Arnold Gerald K, Hess Brian J, Lipner Rebecca S
American Board of Internal Medicine, Philadelphia, PA 19106, USA.
J Contin Educ Health Prof. 2013 Spring;33(2):99-108. doi: 10.1002/chp.21172.
Board certification has evolved from a "point-in-time" event to a process of periodic learning and reevaluation of medical competence through maintenance of certification (MOC). To better understand MOC participation, the transtheoretical model (TTM) was used to describe physicians' perceptions of MOC as a sequence of attitudinal changes.
Data were from a survey of internal medicine (IM) physicians' attitudes toward periodic reevaluation through MOC. An overall importance or decisional balance score was computed for each physician by summing his or her ratings across the 10 quality measures. The decisional balance score was used to classify physicians according to their acceptance of MOC, aligned with the 3 early TTM stages-of-change groups-precontemplation (PC), contemplation (C), and preparation (P)-where PC was least accepting and P was most accepting. Effect sizes assessed whether differences in attitudes toward reevaluation via MOC were of sufficient magnitude to support the TTM principles.
The difference in degree of acceptance of MOC between the P group and the PC and C groups was significant (p < 0.001), but the effect size was lower than predicted by the "strong" principle. Resistance to MOC for the PC and C groups was significantly greater than the P group (p < 0.001) and supported the "weak" principle. Physicians' beliefs about how often they should demonstrate performance on quality measures aligned well with the American Board of Internal Medicine's MOC requirements, with the P group believing in more frequent assessments than the PC and C groups (p < 0.001).
Results show that physicians in the Preparation stage had overcome resistance to MOC as predicted by the "weak" principle of the TTM, but their attitude scores about the benefits of MOC were below what was expected by theory. This suggests that the structure of MOC may have made it easier for physicians to overcome barriers to MOC participation but may have lacked adequate resources to promote the benefits of participating in the process. More effort is needed to understand the specific benefits of MOC for reevaluating competencies, how to engage physicians and other stakeholders in the design of MOC, and how to communicate the rationale and evidence to those who are less accepting of MOC.
专科医师认证已从一个“时间点”事件演变为一个通过持续认证（MOC）进行定期学习和重新评估医学能力的过程。为了更好地理解MOC参与情况，采用了跨理论模型（TTM）来描述医生对MOC作为一系列态度变化的认知。
数据来自对内科（IM）医生对通过MOC进行定期重新评估态度的调查。通过对每位医生在10项质量指标上的评分求和，计算出总体重要性或决策平衡得分。决策平衡得分用于根据医生对MOC的接受程度进行分类，与TTM的3个早期变化阶段组一致——前意向阶段（PC）、意向阶段（C）和准备阶段（P），其中PC接受程度最低，P接受程度最高。效应量评估了通过MOC进行重新评估的态度差异是否足够大，以支持TTM原则。
P组与PC组和C组在MOC接受程度上的差异显著（p < 0.001），但效应量低于“强”原则预测的值。PC组和C组对MOC的抵触明显大于P组（p < 0.001），支持“弱”原则。医生对他们应多久展示一次质量指标表现的信念与美国内科医学委员会的MOC要求高度一致，P组比PC组和C组更相信更频繁的评估（p < 0.001）。
结果表明，处于准备阶段的医生如TTM“弱”原则所预测的那样，已经克服了对MOC的抵触，但他们关于MOC益处的态度得分低于理论预期。这表明MOC的结构可能使医生更容易克服参与MOC的障碍，但可能缺乏足够的资源来促进参与该过程的益处。需要更多努力来了解MOC在重新评估能力方面的具体益处、如何让医生和其他利益相关者参与MOC的设计，以及如何向不太接受MOC的人传达其基本原理和证据。
