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  • CME/MOC for the Transplant Surgeon – New ABS Requirements for MOC and How to Obtain MOC Credits in Transplantation

    Dr. Matthew LevineMatthew Levine, MD, PhD
    Assistant Professor, Perelman School of Medicine, University of Pennsylvania
    Chair, ASTS CME Committee

    The American Board of Surgery (ABS) has specific criteria for a 10-year cycle of maintenance of certification (MOC) for board certified general surgeons. This 10-year cycle until recently involved three-year cycles of MOC, which repeat three times and then are followed by a recertification exam every 10 years. The ABS MOC program consists of four parts: 1) Professional Standing (licensure and hospital privileges), 2) Lifelong Learning and Self Assessment, which will be the subject of this narrative, 3) Cognitive Expertise (the recertification examination), and 4) Evaluating Performance in Practice (involving participation in local, regional, or national outcomes registries (for which UNOS and SRTR qualify). The major effort involved in this, aside from the recertifying examination, is the MOC requirement. Strategies to gain MOC credits for the ABS within the realm of transplantation will be discussed below.

    In early July 2017, the ABS officially altered the requirements for MOC. These changes will significantly relax the requirements for self-assessment MOC and due to the recent nature of these changes, they will be summarized in detail here.

    For the past decade, Part 2 ABS MOC involved three-year cycles of MOC requiring 90 hours of CME credits, of which 60 involve self-assessment with testing that require 75% correct in order to obtain credit. This amounted to a requirement for 20 hours of annual self-assessment credits to be obtained with tabulation and submission every three years.

    The new Part 2 ABS MOC requirements have reduced this requirement by half. Cycles of submission of MOC credits will be lengthened from three to five years. Therefore, only two such cycles will be required for each 10-year period of exam-based recertification as opposed to three such cycles previously. With each new five-year submission period, 150 CME credits will be required, of which only 50 must include self-assessment. This amounts to a requirement of 10 self-assessment hours per year over the longer 5-year cycle. There will be a requirement for an additional 20 hours of non-self-assessment CME per year. These credits are generally easier to obtain and are satisfied by attendance at Grand Rounds/M&M meetings in most institutions as well as by attendance at conferences that do not grant self-assessment credits. These changes in ABS guidelines are new and may have caveats yet to be determined or disseminated. Information regarding these changes can be monitored at the ABS website.

    MOC must be completed by December 31 of the fifth year of each cycle. Diplomates must provide proof of completion to the ABS via a brief online form and submissions are subject to audit.

    Over the past several years there has been a significant effort by the ASTS via the CME Committee to produce current CME/MOC materials with transplant content so that transplant professionals can maintain certification by studying within their field of practice. Under CME Committee leadership preceding mine, a number of steps were taken to create CME/MOC content within the ASTS Academic Universe. This has continued, and there are currently approximately 30 hours of modules on the ASTS Academic Universe site that will renew over time. These modules cover different topics in transplantation and were largely created by CME Committee members from recent American Journal of Transplantation (AJT) published manuscripts. These modules do have a nominal per-module fee attached for access by ASTS members and nonmembers.

    A second source of MOC credits comes from the AJT directly in the form of a monthly Images in Transplantation feature. This feature, which is available at no cost to AJT subscribers (all ASTS members), allows the accumulation of an hour of MOC credit per AJT issue if the testing is completed. These features are available for 12 months on the AJT website. Thus, at any one time, 12 are available. In each five-year cycle, 60 hours of MOC will be available via this feature, but doing so will require attention throughout the five-year period – only 12 will be available if this is left to the last moment to complete. I strongly suggest that ASTS members utilize this resource longitudinally to maximize impact.

    A third avenue for transplant-specific MOC content is a recent partnership between ASTS and AJT called “ASTS MOC – Education through the AJT.” This feature allows selected high impact manuscripts at AJT to be rapidly tracked for MOC content preparation by the authorship group, assisted by ASTS CME Committee members. Operationally we expect content of 1-2 articles most months in AJT going forward. This MOC content will be housed in the ASTS Academic Universe and does come with a nominal per-module fee for members and non-members of ASTS. Each successfully completed module yields 1 hour of MOC credit. These modules will be available for three years on the ASTS Academic Universe site after creation. Once this program matures, it should yield a renewing source of MOC content that should be more than 30-40 hours of available content at any given time. The first MOC article was published in January of 2017, and there has been one article in each of the subsequent issues of AJT.

    A fourth method of MOC credit in transplantation is obvious but significantly underutilized: MOC credits available from attendance at the ASTS Winter Symposium and the ATC. In the past four years, the planning committees of these meetings along with the CME Committee have initially piloted and then fully developed a program of MOC with self-assessments that has averaged 8-13 hours of credit available at these meetings. Essentially, one could obtain all needed MOC credits in a five-year cycle by attending even one of these meetings and completing the self-assessment modules that are provided to attendees after the meeting. In past years, a small percentage of attendees have taken the self-assessment exams to get credits. This is a resource that has the potential to alleviate much of the burden of MOC accrual and is an added rationale to attend these meetings. These modules are at no added cost for meeting attendees.

    Overall, ASTS leadership has paid careful attention to the needs of the membership and has provided a number of resources for transplant-specific MOC modules that are sufficient to meet the ABS requirements without having to study topics well outside of the practice of the transplant surgeon. The work of prior CME Committee chairs Mike Ishitani and Richard Knight set the stage for the production of this MOC portfolio, and Nerissa Legge, the ASTS liaison for CME and MOC content, has greatly facilitated these efforts. The help of Allan Kirk and Jill White at AJT has been essential in building the partnership with AJT that has facilitated much of this MOC content production. We should acknowledge the efforts of ASTS CME Committee members, who have produced the majority of these modules.

    Strategically, it is worth planning ahead and taking advantage of these modules throughout the five years of the recertification cycle, as 50 hours of credits take a long time to accumulate and some content is available on a rolling basis. It is harder to get 50 credits if one waits until the month prior to the due date. The relaxation of the ABS MOC requirements will allow for a fairly painless process of MOC accumulation for most transplant surgeons as long as it is treated as a process to be completed over a 5-year period and not left to the last moment.

    With these policy changes, the ABS also issued a policy statement stipulating that some specialty-specific approaches to the 10-year cycle of written examination recertification are being considered. This change may apply to transplant surgery in the future, but details are not yet available. It should be noted that while currently only the meeting-related credits are certified for the American Board of Internal Medicine (ABIM) for non-surgeon members of ASTS, we are exploring the feasibility of extending ABIM certification to a greater part of the MOC portfolio available to ASTS members.

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  • Transplant Department over Transplant Division of General Surgery?

    Dr. Amy GalloAmy E. Gallo, MD
    Assistant Professor of Surgery (Abdominal Transplantation)
    Stanford University Medical Center

    As the field of abdominal transplant surgery evolved, transplant surgeons fell under a number of hospital departments, including vascular surgery, general surgery, and urology. Financial and academic considerations dictate the reasoning for particular placement; however, what makes the most clinical sense is a multifactorial discussion and might be worth reconsideration in the changing medical environment. For large volume centers, perhaps a Transplant department is the future.

    Currently, even for large centers there is no uniform departmental configuration for transplant physicians. The majority of programs have abdominal transplant surgeons under general surgery. Some kidney programs have surgeons solely in the urology department for both recipient operations and donor nephrectomies. Some surgeons, double boarded in pediatric surgery, remain in the division of pediatric surgery. The medical counterparts, hepatologists and nephrologists, are hired through the medical and pediatric departments, where transplant surgeons may or may not have hiring influence. These physicians may have a special interest in transplant or may be designated to transplant based on other staffing considerations. Fewer centers have transplant hepatologists and nephrologists as dually appointed in medicine and in surgery. Additional individuals vital to transplant success, namely intensivists, cardiologists, radiologists, anesthesiologists, psychiatrics, and oncologists, often have interest in transplantation but are hired based on their individual departmental needs and not the needs of the transplant program.

    There is no doubt that in recent years, quality scrutiny of transplant programs has increased (1). Flagging by MPSC or CMS is a reality, to the extent that a program can be at jeopardy of closing based on outcomes. However, many of the transplant quality measures are unknown to participants outside the transplant community, while their involvement often directly affects patient outcomes.

    A dedicated transplant department could control the flow of personnel in alignment with transplant recipient needs, list volume and management, and oversight of detailed quality measures. Research within the department across disciplines would be more accessible. The ability to collaborate could be more extensive, and the requirement to attend departmental activities outside the interest of transplantation could be curtailed.

    A major consideration for continuing general surgery involvement is for residency training. Within the department of surgery, transplantation may have more clinical exposure to residents and in turn enhance recruitment into the field. I would argue, however, that in the current general surgery environment, transplantation is a low priority. It is no longer mandated as a formal rotation and is required only as a “transplant experience” (2). Exposure is often in the first and second years where the surgical experience, which often entices interest, is limited. The details of immunosuppression management is lost on short rotations.

    If medical students alternatively could be exposed to a transplant science department, potentially it could then attract the best and the brightest early on in training like plastic surgery, ENT, and neurosurgery have over the years. With a bigger presence as a department with emphasis on medicine, research, and surgery, perhaps it will look more appealing to medical students as its own field instead of being buried within general surgery.

     Bibliography

    1: Snyder JJ, Salkowski N, Zaun D, Leppke SN, Leighton T, Israni AK, Kasiske BL. New quality monitoring tools provided by the Scientific Registry of Transplant Recipients: CUSUM. Am J Transplant. 2014 Mar;14(3):515-23. doi:10.1111/ajt.12628. PubMed PMID: 24502435.

    2: Egle JP, Mittal VK. Program directors' perspective of transplant training during general surgery residency. Am Surg. 2014 Aug;80(8):796-800. PubMed PMID: 25105401.

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  • How Do I Get on an ASTS Committee?

    The American Society of Transplant Surgeons is our organization. It exists because of the dedication of transplant surgeons, physicians, and other transplant professionals, who work together with the highly skilled staff of the ASTS to support our primary goal: to advance the field of transplant surgery through leadership, advocacy, education, and training. While there are several organizations working on issues related to organ transplantation, the surgical perspective, particularly as it relates to training and advocacy, is uniquely represented by the ASTS.

    If we did not have members who wanted to be involved, the organization would cease to exist. Maintaining your membership in the ASTS and attending the Winter Meeting (January 26-29, 2017) are essential to being engaged. However, many of you may be ready to increase your participation in the ASTS by joining one of the many committees responsible for the carrying out the Society’s mission. However, you may not be entirely clear on how the ASTS committee process works. Below is a list of common questions you may have as well as a description of the main duties of the various committees. If you have additional questions, please don’t hesitate to contact us.

    Dr. Julie Heimbach 
     Ellie Proffitt  Diane Mossholder
    Julie Heimbach, chair, Communications Committee Heimbach.julie@mayo.edu Ellie Proffitt, staff liaison, Nominating Committee ellie.proffitt@asts.org Diane Mossholder, staff liaison, Communications Committee diane.mossholder@asts.org


    Q: When does the committee nominations process take place?

    A: The committee nominations period varies from year to year, depending on when ATC takes place. Nominations will open several months prior to ATC. All ASTS members will receive notification via email when nominations open.  In 2017, nominations will open in early January.

    Q: How does the nominations process work?

    A: Once nominations are open, members can nominate either themselves or one of their peers for a committee position. Nominations are made through Survey Monkey. Nominations stay open for several weeks, then close to allow time for appointments to be made prior to ATC. All nominees are notified either way via email a few weeks later, and new committee members begin their appointments during the Business Meeting at ATC.

    Q: How are committee appointments made?

    A: Committee appointments are made at the discretion of the current ASTS president. The president considers all nominations before making appointments. The top 6 committee choices are indicated on the nomination form, and a great deal of effort is made to place nominees in their first choice; however, this is not always possible, and the president tries to place each person in a committee where their strengths can be put to the best possible use.  Typically, there are more nominees than committee slots, so you may not be selected when you are initially nominated. Last year, there were 146 people nominated for 73 open positions.

    Q: How are committee chair and co-chair appointments made?

    A: Committee co-chairs (similar to vice-chair) are usually selected from current members of the committee. If a person currently on a committee would like to be considered for the co-chair position, there is space to indicate this in the nomination form. Committee co-chairs usually move into the chair position when the chair slot is open.

    Q: How long do committee appointments last?

    A: Committee chairs and members all serve 3-year terms. Co-chairs are appointed for one-year terms but may be reappointed for up to 3 years.

    Q: Does it help if there multiple nominations for the same person, and does it matter who nominates you?

    A: It is not necessary for multiple people to nominate the same person for a committee appointment. Only one nomination is necessary for the president to consider someone for a position, and typically the qualifications of the nominee and the needs of the committee are the most important factors.

    ASTS Committees

    Advanced Transplant Provider: To decrease the geographical barriers between providers and allow for a close, strong, supportive community to exist. Monthly conference calls.

    ATC Planning: Charged with ensuring that the meeting provides exceptional educational objectives and provides a forum for exchange of new scientific and clinical information.

    Business Practice Services: Assists ASTS members in understanding the business aspect of transplantation and helps them keep up with national trends in transplant practice management. Monthly calls (sometimes more frequent) and in-person meeting at ATC.

    Bylaws: To maintain and update the bylaws of the ASTS to accurately reflect the purpose, structure and function of the organization. Calls as needed and in-person meeting at ATC.

    Cellular Transplant: To promote the advancement of research and clinical applications in cellular transplantation and regenerative medicine, while serving as an advisory expert panel for the ASTS Council in cell transplant-related issues. Monthly conference calls and in-person meeting at ATC.

    CME: To provide support to members of ASTS to allow for their educational growth and development in service to patients, the public, and the ASTS. Monthly conference calls with in-person meeting at ATC and sometimes the Winter Symposium.

    Communications:  To act as an avenue by which the Society conveys information to the membership and transplant community on issues regarding transplantation science and medicine through the ASTS website, the ASTS newsletter (the Chimera), scientific journals, and e-mail communications. Monthly conference calls with in-person meeting at ATC.  

    Curriculum: To develop and implement the National Transplant Surgery Fellowship Curriculum to provide a structured educational and training framework for abdominal transplant surgery fellowship. Monthly conference calls.

    Diversity Issues: To ensure balanced representation among under-represented and underserved minorities specific to organ donation and transplantation. Monthly conference calls and in-person meeting at ATC.

    Ethics: Charged with considering ethical issues related to transplantation and organ donation. Conference calls as needed and in-person meeting at ATC.

    Fellowship Training: To ensure that the highest standards of clinical, professional, and scientific excellence are passed to future generations of transplant surgeons.  The FTC governs accreditation and oversight of surgical training programs in abdominal transplantation, and strives to provide benchmarks and guidance in order to facilitate high quality training across the United States and Canada. Monthly conference calls and in-person meeting at ATC.

    Grants Review: To support basic, clinical, and translational research performed in transplantation. The Committee will review and award applications for ASTS grants that support research performed by ASTS members, their trainees and collaborators. The Committee is responsible for providing advice, education and resources to trainees and members who are applying for funding from the broad range of granting organizations. . Conference calls as needed and in-person meeting at ATC.

    Legislative: To advise Congress and related federal agencies on decisions that influence the practice and science of transplantation by educating Members of Congress and advocating for new legislation, appropriations matters, and changes to existing laws and regulations for the benefit of patients, transplant surgeons, and society. Monthly conference calls and in-person meeting at ATC.

    Living Donation: Outline best practices to improve the safety and long-term care of the living donor, as well as develop informational materials to better inform potential donors and recipients on living donation. Conference calls as needed and in-person meeting at ATC.

    Membership and Workforce: Charged with the monthly review process for all new member applications and a focus on workforce needs, IMG experiences, and other issues impacting the membership. Calls as needed and in-person meeting at ATC.

    Reimbursement and Regulatory Compliance: Charged with helping the ASTS membership optimize professional reimbursement by understanding the issues and being part of the solution, reviewing all new and pending regulations relevant to physician reimbursement, and drafting comments that can be submitted to specific organizations or government agencies on behalf of ASTS. Monthly conference calls and in-person meeting at ATC.

    Scientific Studies: Explores basic science and clinical issues in the field of transplantation and aims to facilitate the dissemination of information regarding opportunities for collaboration in clinical studies. Monthly calls and in-person meetings at ATC and other ASTS events.

    Standards and Quality: To educate the membership about quality, standards, policies, and regulations, and to promote the development of high standards and quality in organ procurement, transplantation, patient safety, and performance improvement. Monthly calls (sometimes more frequent) and in-person meeting at ATC.

    Thoracic Organ Transplant: To propose and/or facilitate clinical and research initiatives aimed at increasing the number of thoracic organ transplants performed annually in the U.S. and improving the quality of life following heart/lung transplantation. Monthly conference calls and in-person meeting at ATC.

    Vanguard: To encourage involvement in the activities and initiatives of the ASTS by its junior members by providing opportunities for interactions between the Society’s leadership and its newer members, thus increasing the cohesive nature of the society. Conference calls as needed and in-person meeting at the Winter Symposium.

    Vascularized Composite Allograft (VCA): To maintain position papers to advise funding and regulatory agencies on the proper development of this complex field: To promote balanced scientifically sound investigation and career development in VCA, educate the membership about regulations and policies as they are being developed for VCA, and foster a place for professionals interested in VCA. Conference calls every other month and in-person meeting at ATC.

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