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:
- Potential new patients — especially as people increasingly turn to the Internet and mobile applications to shop for their physicians;
- Career and advancement opportunities — especially when competing against board-certified candidates for desirable positions;
- Practice privileges at hospitals and acceptance into certain insurance and payer systems, which often require board certification; and
- 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.
Quoted from David H. Johnson, M.D., member of the ABIM Board of Directors
: 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. – ”
Dr. Johnson,
You were not wrong! You were right in your statement before you were the member of the board of director and you were right in your statement after you became the member. Thanks for speaking out for us when you were a doctor.
I have asked the following of the ABIM repeatedly and never received an answer: How do you justify having board certified internists that are grandfathered in? How do you justify having internists of differing ages working side by side but the requirements for board certification are not identical? One group took an exam 30 years ago and another group MUST take an exam every ten years? In its basis this is extremely hypocritical if you assert that the exam is to maintain excellence.
MOC modules are useless. I have certified twice and both times I never really learned anything more by engaging in MOC modules to change my practice. I constantly keep up with my specialty by reading relevant journals; having discussions with colleagues in the field; reading trusted online literature; and meeting my state medical license CME requirements. What is MOC offering me that I can’t already obtain through my present method? Nothing!
I completed my internal medicine residency in 2013 and also became board certified in 2013. I am currently listed as board certified, not meeting MOC requirements. How is that so, if I just took my boards? I know the process, and I can just sign up and not have to pay for a certain period of time since I am now in fellowship but to me that is not the point. I honestly agree that some form of maintenance should occur. While most people are knowledgeable and keep up to date with the literature, there are many who practice non-evidence based medicine and that is unacceptable.
What I disagree with is the cost.
I paid for a board review course and materials, travel, and lodging. Not to mention the additional study materials like question banks, etc. I then paid for the actual board test. Now I am expected to pay for MOC. And oh, lets not forget the board review course, materials, travel, and lodging for my fellowship and as well as the cost of the test itself. And newsflash, I still have loans from medical school as well.
When does this end. We are involved in a money scheme that doesn’t even seem worth the cost or daily sacrifices that we make in devoting our beings to patient care. When will this stop.
I contemplate every day whether it is even worth it and I haven’t even completed my training.
I am torn as to whether I should just given in and just sign up for the MOC.
MOC is a total waste of my valuable time. I have recertified twice and found the process cumbersome and of no merit for my busy practice. I regularly do MKSAP and other CME activities that keep me up to date. Like all of medicine the administrative processes that amount to 57% of health care costs are ripe for IT disruption. Don’t look now health and insurance administrators but IT will cut you middle men out in the not to distance future. Driving down health care costs and improving quality of care.
I passed ABIM Oncology boards in 2013 ( fee 2250$ + travel, lodging and board review course fee) – why do I need to pay more fee ( 256 x 10 = 2560$) and take yearly exams to ‘maintain’ my certification in 2014 or 2015 for the next ten years? Haven’t I proven that I am current with my knowledge if I have passed the board exam? If ABIM doesn’t believe in their board exams then they should abolish those and just have annual online exams at a minimal cost and recognize the CME credits and not have us enroll in their ‘MOC’ programs to make more money.
May be it makes some sense to require physicians who have grandfathered and have not taken any sort of board exams for 30 years to enroll in MOC but not the recent graduates. ABIM should stop finding reasons to collect fee from us on the name of ‘maintenance’ of certification.
150,000 physicians enrolled so far = 384,000,000$ = 384 million! How does ABIM justify this cost? How can ‘online’ exams cost this much? This is a total scam.
I completely agree with your thoughts on price. Highway robbery, just like traffic fines in Ferguson,MO.
Throw the bums out!
This whole board should be replaced. They just claimed a golden parachute. Who votes them in?
The ABIM has made a committment for life-long certification to its older members, however. Pulling that back rightly exposes it and these board members to criticsm and liability. I don’t think anyone should be forced to do and pay for this. State boards already require CME. Professional societies provide it for their own fees. ABIM is just trying to monopolize the action.
I just recently passed re-certification exam and still the ABIM website shows me as ” not certified” because I could not complete practice improvement module. As I am clinically inactive now I could not find any module that I could do. I wrote to ABIM about that and then they asked me to do this module. The first part of the module consisted of six didactic module on principles of problem solving. These principles are very general principles and do not actually have any thing to do with medicine. The second part of the module asked me to apply those principles to the problems that I experience at work or during my practice. I again wrote to ABIM saying as I was not working, I did not have any problems. I received an email from ABIM asking me to come up with problems from personal life and apply those principles to solve those problems. I do not understand how this is medicine and how doing this kind of exercise makes me a better doctor or not doing it not a ” good ” doctor.
I recently spoke with two physicians who have completed MOC requirements. Both of them admitted to furnishing false information for their practice improvement modules. I am surprised that none of the posts mention any thing about that – that ABIM is basically forcing physicians to be dishonest. ABIM is aware of the this but will not audit any physician because it will go against them. I am sure almost every physician who has completed MOC requirement has furnished untrue information in one way or the other.
I am not sure why the physicians are not coming together to form an alternate board to make ABIM and similar boards irrelevant.
Dear Collegues,
I am board certified in Internal medicine as well Endocrinology and have kept up with renewal every 10 years. Unfortunately every time it has costed me close to 6000-7000 dollars to do so- including prep time and closing the office to take exam ect. Now they are adding this new MOC requirement, adding more cost to already very expensive process. I have decided to protest and not keep up with my MOC or recertification.
Instead I have joined a new board NBPAS. National Board for Physicians and Surgeons. It is extremely economical and hopefully more relevant than our outdated ABIM.
If interested please join NBPAS at NBPAS@org and help put ABIM out of business.
Why do we need to be certified by an agency after we have finished an accredited training program? It is like the ABMS telling you that the training you obtained is inferior and you can not continue to practice unless you pass this test we have devised.Hospitals in all states where you practice have an annual CME requirement for you to continue to have the hospital privileges. The Licensing board in each state requires you to complete a certain number of CME to renew the License. Every US hospital has a peer review process where quality of care is monitored. State agencies like Medicaid, medical, medicare monitor care in different ways. Utilization and quality is monitored by outcomes which are screened by the Department of Health and human services.As if this is not enough the doctors are being forced into being clerks entering data on computers. Hardly much time is left for direct patient contact.Physician satisfaction is declining and physician burnout is increasing. The additional burden of a cumbersome and meaningless board certification is adding to all these miseries that the doctors are already fighting hard to keep up with. Many experienced physicians are choosing to quit medicine altogether in order to just have a reasonable family life. The board certification adds nothing to quality and has not been proven to enhance care. And why physicians are being forced to dish out exhorbitant fees and extraordinary expenses to prepare for these exams should puzzle every sensible person involved in Health care.And why all these hospitals , payers and IPA’s are all so hooked up on board certification is hard to understand.It is time to terminate this useless excercise that is threatening to drive physicians out of their profession and potentially causing physician shortage when we need more
Dear Colleagues, I am willing to accept that the MOC program is important for us to keep up our skills. If taking an exam to recertify equals quality and maintenance of excellence, then ALL ABIM CERTIFICATE HOLDERS should be taking it. To exclude ‘grandfathered’ internists exposes this as a complete sham. Hod do you justify a large body of “board certified” internists not taking the exam you mandate for others? What is this? Age discrimination?
A Simple question: What is the difference between the CME requirement of license vs MOC requirements?
CME requirements for the state of Fliorida are 40 hours biannual. Most physicians easily complete this with activity, or conferences during that time. I have never implied with any of my posts that I believe CME to be worthless, nor that MOC shouldn’t have a higher standard of CME requirement. To grandfather board certificates, and not having the same requirements to maintain board certificates is simply malfeasant.
Though I am not a doctor, i have been following the process of becoming a doctor starting from USMLE to the practice of medicine for the past 30 years. The new MOC requirements are the mockery of the whole system. It is a money making practice as they do it in the IT industry ; in the name of project management, quality and other money monger schemes. When one is being tested for Boards, any ways and the CME requirements by respective licensing state authorities (for every licensing period), what is the necessary for MOC satisfaction. It is just purely a money making scandal and I think all doctors need to oppose it. It doesn’t make sense. Everyone is looting the doctors now a days; insurances, government, its own board, and definitely patients too with their abuse and jealous inspired with false hype of doctors life.
All physicians are committed to life long learning. MOC should be flexible enough to include everyones learning styles. The one shoe fits all concept doesn’t work. This is why there is so much dissatisfaction with the program. A more reasonable recertification program has been developed by NBPAS. NBPAS allows physician the flexibility they need to best improve their knowledge and skill sets for their particular practice. It is also administered voluntarily by practicing physicians who understand the time constraints of real world medicine. MOC is administered by non practicing physicians who don’t understand how time consuming a medical practice is. They also have a huge financial stake in keeping the status quo. Practicing physicians, like myself, prefer a certifying board to be run by our peers (practicing physicians) who don’t benefit financially from the process.
Funny how the people that agrees with MOC system is likely benefiting financially from this process in the analogous scheme within IT called “project management” or “quality improvement”, blah blah… To all MD’s that emphasize on patient care and strive to filing the need of physician shortage, are you sicking tired of being squeezed by administration, MOC-of-a-governing-body called ABMI or AOBIM, and state medical board mandates? Are you sicking tired of being pressurized to certify/recertify/CME/reimbursement criteria/insurance/admin-mandates, while being deviated from the most important aspect of the medical profession, which is SEEING PATIENTS! Here’s your way out, find a position in admin, IT, or one of governing bodies, or learn the business side of medicine, then use your credentials to “improve” medical care, at least make the hiring body believe you will, then you are golden, because then you are NON-CLINICAL! Great job America, way to get rid off more docs…just asked the “retired” 50 y.o. MD’s that have a non-clinical job…
Medicine is so subjective, stop making objective demands, unless you can backup every decision with a species study, oh that’s right, it will cost infinite amount of $$ to do that… We spend ~20% GDP on healthcare, 8x more than any other developed western country, yet we are last place in overall population health… Go figure that AMA/AOA/ABIM/AOBIM/ACGME/ACOI etc…
As if it’s not enough in early 2000’s with frivolous lawsuits to physicians causing financial hardship that forced abandoned practices, lost medical licenses, because we allow the injustice system to sue physicians for absurd amount of payouts. Now the governing bodies are digging little deeper with new schemes to ensure you are “certified” to see patients. All MD’s please remember that as a six-figure earner which = “deep pockets” you got a bullseye on the back of your head for $-sucking vermins to seek you out…Capitalism, if there a niche for $$ we will find a way to dig it out…hope that is not news for you…
I am a certified, but no meeting MOC requirement, Pediatrician and Neonatologist . ABP said MOC is necessary b/o the continual progress of medicine: I did recertified in Neonatology with the open book process 12 years ago and there where only ONE question (ONE!!) that I could not have answered 10 years before.
So much for the rapid progress of medicine and its evaluation…
Now MOC asks us to jump loops with the pseudo studies such as Washing Hands module or Breast feeding module: If neonatologists don’t have enough enrolled patients for the module, ABP said, they can invent (create) fake patients !! How scientific is it ?!…
Test every 10 years was acceptable but now the studies and modules are too much. The ABP push its chance too far: I applied to the NBPAS (National Board of Physicians and Surgeons). Do the same.
OThelinMD