On March 10, 2014, an online petition was launched requesting that the American Board of Internal Medicine (ABIM) recall recent changes to its Maintenance of Certification (MOC) process. As of this writing, the petition had obtained 17,092 signatures, representing an average signing rate of approximately 160 signatures per day since the ABIM MOC petition was first established.

The ABIM MOC petition calls for a rollback of recent changes to MOC and advocates for a return to “a simple pathway consisting of a recertification test every ten years.” This effectively stakes out a more moderate anti-MOC position compared with parties advocating for

  • Elimination of all MOC requirements, including secure, high-stakes exams,
  • Abolition of board certification, or
  • Establishment of competing certification boards.

One commenter on the ABIM MOC petition states: “All MOC programs must go or I cannot sign. Even the secure tests every 10 years (items 4 and 5) for MOC are controversial, commercial, and of questionable relevance for demonstrating professional competence.” Several other commenters note that although they signed the petition, they do not believe it goes far enough with its demands.

High Stakes

At the heart of the heated debate on recent MOC changes is the way in which physicians, including those who are technically board certified, may now be designated on both ABIM and American Board of Medical Specialties (ABMS) websites as “Certified, Not Meeting MOC Requirements.” Although professional board certification is quite distinct from medical licensure (i.e., certification is not required to practice medicine), physicians opting out of board certification, MOC, or both risk losing:

  1. Potential new patients — especially as people increasingly turn to the Internet and mobile applications to shop for their physicians;
  2. Career and advancement opportunities — especially when competing against board-certified candidates for desirable positions;
  3. Practice privileges at hospitals and acceptance into certain insurance and payer systems, which often require board certification; and
  4. Status and respect among medical peers and colleagues.

All of this comes against a backdrop of considerable industry change and uncertainty surrounding the Affordable Care Act (ACA), rapidly escalating administrative burdens on physicians, and ever-increasing productivity and cost-control demands from practice administrators and payers. With so many increasing demands on physicians and disruption across the health care industry, it is understandable that changes to MOC requirements have become the focus of such heated debate and even spurred this ABIM MOC petition.

In a June 2014 article titled “Maintenance of Certification and Licensure: Regulatory Capture of Medicine,” which appears in Anesthesia and Analgesia, Paul Martin Kempen, MD, PhD, writes:

The waste of time and money to jump these [MOC] hurdles seems unnecessary and possibly even offensive… I passionately, actively learn every day… We physicians are driven, intelligent, and self-sufficient professionals. We seek and learn the information needed to improve and maintain the clinical knowledge and skills needed to practice safely and avoid patient detriment and lawsuits.

Using 2011 data from the Ohio Medical Board, Kempen goes on to contend that physician incompetence is, in fact, relatively rare and would not, in any case, be detected by the MOC process:

Unless there is unequivocal evidence that testing and recertification is both accurate and sensitive in identifying incompetent physicians, I believe testing every physician at significant cost to identify the rare physician with significant knowledge deficits wastes our increasingly rare resources.

Not everyone agrees, however, with Dr. Kempen’s contention that self-directed, ongoing learning among physicians should be considered sufficient for maintaining and expanding medical knowledge over the longer term. Graham T. McMahon, MD, executive editor of NEJM Knowledge+, wrote previously in the Learning+ blog about the factors that led to his decision to recertify. And, in an essay titled “Maintenance of Certification: Confession of a Grandfather,” published in 2012 by the American Society of Clinical Oncology, David H. Johnson, MD, notes that as a member of the ABIM Board of Directors, he was compelled to undertake MOC in 2008:

Like many of you who were board certified before 1990, I had pretty much ignored the ABIM MOC program; after all, I was “board certified for life.” Moreover, I was doing plenty of meaningful activities to maintain my expertise in medical oncology. I hold a faculty position at a top-ranked medical school; I teach medical students, residents, and fellows on a regular basis; I am engaged in clinical research; I write numerous scientific, peer-reviewed articles; and I edit textbooks of medicine and oncology. I wondered, “How is MOC going to benefit me?” and, more to the point, “Who has the time?” Every minute spent working on MOC is a minute not spent with patients. In short, I thought MOC would add nothing of substance to my knowledge base or my professionalism…. Of course I was wrong! Once enrolled and engaged in MOC, I quickly realized that my efforts to keep up with developments in oncology were not as effective as I had imagined.

Where Is the Middle Ground?

Practicing physicians fall somewhere in the middle of this debate, we discovered while interviewing several physicians about their personal experiences with board certification, recertification, and preparation for high-stakes exams. They support the principle of MOC, if not all the particulars as currently implemented by ABIM.

Akhil Narang, MD, Chief Resident at University of Chicago Medical Center, became ABIM board certified for the first time in November 2013 and remarks:

Medicine is a lifelong learning endeavor, so it makes sense ideologically that there should be some sort of ongoing, formal process to maintain certification versus addressing medical knowledge intermittently only once every ten years. It makes sense to have physicians undergo regular updated CME and practice improvement programs to make sure they are practicing the latest evidence-based medicine. The questions always seem to arise around time commitments, expense (and who profits), and the particulars of how MOC is being implemented.

Azita Hamedani, MD, MPH, FACEP, Chair of Emergency Medicine at the University of Wisconsin School of Medicine and Public Health (University of Wisconsin Hospital and Clinics), will face her first recertification exam this coming fall and says:

Recertification is especially important in emergency medicine where the scope of what we encounter with patients is so broad. A whole decade can go by and there may be certain things we never see, so the board review process has real value in compelling us to refresh our basic knowledge and review information that is no longer as readily top-of-mind as it was when we first certified. I am actually looking forward to taking time off this coming summer to study for my fall board exam. I do not think anyone really has a problem with the exam portion of MOC. Differences of opinion on value apply mostly to the other components such as the QI projects, patient satisfaction evaluations, and yearly exams we must take in order to sit for our 10-year recertification exams.

Sonal Patel, MD, with Durham (NC) VA Medical Center, echoes Dr. Kempen’s objections to MOC when she says: “I work in an academic center where the constant influx of new residents keeps me on my toes and pushes me to stay up to date with my medical knowledge. I do it on my own out of necessity.” At the same time, Dr. Patel acknowledges, “This may be more difficult for people out in private practice because they do not have all the benefits of being steeped in these intensive academic environments.”

Peter Hoenig, MD, practices privately in Lincoln, MA (Lincoln Physicians PC), and became board certified in the very first year after ABIM transitioned from granting lifelong certification to mandating examination once every 10 years. Having recently completed his second of two complete recertification cycles, including MOC practice improvement modules and so forth, he observes:

The exam is easily the most valuable part because it requires a fair amount of study and focus. Studying for the exam forced me to relearn things I had learned quite long ago. And, while the process of preparing for my board exam was painful, I did find it to be very valuable.

For Dr. Hoenig, who will be in his late sixties by the time his third recertification deadline comes due, the big question is:

Will I have the energy to go through it all again? Many health plans now require board certification, and the hospital where I practice only grants privileges to board-certified physicians. The irony is that there are already too few primary care physicians out there. But, because the process is so punishing, I may just decide not to take the exam again.

Board Officials Respond to ABIM MOC Petition

On April 28, ABIM released a statement from its president and CEO Richard J. Baron, responding to the anti-MOC petition directly. While defending the recent expansion of scope in MOC and suggesting that costs to physicians in terms of both dollars and time have been overstated, Baron acknowledges that MOC is imperfect and must continue to evolve:

There is a good deal of research demonstrating the value of MOC: from the validity of the examination, to the importance of independent assessments — clinicians are not good at evaluating their own weaknesses. All of this research drives and informs our program requirements and product development. And while the petition questions the value of our knowledge and practice assessment modules, diplomates who complete them report they are valuable, and that they learned something about their clinical domain or their practice. But I agree — they could be better. And we can and will create even more avenues for physicians to get MOC credit.

In response to claims of MOC’s irrelevance to clinical practice, Baron notes that “ABIM is taking steps to ensure that the practicing physician plays an active part in developing our requirements and approving our products. While we recognize that the program is not perfect, an every-ten-year process is not sufficient to attest that our certified physicians are keeping up.”

For perspective (and, perhaps in contrast to the more than 17,000 signatures acquired so far by the petition), Baron notes that “there are now nearly 150,000 physicians engaged in the ABIM program — with more than 50,000 enrolling in the last four months.”

ABIM asserts that it is listening quite carefully and responding to specific MOC criticisms from its diplomates. ABIM has established the Assessment 2020 task force, which is chaired by Dr. Harlan Krumholz of the Yale School of Medicine and is charged with soliciting input directly from the medical community, undertaking in-depth research, and continually evolving and improving the MOC assessment process.

In an introductory video for Assessment 2020, Dr. Krumholz, who is also the editor-in-chief of NEJM Journal Watch and of NEJM CardioExchange, states:

The task force is taking full advantage of advances in medical practice, technology, cognitive psychology, performance and skill assessment, and pedagogy, bringing together experts in each of these areas to help us determine what the future of board certification should be. While this group will be informed by past approaches and data about the effectiveness of those approaches, it will not be constrained by current methods.

Initiatives already being implemented by the Assessment 2020 task force in response to feedback from the physician community include: embedding high-quality audio in exam questions, providing examinees with the ability to zoom in on images presented in the exam, and enhancing feedback on exam performance. Additional Assessment 2020 initiatives that have moved into the research and development phase include: implementing multistage computer adaptive testing; providing physicians with access to web-based resources during exams in order to better mimic clinical settings and practice; incorporating computer-based simulations into exams; and including clinical calculators.

Greater detail on these initiatives can be accessed at the Assessment 2020 website, where the task force continually reports on its work and also invites physicians to comment, offer ideas and feedback, and interact with the task force directly.

Time Will Tell

It remains to be seen whether the ABIM’s Assessment 2020 initiatives will succeed in allaying physicians’ growing distress regarding the personal costs and time demands of MOC. In the case of grandfathered physicians, some have commented that the new requirements are causing them to consider retirement over recertification; at the same time, anecdotal evidence indicates that a high percentage of grandfathered physicians are enrolling in MOC. Based on ABIM’s MOC participation statistics, it appears that many more physicians are at least tacitly accepting the new requirements than taking an active stand against them.

Let us know your thoughts about the changes to the MOC process and the ABIM MOC petition.