NUMBER 23
AMERICAN BOARD OF NEUROLOGICAL SURGERY 2005

NEUROLOGICAL SURGERY is a discipline of medicine and that specialty of surgery that provides the operative and non-operative management (i.e. prevention, diagnosis, evaluation, treatment, critical care, and rehabilitation) of disorders of the central, peripheral, and autonomic nervous systems, including their supporting structures and vascular supply; the evaluation and treatment of pathological processes that modify the function or activity of the nervous system, including the hypophysis; and the operative and non-operative management of pain. As such, Neurological Surgery encompasses the surgical, non-surgical, and stereotactic radiosurgical treatment of adult and pediatric patients with disorders of the nervous system: disorders of the brain, meninges, skull, and skull base, and their blood supply, including the surgical and endovascular treatment of disorders of the intracranial and extracranial vasculature supplying the brain and spinal cord; disorders of the pituitary gland; disorders of the spinal cord, meninges, and vertebral column, including those that may require treatment by fusion, instrumentation or endovascular techniques; and disorders of the cranial and spinal nerves throughout their distribution.

The broad aim of the AMERICAN BOARD OF NEUROLOGICAL SURGERY is to encourage the study, improve the practice, elevate the standards, and advance the science of neurological surgery, and thereby to serve the cause of public health.

WILLIAM C. CHANDLER, MD CHAIRMAN,2005-2006

M. SEAN GRADY, MD SECRETARY

H. HUNT BATJER, MD CHAIRMAN, MAINTENANCE OF CERTIFICATION COMMITTEE

MARC A. MAYBERG, MD TREASURER

WILLIAM C. CHANDLER, MD CHAIRMAN,2005-2006

In this Message from the Chairman, allow meto update the Diplomates of the AmericanBoard of Neurological Surgery on many of theongoing activities that make up the work ofthe ABNS.

Resident Numbers and Neurosurgical Match
During the 2004-2005 academic year, 94 neurosurgical residency training programs in the United States were accredited by the Residency Review Committee for Neurological Surgeryunder the Accreditation Council for Graduate Medical Education. Eight hundred fifty-one residents were in training; 139 graduated in June 2005.

In January 2005, 346 individuals registered for the Neurosurgical Matching Program. Two hundred fifty-seven rank listswere submitted, a decrease of 9% from 2004. Two hundred twenty-two lists were ranked,and 154 individuals matched.

PGY1 Curriculum
The ABNS firmly believes that neurosurgical Program Directors should have more control over the educational content of the PGY1 experience. It strongly supports the RRC in itsefforts to improve this for neurosurgery. The Board was pleased with the recent trainingrequirement change that allows up to threemonths of neurology and three months ofneurosurgery during the PGY1. The same changes have been written into the ABNS Rules and Regulations. In addition, more rotations relevant to neurosurgery, such as emergency medicine, orthopaedic surgery, and ENT, should be included by Program Directors.

Training in New, Advanced Procedures
The Board continues to advocate efforts to trainneurosurgeons in the complete care of cere-brovascular disease, including all of the latest endovascular advances. Catheter based techniques to treat aneurysms, vascular malformations, andcarotid diseases are now being taught during residency, and ABNS examinations reflect the newprocedures. In addition, the Board supports the training of neurosurgeons to provide stereotactic radiosurgery for the treatment of neoplastic, vascular, and functional disorders. The many advances in complex spine surgery must not be overlooked. The field is growing swiftly. In order to keep up, newquestions are being written just as swiftly forthe Primary Examination.

Primary Examination
The ABNS written Primary Examination is administered annually to neurosurgical trainees and a handful of other individuals. This multiple choice examination covers the breadthof neurosurgery's clinical and basic science curriculum. It may be taken for self-assessment, butmust be taken and passed for credit toward certification prior to applying for oral examinationand certification. For residents entering residencyafter June 30, 1998, the requirements of the ABNS and RRC specify that the examination must be passed during training in order to complete residency. Many Program Directors require their trainees to pass it before progressing to chief resident.

In March 2005 the Primary Examination was administered to 528 examinees. Two hundred seven took it for credit and had a 6% fail rate. Three hundred twenty-one took it for self-assessment, which does not have apass/fail designation.

Oral Examination
In November 2004, 89 candidates sat for oral examination, with a 15% failure rate. In May 2005, 88 candidates were examined; their failure rate was a low 8%. Seventy-three candidates were examined in November 2005 and had a 12% fail rate. Each candidate’s performanceis numerically scored on three tasks by six examiners. The resulting 18 grades are usedto determine the pass/fail status by a computer program which weights for examiner severity, thus maximizing the objectivity of the process. Standardized questions are now being used for a small portion of the examination.

Fifteen to eighteen guest examiners are invited to participate at each oral examination. Usually half of them are Program Directors since the Board believes that they must be kept up-to-date on the process. Several serve on the Extra-Mural Subspecialty Item Writing Committee, which meets annually and submits new items for the Primary and MOC Cognitive Examinations. Other individuals are suggestedby the six Nominating Societies, which nomi-nate new ABNS Directors. At least one is activeon the Council of State Neurosurgical Societies.Their training consists of a handbook and video, which are sent out early, and an orientation seminar held the evening before the oral examinations. They are also assigned a mentor,who is a current Director, and paired with cur-rent or former Directors in examining teams.

Strategic Planning
The ABNS initiated a Strategic and LongRange Planning process during its January 2006 Winter Directors Meeting. The Directors spent an entire day with a professional facilitator formulating a Strategic Plan to prioritize the activities of the Board over the next three tofive years. Dr. A. John Popp is leading the effort, which will continue at the May 2006 meeting.

American Board of Medical SpecialtiesThe ABNS remains committed to the efforts of the ABMS, including cooperating withevery aspect of the initiations to develop an MOC program. You will read more on that in the following pages. Dr. William F. Chandler was appointed by the ABNS to a 3-year term on the newly organized ABMS Board of Directors. Also in conjunction with the ABMS,the ABNS participates in the Surgical Caucus sponsored by the American College of Surgeons.

Interpretive Guidelines – Center for Medicare and Medicaid Services
The CMS has set forth "Conditions of Participation" for all participating hospitals. Several of these guidelines require that the primary surgeon list in both the operative consent and operative notes the "specific significant surgical task" performed by every "practitioner" involved in the operation. These include opening, closing, and altering tissue. The ABNS believes that these requirements are burdensome and unnecessary. It is workingwith the ACS, ABMS and American Board ofSurgery to have the guidelines changed.

Revocation of Certification
At its meeting in May 2005, the ABNS held hearings on revocation of seven certificates. All seven were revoked based upon the former Diplomates’ loss of licenses to practice medicine. Three certificates were suspended. In November 2005 two additional certificates were suspended.Suspension is always done coterminous with suspension of a State medical license. Once the license is returned,the Diplomate will be given a 10-year time-limited certificate requiring participation in MOC beginning the next year. These actions were taken by the Board in order to protect the integrity of certification for its Diplomates,as well as for the public safety.

ABNS Officers and Directors
At its spring 2005 meeting in St. Louis, Drs. Ralph G. Dacey, Jr. and Hal L. Hankinson completed their six years of contributions and leadership on the American Board of Neurological Surgery. Newly elected Directors are Drs. Charles L. Branch, Jr. and Tae SungPark. New officers for the 2005-2006 year are Dr. William F. Chandler, Chairman, andDrs. Jon H. Robertson and A. John Popp, Vice-Chairmen. Dr. M. Sean Grady remains as Secretary, and Dr. Marc R. Mayberg as Treasurer.

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M. SEAN GRADY, MD SECRETARY

OPERATIVE CASE LOGS:STORAGE BY ELECTRONIC DATABASES
A comprehensive and accurate record of operative cases performed at a residency program is a common requirement for both the Residency Review Committee for Neurological Surgeryand the American Board of Neurological Surgery. The RRC requires that data be able tobe categorized as to the institutions where thetraining is undertaken, as well as by the residen trole, either resident surgeon or assistant. The Program Director is responsible for insuringthat the records are maintained and accurate,and needs to submit the case log in a format specified by the RRC when requested, which is usually as part of the survey process. In addition, the Program Director is responsible for the annual compilation of operative records for all cases performed by each resident, whether as surgeon or assistant, completing the program that year. The ABNS requires that residents record their operative procedures for theirentire training period and provide this case log to the Board, in a format specified by the ABNS, as part of the initial certification process. The maintenance of operative case logs is essential in order to document thetraining experience that individuals receive, aswell as the ability of an institution to provide the necessary case material to insure adequatetraining. The importance of such information cannot be underestimated, but the ABNS and RRC recognize the time required to complete such a task. Accordingly, significant efforts have been made by members of both organizations to develop common terminology and recording mechanisms in order to enable residents andProgram Directors to complete these tasks in atime efficient and accurate manner

Terminology: A set of procedure classes hasbeen developed with the central principle being that each patient undergoing surgery has onlyone procedural class assigned to that case soas to avoid duplication in the total number ofcases. This concept is best illustrated in aspine procedure where a patient undergoesan anterior cervical discectomy and fusion utilizing instrumentation; several CPT codesare used in such a procedure. Which oneshould be used? For the purposes of the ABNS and RRC, only a single procedure classis identified and recorded for this patient–cervical spine disc disease with instrumentation. Using this common "language", members ofthe ABNS and RRC share an identical understanding of the resident’s training experience,as well as the program. As new CPT codes are introduced on an annual basis, the proceduresclasses are updated reflecting the evolving nature of the specialty.

Databases: Several databases have been developed to enable electronic storage of case logs. The two most familiar to neurosurgery residentsand Program Directors are NeuroLog, whichwas developed by the ABNS, and the Resident Case Log System developed by the Accreditation Council for Graduate Medical Education. The ACGME system is used by many procedure oriented residency programs and has been somewhat adapted for use by neurosurgery residencies. Through cooperation in design bythe ABNS and RRC, the procedure classes used in both systems are identical, plus thesummary information provided by either system satisfies the required reports of the ABNS and RRC for individual residents andprograms. So, why were two systems developed? What are the differences between the systems,and which one should be used?

Neuro-Log was developed by the ABNS as an electronic web based tool for recording the operative data required as part of the application process for initial certification. Prior to 2004 this was performed by candidates on a written set of forms submitted to the Board. This is case material collected after residency, which is submitted to the ABNS prior toapproval for the oral examination (the last step in the certification process). Included in this data set is outcomes information. When developing the system, ABNS Directors felt itwould be prudent to use procedure classes likethe RRC’s. As the system was in development, they saw that NeuroLog could be useful for residents and Program Directors to track individual and institutional data; thus, it was modified accordingly to enable this feature. Further amplifying the system’s importance, neurosurgery now has mandatory Maintenance of Certification, and this vehicle provides the con-tinuous methodology which neurosurgeons will need to use throughout their active surgical careers during the MOC process. Underthese circumstances, the ABNS felt it would be advantageous for neurosurgeons to learn howto use the system during residency, then continue to use the same system as they becamecandidates for initial certification, and later for MOC requirements. Thus, one single system could take care of neurosurgeons' atabase needs throughout their careers.

Simultaneously, the ACGME realized that electronic case collection would improve case log accuracy, as well as enable the work of the RRCs to progress in a more efficient manneras they review the data in a timely fashion in order to certify programs. An electronic case log system would much more easily enable Program Directors to maintain compliance with RRC requirements for compiling case logs for individual residents and programs as a whole. The system was enabled for use in neurosurgery programs in December 2003, virtually at the same time as the NeuroLog system was finalized.

What are the differences? There are some relatively minor different features, such as page appearance and how reports are prepared. Selection of procedures also differs between the two systems. The ACGME system relieson identifying the correct CPT code, whichthen assigns the case into the correct procedure class. NeuroLog uses a logical drop-downmenu that progressively guides to the finalprocedure class; alternatively, a CPT searchsystem, akin to the ACGME system, can beused to achieve the same result. There is no cost to Program Directors or residents for use of either system. The ACGME system can beaccessed using a PDA with is a minimal chargeof $25/user/year; this is not possible onNeuroLog at this time. Outcome information is not possible on the ACGME system; so Program Directors who require their residents to enter data for morbidity/mortality review cannot utilize that feature, which is present onNeuroLog. The ACGME system also does not provide information essential for a trained practitioner in neurosurgery to collect their data for primary certification or MOC, andany practitioner not involved in a trainingprogram (the majority of neurosurgeons) hasno access to the ACGME system. Recognizing that combining these differences might make for a better system overall, members of theABNS and RRC have met, and with the approval of the ACGME, a pilot study will be undertaken to analyze these features to seehow they can be best combined, including the ability to electronically transfer data betweenthe two systems. What needs to happen? Currently, at the program level each Program Director decides how the data is collected and insists that all residents utilize the same system. It is currently possible for a program to buildits own system, to modify one it is using now, or simply to ask residents, fellows, and participating faculty to collect their own datacapturing all operative cases done at the institution by fellows or faculty without residentinvolvement (as long as it is in the same formatas seen in NeuroLog or the ACGME system)and submit it on a regular basis to the Program Director. Pursuing any of these three strategies seems ill advised when there are two excellent systems organized to provide the required information to the ABNS and RRCat no cost. For the benefit of the specialty and ALL of its practitioners, the two organizations need to integrate their systems in such a way that they are seamless in providing the data to each organization without the need for usersto employ two systems. Further informationon NeuroLog is available at the ABNS website,www.abns.org, and information on theACGME system specifically for neurosurgeryProgram Directors can be accessed at www.acgme.org. On either website look for the data collection system.

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H. HUNT BATJER, MD CHAIRMAN, MAINTENANCE OF CERTIFICATION COMMITTEE

MAINTENANCE OF CERTIFICATION

It is hard to believe that the process of Maintenance of Certification for ABNS Diplomates began in January 2006. In 1998 the ABNS adopted the concept of recertification for the first time. Dr. Volker K. H. Sonntag took over this activity on behalf of the Boardand pushed the program with great skill, commitment, and consensus building over the first years of development.

Enormous pressure had been building through the American Board of Medical Specialties, American Hospital Association,and even public belief that an initial certification process for medical specialists is not adequate to assure that a practicing physician stays current in his or her field. The Institute of Medicine report on medical errors and the Leapfrog consortium produced further pressure leading all ABMS member Boards to adopt MOC principles in March 2000. While the ABNS only requires that Diplomates with time-limited certificates (those certifiedduring or after 1999) participate in MOC, it is likely that in the near future participation by all specialists will be required by the Center for Medicare and Medicaid Services, third party payors, state medical licensing boards, hospital credentialing committees, and perhaps even malpractice insurers.

The concept of MOC is based on the sixgeneral competencies: medical knowledge,patient care, interpersonal and communicationskills, professionalism, practice based learningand improvement, and systems based practice.These have four basic components:

• Part I – Evidence of Professional Standing
  
• Part II – Evidence of Commitment to Lifelong Learning and Periodic Self- Assessment
  
• Part III – Evidence of Cognitive Expertise
  
• Part IV – Evidence of Evaluation of Performance in Practice

As of December 5, 2005, the ABMS accepted Parts 1, II, III, and IV of the ABNS plan with only minor changes for Part IV.
Components of MOC
Part I – Evidence of Professional Standing will beassessed in the following ways:

1. Full unrestricted license to practice medicine in all jurisdictions in which the Diplomate is licensed.
   
2. Unrestricted hospital admitting privileges to practice neurosurgery.
   
3. Recommendation from the Chief of Staff of the participant’s primary hospital.
   
4. All of the above will be on a 3-year cycle

Part II – Evidence of Commitment to Life long Learning and Periodic Self-Assessmentwill require:

1. 150 hours of CME: 60 hours Category I and 90 hours other Category 1 or Category II credits, 80% overall must be neurosurgery related. CME tracking will be coordinated with the American Association of Neurological Surgeons.
   
2. Self Assessment in Neurological Surgery (SANS) examination developed and administered by the Congress of Neurological Surgeons.
   
3. Both of the above will be required on a 3-year cycle.

Part III – Evidence of Cognitive Expertise will be evaluated through a secure computer-based examination every ten years. It may be takenin the eighth, ninth, or tenth year of the 10-year cycle. The examination will consist of 200 questions, 150 of which will be General Neurosurgery. In addition, one of three examination modules of 50 items each will beselected to reflect the Diplomate’s practice: more general neurosurgery, spine surgery, and pediatric neurosurgery.

Part IV – Evidence of Evaluation of Performance in Practicewill be demonstrated in the following ways:

1. Key Cases – The type of case to be logged will be selected from an ABNS list, which covers all of the subspecialties.Then ten current, consecutive cases in that area will be submitted by the Diplomate. A questionnaire is completed on line for each of the ten; it reflects risk stratification for the individual’s practice, as well as out-come measures. The Diplomate must usethe same procedure for the entire 10-year cycle and, thus, may clearly seeimprovement in management over time.
   
2. The Chief of Staff at the participant’s primary hospital will be required to fill out a questionnaire on the Diplomate’s status at that hospital.
   
3. A Communication Assessment Tool will cover the neurosurgeon’s commu-nication skills and other aspects of professionalism. A questionnaire will be given to 20 consecutive patients who can complete it by phone or Internet.
   
4. All three of the above will be required on a 3-year cycle.

MOC for Neurosurgery Components Assessment Methods Frequency Professionalism Unrestricted License Hospital Privileges Chief of Staff Questionaire Every 3 Years Knowledge Secure Cognitive Exam SANS Every 10 Years Every 3 Years Lifelong Learning and Self-Assessment CME (150 Hrs.) SANS Every 3 Years Performance in Practice Consecutive Key Cases CAHPS Chief of Staff Questionaire SANS Every 3 Years Table 1

Table 1 summarizes the four components of MOC, the assessment methods to be employed, and the frequency of assessment for each.

Table 2 shows the MOC roll out, which beganin January 2006. You will note a transition for Diplomates certified between 1999 and 2005. Those certified in 1999 began the first year of a single 3-year cycle in 2006 prior to their recertification in 2009. Diplomates certified in 2002 also began in 2006. Those certified in 2005 initiated their first 3-cycle in January 2006 and will be the first group to complete a full 10-year MOC plan. Y1, Y2,and Y3 signify the three years of the mini-cycles, while at the end of year C, successful participants will receive new 10-year time-limited certificates.

CME Strategy
Acouple of comments are note worthy regarding the ABNS strategy for CME requirements. Sixty Category 1 hours are currently requiredevery three years for membership in the AANSand CNS. The ABNS requirement for MOCwill be 150 hours over each 3-year cycle. Eighty percent of all hours must be neurosurgical. All meetings "sponsored", "jointly sponsored", or "endorsed" by the AANS or CNS will qualify for Category 1 hours. In addition,enduring materials that are printed, audio,video, or peer-reviewed-journal related will alsoquality for Category 1 hours. The additional 90 hours of Category 1 and Category 2 may include more of these, as well as coursesaccredited by the ACCME and state or regional societies, including grand round. Published articles and peer-reviewed journals will alsocount. Presentations at regional and national societies will be credited similarly. In addition,the required SANS examination counts as 24 Category 1 hours. Consistent with the AMAprocess for the Physician’s Recognition Award,Category 2 hours will also be allowed for consultation with peers and experts, medical research, study online, teaching other health careworkers and lay groups, reading peer-reviewed literature, and attendance at local ground rounds or medical conferences not accredited by the ACCME. The completion of a 10-year MOC cycle will earn 25 Category 1 hours for the next cycle.

The AANS has developed a process that automatically adds all Category 1 credits it "sponsors", "jointly sponsors", or "endorses" to each Diplomate’s tracking on MyMOC. The CNS has agreed to report their CME hours for automatic tracking, too. For credits not included in the automatic category, Diplomates will be able to self-enter additional information for credits.

In its deliberations regarding MOC andcommunications with the ABMS, a numberof policy decisions have been made that areimportant to ABNS Diplomates. One ofthese is how Diplomates will be categorized.The ABNS has decided to place eachDiplomate in one of four categories:

1. Certified – Participating in MOC
   
2. Certified – Not participating in MOC
   
3. Certified – Clinically Inactive
   
4. Not Certified

ABMS Boards have struggled with how inactive physicians should be handled. Such physicians include those who pursue, for instance, a lengthy family leave, a deanship, a job in industry, or a research position, anything that takes them out of clinical activities. The following principles will guide theABNS in these situations:

1. Inactive physicians may participate in MOC and maintain their certificate.
   
2. Such individuals will be designated, "Certified - Clinically Inactive" and should not have surgical privileges.
   
3. They will participate in Parts I, II, IIIof MOC; SANS will be used to satisfyPart IV.

The ABNS also recognizes that a number of physicians elect to continue the practice of medicine but not have an active surgical practice. Those Diplomates may also participate in MOC and maintain their certification. For Part IV requirements, they may use a keycase that deals with the medical management of low back pain. They will be designated as "Certified" and either "participating in MOC" or "not participating in MOC". Once a Diplomate has been clinically inactive for a period of time, he or she may wish to re-enter an active clinical practice. The ABNS has established a policy for re-entry, the principles of which are as follows:

1. The Diplomate and his or her hospitalwill submit a proposal regarding re-entry, including preceptorships if needed, for ABNS approval.
   
2. In each individual case, the ABNS will work with the Diplomate to establish the most effective mechanism.

The initiation of the MOC process for neurosurgery represents the culmination of an extraordinary amount of effort by ABNSDirectors and staff, with outstanding help from our neurosurgical organizational partners. The AANS, in addition to providing educational programs and publications, has created a seamless CME tracking mechanism. The CNS,in addition to their educational programs, has developed a robust self-assessment examination, which includes evaluation and teaching inimportant non-clinical competencies. The Sections of the AANS and CNS have beenactively writing questions not only for the Primary Examination, but also for the MOC Cognitive Examination. In addition, theSections are assisting with the Key Cases,including providing guidelines and benchmarks for practice assessment. The Society ofNeurological Surgeons has an active programin outcomes assessment and is working closelywith the ABNS MOC Committee. The Neurosurgical Washington Committee hasdeveloped a Quality Improvement Workgroup that is actively working with ABNS Directors,too.

ABNS Directors are committed to pro-viding a robust and user-friendly MOC process for our Diplomates. This process willbe evolving over the next several years; no aspect is "locked in stone". It is our hope andmission to ensure that ABNS Diplomates continue this lifelong educational process inour very fluid and rapidly advancing field, andthat we as a specialty continue to provide the highest level of safe and innovative clinical care to our patients.

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MARC A. MAYBERG, MD TREASURER

The financial status of the ABNS remain sound, although prominent changes in the nature and volume of Board activities are occurring with the implementation of Maintenance of Certification. The tri-annual audit was completed for 2004. It is supplemented by annual actuarial reviews and monthly cash flow analysis.

For the four quarters of 2005, expenses exceeded revenues by a substantial amount. This was due almost entirely to costs associated with MOC: initiation and implementation of NeuroLog, preparation and testing of the MOC cognitive examination, and increasedmeeting expenses. There has been a significantdecrease in expenses for office supplies, printing,and payroll since office automation was initiated in 2002. Professional fees and insurance costs appear to have stabilized. Long-term hotel contracts and moving all oral examinations in Houston will substantially reduce those expenses. It is anticipated that all of these savings will continue. It should also be noted that ABNS Officers and Directors serve without compensation.

The fundamental precept of the Board’s financial management is that the oral and Primary Examinations are conducted on a budget neutral basis (i.e. expenses are matched by examination fees), while all other Board activities are funded through the annual assessment of actively practicing Diplomates. In the past, Board activities have revolved around preparing the written examination, the credentialing process for initial certification, and theoral examination. Over the past five years, the Directors and Executive Administrator havebeen streamlining operations in order tomaximize efficiency; however, the addition ofthe MOC has significantly increased Boardactivities and added a substantial new work-load that will be ongoing for the ABNS incoming years. The actual incremental cost of MOC is estimated to be about $325,000 peryear, primarily relating to database services,which include data accrual for Practice Performance and Evidence of Professional Standing. Some costs, such as SANS, will be assumed by MOC participants. ABNS fees have been restructured to match expenses.

Following are the sources of the Board’srevenue:

A sliding scale was instituted for the oralexamination application submission feedependenton how close the candidate is tothe 5-year mark for completion of the certifi-cation process. Late submission results inmore work on the part of the office.

Management of the reserve investment portfolio is now performed by UBS. For thepast few years, the Board has been able tomaintain its reserves, although not add to them from the operating account since margins onoperations have been small or negative.Transfers totaling $300,000 were made tocash flow in 2005 in order to accommodate MOC expenses as mentioned above. The current balance is somewhat under two times annual expenses, which may be a satisfactory ratio for the time being. With this in mind, Directors reviewed the investment parameters for the account and feel that, while MOC expenses will continue to accumulate, thereserves are in a satisfactory situation at thepresent time.

The fourteen Directors of the American Board of Neurological Surgery hope this Newsletter has been of interest to you. If you have any questions, advice, or comments, please write to the office or e-mail us at www.abns@tmh.tmc.edu.Notices of change of address a real ways appreciated, and it is helpful to learn of change of status to retired since assessment statements are sent only to active practitioners and those participating in MOC. Diplomates overwhelmingly continue to support the Board’s commitment to continuing improvement of the certification process and the search for an acceptable MOC process through the assessment program. Thank you.