Improving Practice Performance in Aesthetic Surgery

About MOC 

MOC applies to all 24 of the boards of the American Board of Medical Specialties (ABMS). The MOC-PS program, like the Recertification program that it replaces, is mandatory for all American Board of Plastic Surgery (ABPS) diplomates certified in or after 1995 and is elective for those certified before 1995. When the ABMS instituted the concept of MOC in 1999 to replace Recertification, it did so in concert with the Accreditation Council for Graduate Medical Education (ACGME), the organization that oversees residency training. It was through this collaborative effort that the core competencies, now taught and measured in all residency programs, were developed. These competencies are now measured by all certifying boards through MOC.1

MOC-PS 

The four-part MOC-PS program is designed as a 10-year cycle. Part I (Professional Standing) is required every three years and includes an unrestricted state medical license, hospital privileges in plastic surgery, accreditation of outpatient centers, peer review recommendations, and membership in one of the 20 sponsoring organizations of the ABPS, such as the Aesthetic Society. Part II (Lifelong Learning and Self-Assessment) requires 150 hours of continuing medical education (CME) over a three-year period and the completion of one learning collaborative based on the “tracer” procedure selected for practice evaluation in Part IV (Performance in Practice). A cognitive examination (Part III), based on a specific area of practice such as cosmetic surgery, is required once in the 10-year cycle.2

The ABMS requires that physicians, under Part IV, are continually evaluated to assess care compared to peers and national standards, and then improve care based on findings and recommendations.3 Within this guideline, the ABPS chose to develop 20 tracer procedures, with five in each of the areas of plastic surgery practice: (1) comprehensive plastic surgery; (2) cosmetic surgery; (3) craniomaxillofacial surgery; and (4) hand surgery. The cosmetic (aesthetic) tracer procedures are abdominoplasty, augmentation mammaplasty, blepharoplasty, facelift, and suction-assisted lipectomy. The practicing surgeon selects one of these procedures common to his or her practice, reviews 10 consecutive operations performed during the preceding three years, and enters data (including outcomes) for each case on the Board's Web site. After data are entered, the diplomate then completes one of the learning initiatives on the specific procedure, such as attending a course at a national meeting or completing a specially written journal article, similar to Dr. Fritz Barton's excellent CME-credit article, “Aesthetic surgery of the face and neck,” that appears in this issue (page 449) of Aesthetic Surgery Journal. A key feature of the program is the opportunity for the surgeon to privately compare his or her patient data to deidentified surgeon and patient data from all others who have reviewed the same tracer procedure in their own practices. This gives each surgeon the opportunity to see how he or she compares with peers and to identify necessary changes to improve practice performance.

Practice-Based Learning 

Conducting a retrospective review of a series of patients who have undergone a specific procedure is not something that many aesthetic surgeons—at least those who have been in practice for 10 years or more—might ordinarily undertake on their own. Aside from gathering patient data for scientific publications over the years, I never attempted a detailed review of a specific operation until doing so for MOC-PS Part IV. I selected suction-assisted lipectomy from among the 20 tracer procedures and my review was enlightening. The first patient in the series, who underwent surgery more than a year before the chart review, was a young woman taking birth control pills who developed calf deep vein thrombosis soon after thigh and knee liposuction. With the day-to-day demands of a busy practice, it is easy for the memory of complications and their circumstances to fade, even though such complications may have lasting effects for patients. (This young woman was still taking warfarin at the time of my review.) Conducting this retrospective review allowed me to revisit that important case with a fresh perspective and to rethink its implications for future patient outcomes. Part IV of the MOC-PS program is an ideal structured format for us to measure our performance in a specific area, compare our results with those of our peers, engage in a focused learning collaborative, and hopefully improve our practice. The loop on the measure/learn/improve/remeasure circle is closed three years later when the same PA-PS module is selected and data from the then-most-recent 10 consecutive cases are entered. We can then compare to our previous entries and, again, to a much larger database of peers.

This exciting and innovative method of practice-based learning was introduced by the Board in 2008 when diplomates certified in 1999, 2001, 2002, 2004, and 2005 completed their first cycle of MOC-PS. Data entry on the Web site went “live” on May 1, 2008, and by April 15, 2009 a total of 986 certified diplomates completed the assignment. Aesthetic surgeons led the way, as 457 completed a cosmetic module, followed by comprehensive (386), hand surgery (98), and craniomaxillofacial surgery (45).

Augmentation mammaplasty was the most frequently selected of the 20 tracer procedures, with 299 diplomates completing this module. This gave surgeons who completed the augmentation module a chance to compare their data on 10 cases with 2980 other patients entered by colleagues. The database will grow annually as we all enter data in future years.

A glimpse at some of the sample data from the aggregate group on breast augmentation in the first year shows that 71% placed implants in the subpectoral position, 97% used smooth implants with an average size of 385 mL, and 84% used antibiotics for more than one day. These are but a few current practice patterns noted from the 37 data points on the augmentation mammaplasty benchmarking report.

The most rewarding data we have seen involve the action plan that is completed at the end of the module. From the “Self-Evaluation for Improvement” menu, we received 1138 responses, with the majority (55%) indicating they would change something. The most frequent change noted was a desire for more thorough preoperative analysis (11%), while 10% would change operative technique, 8% postoperative management, and 7% indicated a need for better patient selection. If only a small percentage of these plans are actually put into action, it is obvious that a broad change in plastic surgeons' practice behavior will result.

There are many reasons why measuring practice performance is important. The first, obviously, is the responsibility we have to our patients to institute improvements that will achieve the best possible outcomes. Also important is the fact that various public interests now demand that physicians demonstrate competence on an ongoing basis rather than simply pass a computer-based cognitive examination every 10 years. Physicians today are under scrutiny from state licensing boards, independent national quality organizations, big business, consumer organizations, healthcare providers, and hospital staff credentialing committees, to say nothing of the federal government. These entities, organizations, and agencies want to know if we are actually engaged in methods of continuously improving practice performance.

Participating in practice assessment every three years is not difficult. All it requires is access to a computer, registration in the MOC-PS program, 10 consecutive charts, and one to two hours every three years. The cost is about the same as four tickets to see the 2008 World Champion Philadelphia Phillies play one home game. I can attest from my own personal experience that the rewards of participation in MOC-PS, with its unique Performance in Practice data comparison format, far outweigh the minimal effort and cost.