Whether having meals with physician-relatives, attending a professional society meeting, or walking the halls of a hospital, I find that a common issue on physicians’ minds during our discussions is the American Board of Medical Specialties’ (ABMS) Board Certification process – and particularly our program for maintaining certification known as Maintenance of Certification (MOC).
Questions range from “I know you’re old enough to have grandmother status – do YOU do MOC?” (Yes) to “How can I fit this into my already insanely busy life?” Comments range from appreciation for some aspect of the program to frustration with one of the program components.
As the relatively new leader of ABMS, I welcome the opportunity to discuss issues pertaining to Board Certification and MOC. I hope this post will generate thoughtful dialogue that will result in continuing improvements to the certification process developed by ABMS and our 24 Member Boards. That, in turn, will help us render MOC more relevant and meaningful to participating physicians and will assist them in their efforts to provide quality patient care and improve our health care system.
For many years there were few, if any, requirements for maintaining ABMS Board Certification. Physicians took an exam after graduating from their residencies and thereafter had no further obligations for testing or evaluation. However, over time the error of this approach became obvious. Medical science continuously changes, and the pace of that change has accelerated.
For example, it is well known that the number of identified diseases, diagnostic options, and therapeutic interventions is constantly increasing. Studies have demonstrated that knowledge and skills decline over time [1] and we do not always recognize our limitations because we don’t assess ourselves very well [2]. In the meantime, American society has demanded ongoing learning and assessment of health professionals – and documentation of those activities.
Patients do not interpret “ABMS Board Certification” as an event that may have occurred 25 years ago, but instead as a more current statement of quality. Most patients believe that it is important for physicians to maintain certification[3],[4],[5], and more than one million searches of physicians’ certification status were conducted last year on ABMS’ public website (www.CertificationMatters.org).
Importantly, the medical profession, wishing to retain our privilege and responsibility to self-regulate, also has called for better methods of ongoing professional review and improvement. As a result, Board Certification has changed over time to meet these needs: first, in the last quarter of the 20th century when time-limited certification was adopted and then again, approximately a decade ago when MOC was adopted by the ABMS Member Boards Community.
Critiques of MOC
MOC receives a fair amount of criticism, some deserved and some not. For example, some critics charge that there is no evidence that MOC is beneficial. Because the program is young, the amount of research on MOC-specific outcomes is necessarily limited. However, it simply is not true that there is no evidence about MOC. In fact, the ABMS Member Boards’ MOC requirements are anchored in evidence-based guidelines, national clinical and quality standards, and specialty best practices.
Physician participation in MOC activities has been linked to enhanced clinical performance and improved patient care. Practice improvement methods of the type used in MOC have been shown to improve clinical care in areas ranging from cardiology to pediatrics and covering chronic conditions such as asthma, diabetes, and depression [6],[7],[8],[9],[10],[11],[12],[13],[14],[15].
Physicians who participate in MOC improve their interpersonal and communication skills and medical knowledge, including their ability to identify gaps in knowledge and care 11,[16] These and other research findings are housed in the ABMS Evidence Library™ (www.abms.org/EvidenceLibrary). An important planned initiative of ABMS is to support additional research that rigorously evaluates MOC and its component parts; research that will be made available to the public.
Physicians’ lives have become increasingly complex and busy in recent years, and some criticize MOC for adding complexity in the form of time, effort, and expense. There is no question that any program of continuing development and assessment involves these things; MOC is no different. Efforts are ongoing to reduce costs and to ensure that all program elements are highly relevant and meaningful to physicians. Each Member Board is committed to ensuring that the value obtained by each diplomate merits his or her time, effort, and expense. Several Member Boards are looking at ways to make their tracking systems, websites, call centers, and other diplomate interfaces more user friendly.
A common misconception is that MOC is the same as Maintenance of Licensure (MOL) and that all physicians will be required to become ABMS Board Certified to maintain their medical license. This is simply not true. MOL, a Federation of State Medical Boards (FSMB) initiative, and MOC are distinct and separate programs that share a common conviction that ongoing physician learning and development are both a public expectation and professional obligation. Recognizing the high quality of MOC programs and the efforts made by physicians who voluntarily participate in MOC, ABMS has strongly advocated that if MOL is implemented in any state (and this has not yet happened), physicians who are participating in MOC should be deemed to have met the requirements for MOL. The FSMB has been supportive of this principle.
What Physicians Like About MOC
I regularly hear from physicians that the MOC program has helped them identify previously unrecognized weaknesses and remain up-to-date in their specialty. Learning activities used by physicians to meet their MOC requirements, whether developed by a specific Member Board, a specialty society or another education provider, are usually of high quality. Simulation exercises, chart review, and just-in-time technology-enabled learning at the patient’s bedside are only a few of the ways that adult learning principles and real-life situations are being incorporated into MOC, making it even more meaningful.
One of the most appreciated learning programs, now offered by several Member Boards, identifies key journal articles representing the most important new evidence in the discipline and provides accompanying self-assessment activities. Physicians often tell me that this program improves their patient care and teaching, as well as their own sense of “being caught up.” And although no physician has told me that he or she liked preparing for the secure exam, many have told me that, in retrospect, it was an excellent review and learning experience.
Part IV of the MOC program focuses on practice assessment and improvement. Some physicians who were initial skeptics of this part of MOC have become strong supporters. As noted above, studies have demonstrated the value of MOC in the improvement of patient care. In addition, physicians tell me that Part IV has become a means of evaluating office practice, reorganizing office systems, developing staff skills, and improving employee satisfaction.
Through their engagement in the Multi-Specialty Portfolio Program, which provides Part IV credit to physicians from multiple specialties for participating in institutional quality improvement activities, diplomates are seeing substantial improvements in their practice settings. In response to diplomate concerns about Part IV activities, work also is being done to identify additional ways for physicians to participate in Part IV activities that have the greatest meaning and relevance to their practices.
ABMS is committed to aligning the various activities of practicing physicians, and this commitment is appreciated by many. For example, the MOC Part IV programs of many Member Boards align with such quality initiatives as the Physician Quality Reporting System (PQRS), thus reducing the data collection burden on physicians and increasing their participation in quality reporting. Linking MOC to PQRS helps physicians use the latter to further improve patient care. This year and through 2014, physicians certified by many Member Boards can earn an incentive from the Centers for Medicare & Medicaid for participating in the MOC:PQRS program.
Continuing Improvement for MOC
As part of our own continuing improvement processes, ABMS and our Member Boards have spent the past year evaluating MOC. We have listened to the concerns and preferences of the public, our physician diplomates, institutional representatives, and others as we develop the 2015 Standards for the Program for MOC. These standards will be implemented by the 24 Member Boards in ways that allow appropriate specialty-based emphasis and activities. It is currently anticipated that the standards will take effect in January 2015.
In September, the Proposed Standards for the ABMS Program for MOC was posted online for public comment and is currently available through November 20th. A link has been provided on the ABMS website (www.abms.org). I encourage all readers to review the standards and provide comments.
Studies show that physicians believe in the value of MOC, and more than 450,000 physicians currently participate in MOC programs. Specialists believe that those providing patient care should maintain certification.[17],[18] They participate in MOC to update their knowledge,17,18 and they report positive experiences with components of MOC, such as self-directed assessment modules and examinations. 11,15,[19],[20],[21],[22],[23] ABMS and our Member Boards are committed to continuous improvement of all aspects of the program, including the experience of the participating physician.
Why MOC? Because it is simply untenable in today’s world that a quality credential – and particularly one as meaningful as ABMS Board Certification – would be granted or used without associated expectations of continued professional development. Because it is untenable that the ABMS Member Boards would grant an initial certificate to physicians who met rigorous quality standards and not offer those same physicians a program to help them maintain and demonstrate ongoing quality throughout their careers.
MOC is part of our responsibility to our profession, our ABMS Board Certified physicians, and, most importantly, the patients, families, and communities that we all serve.
Lois Margaret Nora, MD, JD is President and Chief Executive Officer of the American Board of Medical Specialties (ABMS).
References
[1] Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: the relationship between clinical experience and quality of health care. Ann Intern Med. 2005;142(4):260-273.
[2] Davis DA, Mazmanian PE, Fordis M, Van Harrison R, Thorpe KE, Perrier L. Accuracy of physician self-assessment compared with observed measures of competence. JAMA. 2006;296(9):1094-1102.
[3] Brennan TA, Horwitz RI, Duffy FD, Cassel CK, Goode LD, Lipner RS. The role of physician specialty board certification status in the quality movement. JAMA. 2004;292(9):1038-1043.
[4] Freed GL, Dunham KM, Clark SJ, Davis MM; Research Advisory Committee of the American Board of Pediatrics. Perspectives and preferences among the general public regarding physician selection and board certification. J Pediatr. 2010;156:841-845.
[5] American Board of Medical Specialties. Facts about the 2010 ABMS consumer study: lifelong learning and other qualities in choosing a doctor. http://www.abms.org. (Accessed August 27, 2013.)
[6] Hagen MD, Sumner W, Fu H. Diuretic of choice in ABFM hypertension self-assessment module simulations. J Am Board Fam Med. 2012;25(6):805-809.
[7] Duffy FD, Lynn LA, Didura H, et al. Self-assessment of practice performance: development of the ABIM practice improvement module (PIM). J Contin Educ Health Prof. 2008;28(1):38-46.
[8] Miller MR, Griswold M, Harris JM 2nd, et al, Decreasing PICU catheter-associated bloodstream infections: NACHRI’s quality transformation efforts. Pediatrics. 2010;125(2):206-212.
[9] Mandel KE, Kotagal UR. Pay for performance alone cannot drive quality. Arch Pediatr Adolesc Med. 2007;161(7):650-655.
[10] McClellan WM, Millman L, Presley R, Couzins J, Flanders WD. Improved diabetes care by primary care physicians: results of a group-randomized evaluation of the Medicare Health Care Quality Improvement Program (HCQIP). J Clin Epidemiol. 2003;56(12):1210-1217.
[11] Holmboe ES, Meehan TP, Lynn L, Doyle P, Sherwin T, Duffy FD. Promoting physicians’ self-assessment and quality improvement: the ABIM diabetes practice improvement module. J Contin Educ Health Prof. 2006;26(2):109-119.
[12] Wells KB, Sherbourne C, Schoenbaum M, et al. Impact of disseminating quality improvement programs for depression in managed primary care: a randomized controlled trial. JAMA. 2000;283(2):212-220.
[13] Sherbourne CD, Edelen MO. Zhou A, Bird C, Duan N, Wells KB. How a therapy-based quality improvement intervention for depression affected life events and psychological well-being over time: a 9-year longitudinal analysis. Med Care. 2008;46(1):78-84.
[14] Hess BJ, Lynn LA, Holmboe ES, Lipner RS. Toward better care coordination through improved communication with referring physicians. Acad Med. 2009;84(10 Suppl):S109-S112.
[15] Hagen MD, Ivins DJ, Puffer JC, et al. Maintenance of certification for family physicians (MC-FP) self assessment modules (SAMs): the first year. J Am Board Fam Med. 2006;19(4):398-403.
[16] Meredith LS, Jackson-Triche M, Duan N, Rubenstein LV, Camp P, Wells KB. Quality improvement for depression enhances long-term treatment knowledge for primary care clinicians. J Gen Intern Med. 2000;15(12):868-877.
[17] Freed GL, Dunham KM, Althouse LA; American Board of Pediatrics, Research Advisory Committee. Characteristics of general and subspecialty pediatricians who choose not to recertify. Pediatrics. 2008;121(4): 711-717.
[18] Lipner RS, Bylsma WH, Arnold GK, Fortna GS, Tooker J, Cassel CK. Who is maintaining certification in internal medicine—and why? A national survey 10 years after initial certification. Ann Intern Med. 2006:144:29-36.
[19] Levinson W, Holmboe E. Maintenance of certification in internal medicine: facts and misconceptions. Arch Intern Med. 2011;171(2):174-176.
[20] Holmboe ES, Lipner R, Greiner A. Assessing quality of care: knowledge matters. JAMA. 2008;299(3):338-340.
[21] Holmboe ES, Cassel C. Continuing medical education and maintenance of certification: essential links. Perm J. 2007;11(4):71-75.
[22] ABIM PIM survey results. January 2011-July 2012.
[23] ABIM SEP modules survey results. July 2009-January 2012.
Categories: Uncategorized
Board certification which includes MOC/OCC is a joke at best. Passing an exam, board certified, does not make you a better doctor period. What that is basically saying is a board certified doctor only makes correct decisions and is more knowledgeable than a non-boarded doctor and given that lowers health care cost by not ordering tests etc unnecessarily. Another way to put it is god like. How about all those board certified doctors who have to pay back millions to Medicare/Medicaid for billing issues. So that is how health care cost is lowered. And as for having more knowledge goes. So the doctor who is just out of residency and just got notified they are now board certified knows more than a non-boarded doctor who has been out of residency for a year, five years etc. not likely. There is way more to say and comment on. There is a simple solution to this issue. Do away with all board certifications. If there is no board certification then there is no MOC/OCC and therefore no hassles and headaches. All that data being collected to so called improve health care can still be collected. The only thing that it is doing is giving insurance companies an excuse not pay. But what do I know since I am not board certified and I am proud of that.
Look at the tax returns from these pigs, nice cash cow you have going there Dr. Nora. MOC is nothing but a big scam, making people like her rich off the sweat of us hard working docs in the trenches. Thank God for the NBPAS, no more MOC BS for me.
True, true and true. Fight this. Check out this website: http://www.changeboardrecert.com/index.php
Lois Margaret Nora the president and CEO of ABMS was boarded in 1987 and therefore is exempt from having to ever recertify. Why should we have to deal with the costly and time-consuming process of recertification when the elite’s who make the rules don’t have to? Actually I can think of one reason…
To pay the outlandish salaries of Dr Lois Margaret Nora and her colleagues. In 2009 the president and CEO of ABMS was paid over $400,000. Six years later that number has gone up (do you think she would give herself a pay cut?) Guess who’s paying their salaries? We are.
So this is what we need – an ALTERNATIVE – and not a costly one. If we all jump on this bandwagon – we might have some “reasonable” hope of getting out of this MOC nonsense. Check it out – http://www.NBPAS.org
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This ivory-tower double-speak sickens me. Dr. Nora says she participates in MOC and yet her last certification was in 1987.
How can we take anything this woman says seriously when the ABIM just opened up board certification to NON-physician providers?
MOC and everyone who runs it can go straight to hell.
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“Lois Margaret Nora, MD, JD is President and Chief Executive Officer of the American Board of Medical Specialties (ABMS).”
Hmm. Wonder what they pay you, Dr. Nora.
FELLOW PHYSICIANS!!!!!!!! Mass non-compliance will defund this nonsense. DO. NOT. COMPLY!!!!
Interesting how whenever an article comes out about MOC, the overwhelming, almost to a doctor, comments are extremely negative. JUST SAY NO!
Why? Because they have no interest in pursuing anything that might stop their gravy train; its a simple as that. So either we front line docs bow to that, or fight that.
Why doesn’t the ABMS conduct a randomized trial in which a large number of randomly selected diplomates is given a waiver from the MOC requirements for 5 years, and various outcomes like patient satisfaction scores, clinical outcomes, malpractice claims, physician satisfaction indicators such as likelihood of the physician retiring when their certification period is up for recent, etc , are compared with a large number of randomly selected diplomates who continue with the MOC in the usual fashion for the same five year period? If the ABMS really wants evidence to support their position then this would be a way to do it. However, I think they know that the outcomes would be the same, except for the physician satisfaction outcomes which would be significantly different between the two groups.
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Sadly, Dr. Nora has a fatal condition like most of her colleagues at the ABMS and the FSMB – an inability to speak the truth. This disease is rampant among the Gucci-heeled Presidents of the Boards, who have extorted annual compensation ranging from $500,000 to over $1.25 million annually from hard-working physicians in the trenches who actually provide care and expertise to real patients.
I am Board Certified and re-certified a couple of times, most recently passing the ABP MOC exam last fall. I refuse to continue to comply at the point of a gun wielded by a private group of shysters exploiting a form of regulatory capture for greed and control over physicians. The ABMS should be prosecuted to the fullest extent of the law for racketeering, mail fraud, and extortion. They should be convicted of criminal activity, paying triple damages in clawback from their organizations and leaders, who should serve serious prison time for their criminal conspiracy.
What do I think of the Boards, Dr. Nora, and her criminal coconspirators? I think they are full of something that several quarts of PEG solution is unlikely to cure.
That should have been “four or more drugs, including HIV drugs.”
Dr. Nora and colleagues. I’ve decided I will take the MOC…just as soon as you people who run ABIM MOC take the exam and post your own scores for all to see. Game? What? What do you mean, you’re too specialized to take it? Isn’t each doctor specialized for their niche as well? I don’t see a single HIV patient in my practice. Yes, it’s strange, but we have NONE in the town I work in. Yet, I’m supposed to be nearly a semi-expert on the ever changing field of infectious disease that is HIV. We’re strongly encouraged in our area to refer any HIV positive patients to the HIV clinic in the large city nearby. My government-stamped EHR tells me all 56 interactions possible for each patient on four or more drugs. Why should my wife’s GYN surgeon be responsible for knowing about renal transplant surgery? It just makes no sense. Again, I challenge you at MOC to practice what you preach by taking the ABIM MOC and posting your scores or at least a pass-fail record. Everyone of you who fails to pass should get fired, too. That’s what happens to busy doctors who don’t have the time or the money to certify. They get fired off the staff at the hospital you’ve brainwashed into believing passing your test makes them a competent doctor. By the way, your oft quoted estimates on time and money to re-certify are WAY off.
You ugly obese woman!! How do you sleep at night? Yes that is how livid I am over moc! Its personal!!
MOC is a fee scam to enrich the specialty boards.
The MOC requirements are mostly useless.
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35% who will need to pay more fees to retest; what a scam
News flash: just took the IM recert exam May 19, 2014…. the ABIM has reported that 35 % of the test takers failed the exam.
“Does the MOC process help make us meet that goal? I hear that it does” based on the anecdotes of some OB/GYNs, “an anesthesiologist”, and “a general inernist”????
ARE YOU KIDDING ME? Where is the evidence? As a physician I would expect you to produce some empirical evidence and not point to anecdotes to support a position that has no basis in science and is so universally unpopular outside of your ABMS offices.
How about you study the cost effectiveness of your initial “CPD” changes to the recertification process first instead of charging ahead and changing the process YET AGAIN into YET ANOTHER UINPROVEN AND MORE EXPENSIVE AND ONEROUS process like MOC? You have 10 years of CPD data to work with. Come back when you have something more substantial than “Dr. Bob said it helped so it must be a good idea.”
*crickets*
Questions range from “I know you’re old enough to have grandmother status – do YOU do MOC?” (Yes)
A half-truth at best. As of 1/13/2013 Dr. Nora was not enrolled nor meeting MOC requirements and never recertified in her specialty because she didn’t have to. See the 15:27 mark:
https://www.youtube.com/watch?v=2O83c-6G7oo&feature=youtu.be
No doubt she signed up for MOC after that date for appearances sake, but per Dr. Kemper’s lecture she never recertified since she was granted an indefinite certification in 1987.
Unless she cares to dispute this. If it’s true (and I believe it is as she has not responded to Dr. Kemper’s lecture assertion) I find it disingenuous that she claims to be such a champion for ongoing recertification yet never participated in any sort of recertification prior to her election to CEO/President of the ABMS (with its accompanying salary of over $400,000/year).
Maybe I missed it. Would any proponent of the MOC program please provide a study documenting that it improves patient care. The study question is simple. I see a lot of opinion thrown around. Why are we told that this is valuable and told to accept that as fact without any study to back it up. Would anyone prescribe a therapy based this type of recommendation?
Backlash grows against MOC process
By: ALICIA AULT, Internal Medicine News Digital Network
Resistance against the American Board of Internal Medicine’s maintenance of certification process is growing, with an online petition to overturn the board’s most recent changes having collected more than 13,000 signatures at press time.
Physicians who commented on the petition did not agree.
Dr. Jesse Naghi, a third-year fellow at the University of California, San Diego, Sulpizio Cardiovascular Center, wrote, “Asking for more money on top of our already high recertification fees seems rather greedy.”
“This is an arm-twisting and money-making scam by our own board,” said Dr. Garrett Sanford, of Little Rock, Ark.
“We do recognize that there is a cost – for the large majority of our physicians, the entire program costs from $200 to $400 per year,” said Dr. Baron, in his statement. “Our fee structure covers the costs of developing and administering the secure, computer-based exams at test centers nationwide, as well as the ongoing development and release of all ABIM self-assessment products,” he said, adding, “I encourage the petition signers to visit ABIM’s revenue and expenses [Web page] for more information.”
See: http://www.internalmedicinenews.com/specialty-focus/practice-trends/single-article-page/backlash-grows-against-moc-process/376e81d9cf7ff3e8126c8ec627a9beaa.html for full details why MOC is Extortion!
As a doctor, I don’t even have time to scratch my head and yet these blood suckers keep piling on these stupid requirements year after year just to make an extra buck and put the burden on me to pay their lazy asses. I started loving medicine but I hate it now because of these idiots. I will quit very soon to do something else. Thank God that I have other skills and I don’t need to deal with their nonesense. So MOC my words: I will not pay you a dime; take your certification and shove it.
http://m.youtube.com/watch?v=XFVF0Pb_my8
I should get my JD and MBA just like Dr. Nora, so I can find ways to make money off of other doctors.
Dr. Nora, how much is ABIM paying you? And are you paying for your MOC or is it on the house.
I can sum up MOC in one word: “SCAM”
If this is a legitimate certification process, there shouldn’t be exorbitant ABIM profits. This MOC SCAM is costing physicians way too much money, and SHAME ON YOU ABIM for posting such enormous profits. I hope you are sued and go out of business.
Micheal Goldman, MD
New York, NY
David, we all agree with you; check out changeboardrecert.com
I nave recertified now 2 times and each time the process has less to do with medical practice and more to do with regurgitating the policy lines of the ABIM.. I have tried for months to get a simple answer, what do people like me who are not in private practice, not on committees not in teaching do to meet the practice improvement requirement? No answer so far.
Unfortunately ABMS and ABIM have a lot of money to push this nonsense.
The exam makes sense every 10 year. CME makes sense. Doing modules where patients or collegues do surveys is just plain dumb! It’s a waste of time. Furthermore why is a non profit organization making insane amounts of money -you can look up their tax returns online! Enough is enough! Don’t fall for MOC. It’s a money making cash grab under the guise of improving healthcare.
MOC is a time-waster AND WAY TOO EXPENSIVE!!!!!. We all have different ways of learning/keeping up. We have cme requirements for licensure. Simple testing is enough. Submitting logs, patient popularity questions, etc. is twofold: money to support societies and leaders/board members and abms/societies wanting to look good that has no evidence. Most of studies are 2005-2009 and relate to testing, not all the other clerical work that we are overwhelmed with with pqrs, meaningful use, data submissions for pqrs, local licensing, hospital/insurance credentialing. Say all you want that “at least we are trying” and “we are listening to complaints” How about testing with scientific method if components of MOC are RELIABLE predictors of care instead of instituting them for your self-gain and trying to show “doing something.
It is very wrong to proclaim “myths” when the only evidence is for testing and not all the other steps of MOC. The studies listed are pitiful in content, correlation to present “hoops” for us to jump through, and mostly old–where are new studies?
THE REAL CORRELATION IS THAT DOCTORS WHO JUMP THROUGH THESE HOOPS ARE GOOD PEOPLE WHO JUMP THROUGH HOOPS TO GIVE BEST CARE FOR THEIR PATIENTS, NOT THAT THIS PROCESS HELPS PHYSICIANS BEGIN TO FIND OUT HOW TO TAKE CARE OF PATIENTS BETTER!!!!!!!!!!!! WHAT A CLEAR LACK OF HONESTY IN CORRELATIONS, ASSUMPTIONS, AND SCIENTIFIC METHOD!!!!!