) programs of American Board of Medical Specialties member boards, calling for research about...

BackgroundIn many healthcare systems, physicians are accustomed to periodically participate in individual performance appraisals to guide their professional development. For the purpose of revalidation, or maintenance of certification, they need to demonstrate that they have engaged with the outcomes of these appraisals. The combination of taking ownership in professional development and meeting accountability requirements may cause undesirable interference of purposes. To support physicians in their professional development, new Dutch legislation requires that they discuss their performance data with a non-hierarchical (peer)coach and draft a personal development plan. In this study, we report on the design of this system for performance appraisal in a Dutch academic medical center.MethodsUsing a design-based research approach, a hospital-based research group had the lead in drafting and implementing a performance appraisal protocol, selecting a multisource feedback tool, co-developing and piloting a coaching approach, implementing a planning tool, recruiting peer coaches and facilitating their training and peer group debriefings.ResultsThe system consisted of a two-hour peer-to-peer conversation based on the principles of appreciative inquiry and solution-focused coaching. Sessions were rated as highly motivating, development-oriented, concrete and valuable. Peer coaches were considered suitable, although occasionally physicians preferred a professional coach because of their expertise. The system honored both accountability and professional development purposes. By integrating the performance appraisal system with an already existing internal performance system, physicians were enabled to openly and safely discuss their professional development with a peer, while also being supported by their superior in their self-defined developmental goals. Although the peer-to-peer conversation was mandatory and participation in the process was documented, it was up to the physician whether or not to share its results with others, including their superior.ConclusionsIn the context of mandatory revalidation, professional development can be supported when the appraisal process involves three characteristics: the appraisal process is appreciative and explores developmental opportunities; coaches are trustworthy and skilled; and the physician has control over the disclosure of the appraisal output. Although the peer-to-peer conversations were positively evaluated, the effects on physicians’ professional development have yet to be investigated in longitudinal research designs.

BACKGROUND Maintenance of Certification (MOC) is a controversial topic in medicine for many different reasons. Studies have suggested that there may be associations between fewer negative outcomes and participation in MOC. However, MOC still remains controversial because of its cost. We sought to determine the estimated cost of MOC to the average orthopaedic surgeon, including fees and time cost, defined as the market value of the physician's time. METHODS We calculated the total cost of MOC to be the sum of the fees required for applications, examinations, and other miscellaneous fees as well as the time cost to the physician and staff. Costs were calculated for the oral, written, and American Board of Orthopaedic Surgery Web-based Longitudinal Assessment (ABOS WLA) MOC pathways based on the responses of 33 orthopaedic surgeons to a survey sent to a state orthopaedic society. RESULTS We calculated the average orthopaedic surgeon's total cost in time and fees over the decade-long period to be $71,440.61 ($7,144.06 per year) for the oral examination MOC pathway and $80,391.55 ($8,039.16 per year) for the written examination pathway. We calculated the cost of the American Board of Orthopaedic Surgery web-based examination pathway to be $69,721.04 ($6,972.10 per year). CONCLUSIONS The actual cost of MOC is much higher than just the fees paid to organizations providing services. The majority of the cost comes in the form of time cost to the physician. The ABOS WLA was implemented to alleviate the anxiety of a high-stakes examination and to encourage efficient longitudinal learning. We found that the ABOS WLA pathway does save time and money when compared with the written examination pathway when review courses and study periods are taken. We believe that future policy changes should focus on decreasing physician time spent completing MOC requirements, and decreasing the cost of these requirements, while preserving the model of continued evidence-based medical education.

BACKGROUND Older patients are often prescribed potentially inappropriate medications (PIMs) given their age. We measured the association between a physician's general knowledge and their PIM prescribing. METHODS Using a 2013-2017 cross-sectional design, we related a general internist's knowledge (n = 8196) to their prescribing of PIMs to fee-for-service Medicare beneficiaries, age ≥ 66 years with part D coverage, which they saw in the outpatient setting the year after their exam (n = 875,132). Physician knowledge was based on the American Board of Internal Medicine's (ABIM) Internal Medicine Maintenance of Certification (IM-MOC) exam scores. Medications included 72 PIMs from the American Geriatric Society's Beers Criteria and appropriate alternatives to these medications. Logistic regressions controlled for physicians practice/training characteristics and patient-risk factors. RESULTS Annually, 11.0% of patients received a PIM and 57.2% received an appropriate alternative medication. Patients seen by physicians scoring in the top versus bottom quartile were 8.6% less likely (95% confidence interval [CI]: -12.7 to -4.5, p

Continuing medical education is an ongoing process to educate clinicians and provide patients with up-to-date, evidence-based care. Since its inception, the maintenance of certification (MOC) program has changed dramatically. This article reviews the development of MOC and its integration with the 6 core competencies, including the practice-based learning and improvement cycle. The concept of lifelong learning is discussed, with specific focus on different methods for surgeons to engage in learning, including simulation, coaching, and communities of practice. In addition, the future of MOC in continuous professional development is reviewed.

BACKGROUND Amid concerns about the pediatrician-scientist workforce, we hypothesized that declining numbers of pediatric subspecialists devote at least 25% of their professional time to research with fewer younger and female pediatricians engaged in research over the study period. METHODS Board-certified pediatricians enrolling online in the American Board of Pediatrics (ABP's) Maintenance of Certification (MOC) program October 2009 through 2016 were invited to complete a survey with questions about the allocation of their professional time. Responses from individuals in the 14 ABP-certified subspecialties were analyzed. The number and proportions of respondents devoting 25-49% and 50% or more of professional time to research were calculated over time. Age and gender were also examined. RESULTS We analyzed 21,367 responses over 8 years. A small number of pediatric subspecialists engaged in research with 5.2-6.7% devoting 25-49% and 5.6-8.4% at least 50% of their professional time to research across subspecialties. There was no discernable increase or decrease over time or pattern by age or gender. CONCLUSION Less than 10% of pediatric medical subspecialists devote at least 50% of their professional time to research. Efforts to promote research among pediatric subspecialists have not increased the size of the population that reports engaging in research at this level.

Background In January 2016, as part of the Maintenance of Certification in Anesthesiology (MOCA) program, the American Board of Anesthesiology launched MOCA Minute, a web-based longitudinal assessment, to supplant the former cognitive examination. We investigated the association between participation and performance in MOCA Minute and disciplinary actions against medical licenses of anesthesiologists. Methods All anesthesiologists with time-limited certificates (ie, certified in 2000 or after) who were required to register for MOCA Minute in 2016 were followed up through December 31, 2016. The incidence of postcertification prejudicial license actions was compared between those who did and did not register and compared between registrants who did and did not meet the MOCA Minute performance standard. Results The cumulative incidence of license actions was 1.2% (245/20,006) in anesthesiologists required to register for MOCA Minute. Nonregistration was associated with a higher incidence of license actions (hazard ratio, 2.93 [95% confidence interval {CI}, 2.15-4.00]). For the 18,534 (92.6%) who registered, later registration (after June 30, 2016) was associated with a higher incidence of license actions. In 2016, 16,308 (88.0%) anesthesiologists met the MOCA Minute performance standard. Of those not meeting the standard (n = 2226), most (n = 2093, 94.0%) failed because they did not complete the required 120 questions. Not meeting the standard was associated with a higher incidence of license actions (hazard ratio, 1.92 [95% CI, 1.36-2.72]). Conclusions Both timely participation and meeting performance standard in MOCA Minute are associated with a lower likelihood of being disciplined by a state medical board.

The American Thoracic Society Pediatric Core Curriculum updates clinicians annually in pediatric pulmonary disease in a 3 to 4 year recurring cycle of topics. The 2019 course was presented in May during the Annual International Conference. An American Board of Pediatrics Maintenance of Certification module and a continuing medical education exercise covering the contents of the Core Curriculum can be accessed online at www.thoracic.org.

Background Historically, individual doctors were responsible for maintaining their own professional competence. More recently, changing patient expectations, debate about the appropriateness of professional self-regulation, and high-profile cases of malpractice have led to a move towards formal regulation of professional competence (RPC). Such programmes require doctors to demonstrate that they are fit to practice, through a variety of means. Participation in RPC is now part of many doctors’ professional lives, yet it remains a highly contested area. Cost, limited evidence of impact, and lack of relevance to practice are amongst the criticisms cited. Doctors’ attitudes towards RPC, their beliefs about its objectives and effectiveness, and their experiences of trying to meet its requirements can impact engagement with the process. We aim to conduct a scoping review to map the empirical literature in this area, to summarise the key findings, and to identify gaps for future research. Methods We will conduct our review following the six phases outlined by Arksey and O’Malley, and Levac. We will search seven electronic databases: Academic Search Complete, Business Source Complete, CINAHL, PsycINFO, PubMed, Social Sciences Full Text, and SocINDEX for relevant publications, and the websites of medical regulatory and educational organisations for documents. We will undertake backward and forward citation tracking of selected studies and will consult with international experts regarding key publications. Two researchers will independently screen papers for inclusion and extract data using a piloted data extraction tool. Data will be collated to provide a descriptive summary of the literature. A thematic analysis of the key findings will be presented as a narrative summary of the literature. Discussion We believe that this review will be of value to those tasked with the design and implementation of RPC programmes, helping them to maximise doctors’ commitment and engagement, and to researchers, pointing to areas that would benefit from further enquiry. This research is timely; internationally existing programmes are evolving, new programmes are being initiated, and many jurisdictions do not yet have programmes in place. There is an opportunity for learning across different programmes and from the experiences of established programmes. Our review will support that learning. Systematic review registration PROSPERO does not register scoping reviews. Electronic supplementary material The online version of this article (10.1186/s13643-019-1132-3) contains supplementary material, which is available to authorized users.

BACKGROUND: For infants with neonatal abstinence syndrome (NAS) in children’s hospitals, treatment protocols emphasizing nonpharmacologic care have revealed improved hospital outcomes. We sought to improve NAS care within the community hospital setting through the implementation of an Eat, Sleep, Console (ESC) protocol. METHODS: Using a multidisciplinary quality improvement approach, we implemented an ESC protocol at 2 community hospitals. Primary outcomes were to decrease length of stay (LOS) by 20% and decrease scheduled morphine use to RESULTS: A total of 304 NAS patients were admitted from January 2017 to December 2018, with 155 during the postintervention period. After implementation, mean LOS decreased from 9.0 to 6.2 days, and morphine use decreased from 57% to 23%, both with special cause variation. There were 2 unplanned readmissions in the postintervention period compared with 1 preintervention and no transfers to higher level of care in either period. CONCLUSIONS: Implementation of a nonpharmacologic care protocol within 2 community hospitals led to significant and sustained improvement in LOS and morphine exposure without compromising safety. In this study, we illustrate that evidence-based practice can be successfully implemented and sustained within community hospitals treating infants with NAS.

Objectives Hematopathology (HP) is a rapidly changing field with insufficient data to provide guidance to program directors (PDs), the Accreditation Council for Graduate Medical Education, or the American Board of Pathology. Methods Two surveys were performed—one for HP PDs and one, given twice, for HP diplomates doing Maintenance of Certification/Continuing Certification reporting in 2017 to 2018. Results Bone marrow (BM), lymph node (LN), and flow cytometry interpretations and peripheral blood/fluid reviews are performed by more than 80% of hematopathologists and are the areas with the greatest amount of training. A smaller proportion of hematopathologists is involved in other HP-related activities. Most PDs believed fellows should perform BM procedures. Interpretation of 400 or more LNs and 500 BMs was PDs’ median expectations for fellows. PDs and HP diplomates considered coagulation and benign RBC disorders overemphasized on the certification examination. Conclusions These results highlight how varied the practice of HP is and can provide guidance to HP PDs, those responsible for assessing HP programs, and the American Board of Pathology.

BACKGROUND: A key component of Maintenance of Certification (MOC) for family and internal medicine physicians is the requirement to pass a periodic examination of medical knowledge. Little is known about the effects of preparing for MOC exams on knowledge and practice. OBJECTIVE: To understand how MOC exam preparation can affect knowledge and practice. DESIGN: Qualitative, semi-structured interviews, 45–60 min each, conducted by telephone at participants’ convenience. PARTICIPANTS: A total of 80 primary care physicians from the American Board of Family Medicine (ABFM) and the American Board of Internal Medicine (ABIM) who had recently taken an MOC exam; the sample purposefully selected to represent diversity of experiences with MOC exams and range of opinions about MOC, as well as diversity of participant backgrounds—gender, practice type, etc. APPROACH: Close analysis of physicians’ accounts of what they learned when preparing for an MOC exam and how this knowledge affected their practice. RESULTS: Sixty-seven of 80 physicians stated they gained knowledge relevant to their practice. Sixty-three gave concrete examples of how this affected their practice, including direct changes to patient care (e.g., improved diagnosis or prescribing and reduced unnecessary testing) or less direct changes (e.g., improved ability to co-manage with other providers or communicate with patients). Physicians also described sharing what they learned with others, including peers and trainees. LIMITATIONS: Interviews could have been affected by recall and/or social desirability bias, as well as researchers’ role as board staff. Although we followed a recruitment protocol designed to mitigate recruitment acceptance bias, our findings may not be generalizable to wider groups of physicians. CONCLUSIONS: Most physicians from two primary care specialties interviewed reported ways in which studying for an MOC exam resulted in acquiring knowledge that was both relevant and beneficial to their patient care. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-019-05118-z) contains supplementary material, which is available to authorized users.

In 2016, the American Board of Medical Specialties (ABMS) and the National Patient Safety Foundation issued a joint call encouraging each ABMS member board to integrate patient safety principles and activities into their initial and continuous certification processes. This article describes how the American Board of Obstetrics and Gynecology integrates various aspects of patient safety principles into its initial and continuous certification processes. The authors first describe how they assess patient safety within their initial certification processes. They then describe each component of their maintenance of certification program, and how they intentionally embed patient safety principles within each component.

OBJECTIVE There continues to be a debate about the value and purpose of maintenance of certification (MOC) programs in the US. The goal of this study is to assess the impact, value, and purpose of MOC programs in rheumatology. METHODS A survey was sent to 3,107 rheumatologists in the US. The survey addressed how rheumatologists perceive the value and impact of MOC programs on rheumatology practice and patient care. RESULTS A total of 515 rheumatologists completed this survey. The majority (74.8%) believed there was no significant value in MOC, beyond what is already achieved from continuing medical education. Most rheumatologists did not believe MOC was valuable in improving patient care (63.5%), and the majority felt that the primary reason for creating MOC was either the financial well-being of board-certifying organizations (43.4%) or to satisfy administrative requirements in health systems (30%). Although 65.6% perceived that staying current with new medical knowledge was a positive impact of MOC programs, the MOC was perceived to result in time away from providing patient care (74.6%) and time away from family (74%). When asked about potential effects of requiring MOC, 77.7% reported physician burnout, 67.4% early physician retirement, and 63.9% anticipated an effect on reducing the overall number of practicing rheumatologists. CONCLUSION The majority of rheumatologists do not believe there is significant value for MOC programs. There is evidence for lack of trust in board-certifying organizations, and rheumatologists believe MOC programs contribute to physician burnout, early retirement, and loss in the rheumatology workforce.

[Figure][1] ![Figure][1] ![Figure][1] ![Figure][1] American Board of Internal Medicine (ABIM) maintenance of certification (MOC) continues to be a subject of interest, generating multiple questions from cardiologists of all subspecialties. MOC changes announced in

Physician credentialing processes aim to improve patient safety and quality, but little research has examined their direct relationship with surgical outcomes. Using national Medicare claims for 2009 to 2013, the authors studied the association between board certification and completion of Maintenance of Certification (MOC) requirements and surgeon rates of complications for 8 elective procedures. Exemplar surgeons were defined as those in the lowest decile of complication rates, and outlier surgeons were those in the highest decile. The analysis included 1.9 million procedures performed by 14 598 surgeons (64% orthopedics, 17% general surgery, 11% urology, 7% neurosurgery). Board-certified surgeons were less likely to be outliers (odds ratio 0.79 [0.66-0.94]). However, completion of MOC was not associated with differences in complication rates in orthopedic surgery or urology. Incorporating additional assessment methods into MOC, such as video evaluation of technical skills, retraining on state-of-the-art care, and peer review, may facilitate further improvements in surgical quality.

Introduction: Maintenance of Certification (MOC) was implemented to help physicians remain current with evolving medical standards, but has been criticized for being irrelevant to practice. We assessed family physicians9 (FPs9) opinions about the content of American Board of Family Medicine (ABFM) self-assessment modules (SAMs). Methods: We used ABFM administrative data from feedback surveys completed after each of the 16 SAMs from 2006 to 2016. FPs rated agreement with 2 statements—1) “Content is appropriate for my practice,” and 2) “Content was presented at an appropriate level”—on a scale of 1 (strongly disagree) to 6 (strongly agree). We calculated mean ratings of each statement by year and stratified by Knowledge Assessment (KA) and Clinical Simulation (CS) portions of the SAM. We plotted mean ratings by FPs9 age at their first SAM completion and the total number of SAMs completed. Results: SAMs were completed (n = 633,198) from 2006 to 2016 with 448,408 (71%) feedback surveys completed. The annual mean ratings of both statements varied little (less than 0.5) and were above 4.5 for all SAMs. CS ratings were consistently lower than KA ratings. FPs of all ages at first SAM provided similar ratings and agreement with content appropriateness increased with repeated exposure to SAMs. Conclusion: Over 11 years, the content of ABFM SAMs was regarded by FPs as appropriate for practice and presented at an appropriate level. Continued monitoring of feedback is necessary to keep the content of MOC programs relevant for physicians9 practice.

Starting in 2022, the American Board of Pediatrics will launch the Maintenance of Certification Assessment for Pediatrics: Pediatric Emergency Medicine (MOCA-Peds: PEM) longitudinal assessment, which will provide an at-home alternative to the point-in-time examination. This longitudinal assessment will help engage PEM physicians participating in continuing certification in a more flexible and continuous lifelong, self-directed learning process while still providing a summative assessment of their knowledge. This commentary provides background information on MOCA-Peds and an introduction to MOCA-Peds: PEM and how it gives the PEM physician another option to participate in continuing certification.

Upon completion of this activity, participants will: In support of improving patient care, this activity has been planned and implemented by Medscape, LLC and Springer Nature. Medscape, LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. Medscape, LLC designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 1.0 MOC points in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) programme. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit. All other clinicians completing this activity will be issued a certificate of participation. To participate in this journal CME activity: (1) review the learning objectives and author disclosures; (2) study the education content; (3) take the post-test with a 75% minimum passing score and complete the evaluation at www.medscape.org/journal/eye ; (4) view/print certificate. 1.0 Release date: Expiration date: Post-test link: https://medscape.org/eye/posttest943521 SS has disclosed the following relevant financial relationships: Served as an advisor or consultant for: Allergan, Inc.; Apellis; Bayer AG; Boehringer Ingelheim Pharmaceuticals, Inc.; Heidelberg Pharma GmbH; Novartis; Oculis; Optos; Oxurion; Roche; Served as a speaker or a member of a speakers bureau for: Allergan, Inc.; Bayer AG; Novartis Pharmaceuticals Corporation; Optos; Received grants for clinical research from: Allergan, Inc.; Bayer AG; Boehringer Ingelheim Pharmaceuticals, Inc.; Novartis Pharmaceuticals Corporation; Optos. RS, LC, WW, YD, YZL, HZ. RL have disclosed no relevant financial relationships. Laurie Barclay has disclosed no relevant financial relationships. Retinal neurodegeneration is an early pathological change in diabetic retinopathy (DR). Early-stage retinal neurodegeneration is usually asymptomatic. This study aims to identify circulating microRNAs (miRNAs) as sensitive biomarkers for early retinal neurodegeneration. We profiled the plasma miRNA expression in three mild nonproliferative diabetic retinopathy (NPDR) cases and three matched non-DR patients using RNA sequencing. The differential miRNAs were validated with qRT-PCR. The retinal nerve fibre layer (RNFL) thickness of the eyes was measured using spectral-domain Optical coherence tomography (SD-OCT). The association between differential miRNAs and RNFL thickness was analysed using the Pearson correlation analysis. Bioinformatics tools were used to predict potential targets of miRNA associated with RNFL thickness and investigate the functions of the potential target genes. RNA sequencing identified 69 differential miRNAs and eight of them were reported to be associated with DR. The qRT-PCR for these eight miRNAs validated the down-regulation of circulating miR-26a-5p and miR-126-5p in a larger validating cohort. A positive correlation between plasma miR-26a-5p level and the RNFL thickness of the superior quadrant of both eyes was identified in another cohort, including 33 mild NPDR cases, 33 matched non-DR patients and 20 healthy controls. Furthermore, 367 candidate targets of miR-26a-5p were predicted. The functional studies revealed that these target genes are profoundly involved in various cellular functions and signalling pathways. Circulating miR-26a-5p is a potential biomarker for early-stage retinal neurodegeneration and it may be involved in the development of DR via profoundly influencing the functions of retinal cells.

A gaping void of adequate lifestyle medicine (LM) training exists across the medical education continuum. The American College of Lifestyle Medicine’s (ACLM’s) undergraduate medical education (UME) Task Force champions the need for widespread integration of LM curriculum in UME by sharing ideas for catalyzing success, lessons learned, and publishing standards and competencies to facilitate curriculum reform. When it comes to graduate medical education and fellowship, the ACLM and American Board of Lifestyle Medicine have made great strides in filling the void, developing both Educational and Experiential Pathways through which physicians may become certified LM Physicians or LM Specialists (LMSs). The Lifestyle Medicine Residency Curriculum meets the Educational Pathway requirements and prepares resident graduates for the LM Physician board certification. LMS is the second tier of LM certification that demonstrates expertise in disease reversal. The LMS Fellowship is an Educational Pathway intent on American Board of Medical Specialties recognition of LM as a new subspecialty in the near future. Finally, continuing medical education and maintenance of certification equip physicians with LM training to support knowledge, application, and certification in LM.

ObjectiveDiagnostic error is a key healthcare concern and can result in substantial morbidity and mortality. Yet no study has investigated the relationship between adverse outcomes resulting from diagnostic errors and one potentially large contributor to these errors: deficiencies in diagnostic knowledge. Our objective was to measure that associations between diagnostic knowledge and adverse outcomes after visits to primary care physicians that were at risk for diagnostic errors.Setting/participants1410 US general internists who recently took their American Board of Internal Medicine Maintenance of Certification (ABIM-IM-MOC) exam treating 42 407 Medicare beneficiaries who experienced 48 632 ‘index’ outpatient visits for new problems at risk for diagnostic error because the presenting problem (eg, dizziness) was related to prespecified diagnostic error sensitive conditions (eg, stroke).Outcome measures90-day risk of all-cause death, and, for outcome conditions related to the index visits diagnosis, emergency department (ED) visits and hospitalisations.DesignUsing retrospective cohort study design, we related physician performance on ABIM-IM-MOC diagnostic exam questions to patient outcomes during the 90-day period following an index visit at risk for diagnostic error after controlling for practice characteristics, patient sociodemographic and baseline clinical characteristics.ResultsRates of 90-day adverse outcomes per 1000 index visits were 7 for death, 11 for hospitalisations and 14 for ED visits. Being seen by a physician in the top versus bottom third of diagnostic knowledge during an index visit for a new problem at risk for diagnostic error was associated with 2.9 fewer all-cause deaths (95% CI −5.0 to −0.7, p=0.008), 4.1 fewer hospitalisations (95% CI −6.9 to −1.2, p=0.006) and 4.9 fewer ED visits (95% CI −8.1% to −1.6%, p=0.003) per 1000 visits.ConclusionHigher diagnostic knowledge was associated with lower risk of adverse outcomes after visits for problems at heightened risk for diagnostic error.

Objective To evaluate the effectiveness of a multilevel intervention using national partnerships on human papillomavirus (HPV) vaccination rates. Methods The American Cancer Society's Vaccinate Adolescents against Cancer program is a multilevel intervention focusing on systems and providers. The 2017 cohort introduced national partnerships to deliver intervention elements and Maintenance of Certification and continuing medical education credits for physicians. Eleven federally qualified health center (FQHC) systems completed interventions in 2017. Interventions included provider training and ≥1 other evidence-based systems improvement. We compared adolescent vaccination rates in the preintervention period (2016) and intervention period (2017) among adolescents who turned 13 during the calendar year. Intervention effectiveness was assessed using repeated measures paired t tests and Cohen's d effect size for vaccination rate change. Results All FQHC systems implemented provider training plus an average of 2.3 additional systems improvements. Series initiation increased by an average of 23.6 percentage points (47.2%–70.8%). HPV completion rates increased by an average of 22.7 percentage points (24.6%–46.3%). Meningococcal and Tdap vaccination rates increased by 23.3 and 25.9 percentage points respectively (47.9%–71.2% and 48.8%–74.7%). All changes were statistically significant (all P Conclusions Multilevel interventions focusing on provider training and systems changes can substantially improve on-time adolescent vaccination coverage and can be successfully performed using national partnerships and a train-the-trainer model.

From the time of initial incorporation of the of the American Board of Medical Specialties (ABMS) in 1933, through the early 1990s, diplomates of 23 of its 24 member boards understood that their initial certification awards extended throughout the continuum of their careers. From the time of its founding in 1969, only the American Board of Family Medicine required continuous certification. As early as the post–World War II era, the appropriateness of this “once and done” certification process was questioned by medical educators, and more recently by legislators, regulators, and the public. To meet the demands of rapidly changing scientific and clinical advances, and to maintain the values accrued by hard-fought self-regulation, the ABMS and its member boards agreed to implement programs that required continuous elements of professionalism, attainment, and assessment of current medical skills and knowledge and elements of practice improvement, throughout the career of each certified physician. Each of the medical specialty boards was provided some flexibility to determine specifics of their program within the general framework of the ABMS core competencies and four defined maintenance of certification (MOC) foundational parts. Herein, we describe the programs in general and more specifically, as they relate to the field of radiation oncology.

Credentialing and privileging are fundamental mechanisms employed by healthcare facilities to ensure that only qualified, competent healthcare professionals are granted access to patients and authorized to practice medicine. This chapter outlines best practices for credentialing, privileging, and ensuring maintenance of certification for APPs performing invasive procedures. Additionally, processes for evaluating initial competency and ensuring ongoing competency for invasive procedures are discussed.

SUMMARY The current status of the plastic surgeon in the medical liability spectrum and ways to avoid litigation are explored by using pooled national data from the Medical Professional Liability Association, private information from Applied Medico-Legal Solutions RRG, and a detailed literature search. The medical liability system in the United States costs $55.6 billion, or 2.4 percent of total health care spending. Plastic surgery accounts for 3.31 percent of reported claims and 3.16 percent of paid claims. Total payments for plastic surgeons represent 1.75 percent of the total paid for all specialties. Malpractice awards are relatively light for plastic surgeons. Nevertheless, they still have a 15 percent chance per year of being sued. However, 93 percent of cases will close with a dismissal or a settlement, and only 7 percent will go to trial. Of these, the plastic surgeon will prevail in 79 percent. Most importantly, 75 percent of all cases will result in no payment. To minimize the chances of a lawsuit, plastic surgeons should maintain excellent communication with their patients and participate in shared decision-making. They should take a leadership role and buy in to the performance of perioperative checklists, embrace patient education, and actively participate in Maintenance of Certification. They should be transparent in their dealings with patients by preoperatively declaring their policies on revisions, refunds, complications, and payments. Plastic surgeons must maintain complete and accurate medical records and participate in hospital-based programs of prophylaxis. They should be aware that postoperative infection is the single costliest adverse outcome and proactively deal with it.

The creation of pain as the fifth vital sign in 2001 led to an unforeseen and dramatic increase in postoperative narcotic use. It became clear that chronic opioid use was associated with overdoses and deaths, and state medical licensing boards began to require completion of narcotic Continuing Medical Education courses to maintain licensure. Despite the overwhelming evidence of adverse effects of narcotic usage in both the pre- and postoperative periods, this continues to be a persistent problem in all areas of orthopaedic surgery. The magnitude of the problem is significant and now opioid-specific training is a mandated component of the American Board of Orthopaedic Surgery Maintenance of Certification for their Web-based Longitudinal Assessment of continuing medical education. Large database studies are helpful in identifying trends and factors that influence outcomes, potentially cut cost of care, and hopefully help us find a way out of this ongoing dilemma. This dilemma has taken a long time to create and will require a concerted disciplined effort to eliminate.

Objective: To evaluate evolving practice patterns in secondary cleft rhinoplasty. Design: Retrospective review of data submitted during Maintenance of Certification (MOC). Setting: Evaluation of MOC data from the American Board of Plastic Surgery. Participants: Tracer data for secondary cleft rhinoplasty were reviewed from August 2006 through March 2020, and the data subdivided from 20062012 and 20132020 to evaluate changes in practice patterns. Interventions: Practice patterns in tracer data were compared to those from evidence-based medicine (EBM) literature over this time period. Main Outcome Measures: Practice patterns were compared to EBM trends during the study period. Results: A total of 90 cases of secondary cleft rhinoplasty were identified. The average age at operation was 13 years (range 4-77). Cumulative data demonstrated 61% to present with nasal airway obstruction and 21% to have undergone primary nasal correction at the time of cleft lip repair; 72% of patients experienced no complications, with the most common complications being asymmetry (10%) and vertical asymmetry of alar dome position (6%). Cartilage graft was used in 68% of cases, with 32% employing septal cartilage. Change in practice patterns between 2006 to 2012 and 2013 to 2020 demonstrated increase in dorsal nasal surgery (26% vs 43%, P = .034), use of osteotomies (14% vs 38%, P = .010), septal resection and/or straightening (26% vs 48%, P = .034), and turbinate reduction (8% vs 30%, P = .007). Conclusions: These tracer data provide long-term data by which to evaluate evolving practice patterns for secondary cleft rhinoplasty. When evaluated relative to EBM literature, future research to further improve outcomes can be better directed.

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.