Physicians

Why Maintenance of Certification Will Make You a Better Doctor

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.

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73 replies »

  1. 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.

  2. 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.

  3. 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.

  4. 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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  12. 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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  14. “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!!!!

  15. Interesting how whenever an article comes out about MOC, the overwhelming, almost to a doctor, comments are extremely negative. JUST SAY NO!

  16. 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.

  17. 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.

  18. 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.

  19. 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.

  20. You ugly obese woman!! How do you sleep at night? Yes that is how livid I am over moc! Its personal!!

  21. MOC is a fee scam to enrich the specialty boards.
    The MOC requirements are mostly useless.

  22. News flash: just took the IM recert exam May 19, 2014…. the ABIM has reported that 35 % of the test takers failed the exam.

  23. “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.”

  24. 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).

  25. 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?

  26. 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!

  27. 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.

  28. 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.

  29. 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

  30. 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.

  31. 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.

  32. 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!!!!!

  33. Continual physician education is good. The MOC is time consuming and costly make work. Board certified 4 times. Even took the time to ‘re-review info after test results reported. In over 25 years there is extremely little value f2f aimed from the testing.
    Additionally, look at the constant journal article information infusion that often have conflicting opinions and results. Rarely is there real world physician to patient encounter value.

  34. I see 29 responses to Dr Nora’s blog post. Espousing dialogue. Yet for each response so far there has been no comment and dialogue by Dr Nora. She and the Board of the ABMS should disclose publicly their salaries as well as respond to each response here to truly, openly and transparently carry on a dialogue.

  35. Take a look at organizations like these two: http://www.changeboardrecert.com/index.php and http://www.aapsonline.org. They will help you gather the info you need to fight this, but in the end, other than supporting the AAPS lawsuit, don’t look for some magic organization to organize mass non-compliance. Non-complance is a grass roots process and each and every one of us can be part of the engine that makes it happen, and with the internet, it is far easier than ever before. Whether you prefer email, a blog, twitter, Facebook, Sermo, etc, etc, each of us has to continually reach out to every medical colleague we can, from our med school days, from internship, residency and fellowship right up until our current local medical communities and keep spreading the word and pushing the agenda, which is to not cave into this unproven, insanely onerous (for us) cash cow (for Board members). Just say no; don’t do it. Convince your hospital not to require MOC for privileges, convince your politicians that MOC should not be needed for MOL. Talk to your state medical boards. It’s time not to take it anymore!

  36. if there was an organization with the only objective to organize mass non-compliance among physicians, i’d sign up in a heart beat!

  37. Virginia H’s statement: about expectations is founded in fantasy. If all expectations were met, there would never be any complications, overweight people, drug addict or wars. Medicine is inherently dangerous and physicians ARE competent. The only ones pushing this MOC crap are those who stand to profit from it-ABMS employees, academics, politicians and confidence scammers. The ABMS-MOC is the pure confidence scheme, selling “confidence attestation” base on home cooked productions. At least the “good housekeeping seal of approval” promises a money back guarantee-no such thing with ABMS certificates which expire if you fail to keep buying their products EVERY year! Their own 10 year certification is a fantasy-as it “expires” unless you continue to pay them for the privilege. The ABMS does not even produce educational materials-just non-validated nonsense.
    The patients want inexpensive healthcare that is free and they are willing to go to Walmart, CVS or other mall centers to get care from non-physicians without ANY medical school education. DUmb the practice of medicine down to the lowest paid denominator and keep making physicians even more expensive by keeping them out of the practice and doing ABMS busy work! Right! Now THAT is a real corporate (i.e. ABMS!) plan for success-but not for medical care!
    I have NEVER in 32 years been asked if I am board certified and NO physicians in Europe are ever required to do this nonsense-an I guess that is why Americans are going to Europe for their out of pocket “medical tourism” excursions-they aren’t paying for the ABMS nonsense in Europe!

  38. Having recertified and participated in the MOC a few years ago, I can attest it did not add one iota to my knowledge or ability to care for my patients cost-effectively.

    Interestingly, the financial nexus between ABMS and the ACP (which Virginia H most likely represents), is clear. The ACP loves to sell MOC courses to its members while ABMS loves to create more expensive hurdles of unproven value. No wonder Virginia goes out of her way to extol the virtues of MOC, when there is no documented proof to support it. To the contrary, we have results of national surveys from 2013 that demonstrate unequivocally that physicians find little value in MOC and the general public has little clue what BC or MOC really means. What a shame that Dr. Nora or her colleagues from ABIM refused to even debate MOC in Philadelphia (just a few blocks away from ABIM) even when provided a full month’s notice. Actions speak louder than words and propaganda.

    If ABMS truly believes that MOC brings value to the physicians and their patients, the most objective way to prove it, would be to make BC permanent and let MOC compete with all other methods of lifelong learning…Dr. Nora, are you up the challenge?

  39. Really Virginia? We all recognize everyone wants perfection from physicians. Do you really believe MOC is going to improve outcomes in any way? There is absolutely no reason to believe that is the case. We understand all the criticisms physicians have heard over the last ten years. We strongly believe MOC IS NOT THE ANSWER. Everybody wants more from physicians at lower and lower costs. Good luck finding a physician able to keep his/her head above water with all these restrictions, rules, cries for perfection and increased productivity. And when you do, you will not be able to show that expensive, bureaucratic education helped at all. I suggest you read physician social media such as Sermo, where countless physicians in the trenches have stated that they would rather retire than recertify.

  40. What everyone seems to be ignoring is what the public, the hospitals, insurance companies and the quality industry are demanding/expecting. They want doctors who keep up with evidence based medicine and “trust us” we are reading journals & going to CMEs is not good enough. These groups do not think MOC goes far enough– they want to stratify physicians based on quality and outcomes and though we are not there yet that is what they want. Patients want access to the latest thinking. And good doctors want to provide that level of care.The majority of people writing here are ignoring all the data that has come out in the last ten years that talks about mistakes, waste and patients not getting the right care. Instead of reading the changeboardrecert website look at the Institute of Medicine website. MOC is not perfect but it is a step and a step that is being demanded. The Boards have a choice– they can either move the physician self improvement process closer to what the public demands or the situation will be taken out of their hands either by ACOs/insurance companies or the federal government. Are you part of the solution or the problem? The Boards at least are making an effort.

  41. Dr. Eggen’s comments could have been taken from the ABIM or FSMB websites, merely rehashing the party line that MOC is good and necessary because a small group of (self-interested) physicians, citing the flimsiest of scientifically compelling reasoning, say so. Far more on target are the comments of Joe Hauser and Miguel Cabrera, who accurately portray MOC for what is really is, a scam, and instead advocate what has worked, and worked well, for decades, cost appropriate and time efficient self-directed life-long learning via CME and similar programs.

  42. The ABMS can only truly “reassure” the public that many physicians are forced to enroll in an expensive, onerous, bureaucratic educational hurdle that is despised by many, liked by a few, and has no high quality evidence of accomplishing anything but ABMS/ABIM revenue generation.

  43. Mark, no one is against lifelong learning. Many are against institutional lifelong learning, especially with an inflexible, expensive, intrusive model that may not be applicable to any one physician. Many are against institutionalized lifelong learning that has no evidence for efficacy when compared to self-directed education, and therefore, is completely irrelevant. It is fine for institutionalized lifelong learning to be offered. It is not right to make it mandatory in any way, especially when such huge revenue is at stake. Just because MOC is physician led, there is still no evidence it accomplishes what it is supposed to do. One could say that self-directed education is entirely more flexible, much more efficient, much less costly, and physician led.

  44. With medical knowledge and technology changing at an accelerated pace and knowing that knowledge and skills decline over time, how could a physician not be expected to keep current through a process of lifelong learning and assessment? MOC is a physician-led effort that offers lifelong learning and continued professional development. When taken collectively, the four components of MOC assess physicians’ proficiency across the six core competencies that are designed to help define clinical judgment and skills essential for providing high quality patient care.

  45. Dear Lois: Here is my survey results from an online survey of WORKING PHYSICIANS, What are the ABMS’s?

    86%
    Shim
    It is an unnecessary revenue generator for the ABMS and specialty boards (56/65)

    29%
    Shim
    They should be repeatedly asked to show Level I ‘evidence’ to support the idea. (19/65)

    18%
    Shim
    It is one of the factors determining when I retire. I am NOT going to do any more MOC. (12/65)

    17%
    Shim
    It is yet another sign of the widespread corruption in this country (11/65)

    15%
    Shim
    It is part of controlling and regimenting physicians so they will obey their taskmasters (10/65)

    14%
    Shim
    Funny that they’d ask, like they care. (9/65)

    2%
    Shim
    reason that NPs and PAs have more options than MDs for practice (1/65)

    0%
    I can’t wait to participate in my MOC when I arise each AM (0/65)

  46. Dr Nora, you say you want to “discuss” issues related to MOC. But you never respond to Dr. Kempen or anyone who dares to criticize your beloved MOC. Why not?

  47. Dear Dr Nora: Be sure that there is NO “misunderstanding about the relationship between MOC and federal quality reporting programs such as PQRS.”
    THe ABMS LOBBIED congress to impose this nonsense/tax on physicians and this can be verified by the statement of YOUR American Board of Anesthesiology (ABA) which THEY published in 2011 at: http://www.theaba.org/pdf/MOC_PQRS.pdf
    Here you will read and I quote: “Throughout 2009 and 2010, ABMS lobbied Congress for language in the healthcare reform bill to establish a MOC-PQRS program that would include incentive payment for MOC activities.”

    The ABA went on to state the following at the bottom in a grey box as:
    “Key Messages on the MOC-PQRS bonus:
    Based on its understanding of the current CMS requirements, the ABA does not believe that the additional requirements for the MOC bonus will have a sufficient impact on patient care, nor will the reimbursement bonus justify the additional time and resource burden on its diplomates. Accordingly, the ABA does not intend to submit an application for CMS approval of an ABA MOC-PQRS program in 2011.”

    Only in 2013, in an effort to stave OFF the taxation of ABA MOC on participating members, has the ABA become a “provider” for this service.
    The ABMS has corrupted congress to meet their OWN financial need to conscript EVERY PHYSICIAN via REGULATORY CAPTURE into their program. The 24 boards were all FORCED to follow the ABMS “central plan” or lose the “franchise”. This is simply offensive and clearly un-American, monopolistic and wasteful conscription-familiar from the cold war programs of asia.
    I am Well informed and again invite you to debate me in public forum before practicing physicians on the scam created from lifelong certification of “attainment of consultant status” into this entry level subscription to an unproven, unnecessary and wasteful program. The facts will be known and the anger is increasing. Take the hint. Physicians have abandoned the AMA in droves over the stark regulatory capture regarding billing and coding power-plays and this can also happen to the ABMS and the 24 affiliates.

  48. Dr. Nora, how can the MOC process be improved when it is perceived as a scam and a money grab by many physicians? I would suggest that the MOC fees should be dramatically slashed, and I would suggest the board chairs have their salary changed to the median of practicing physicians in that specialty. I assure you they would then be more sympathetic to those poor individuals who are compelled to complete MOC.

    It is worth considering that MOC can never be improved enough to ever be truly useful, and should therefore be stopped altogether.

  49. Thanks to the many who have provided your thoughtful comments and insights. Your responses and the public comments on the standards will help us continue to improve the MOC process. For example, the comments about when physicians should be asked for feedback about their MOC experience will be considered as we work with the Boards on the best ways to incorporate diplomate feedback into their own review and continuous quality improvement of their MOC Programs.

    A common value that comes through in your responses is the commitment to quality medical care. Does the MOC process help make us meet that goal? I hear that it does – even as I hear about the ways that the Program can improve. For example, obstetrician-gynecologists point, with appreciation, to their MOC program’s learning and self-assessment approach to keeping those specialists up-to-date. An anesthesiologist, who reported initial skepticism about MOC, also told of skills that he gained through his MOC training later being used for the emergent care of a patient. A general internist reports that her MOC Practice Improvement activities not only improved the care of her patients but functioning of her front office.

    There appears to be misunderstanding about the relationship between MOC and federal quality reporting programs such as PQRS. ABMS Member Board MOC programs are defined by the profession with specific regard to the best practices, clinical requirements and measures developed by experts within a given medical specialty. The Centers for Medicare & Medicaid (CMS) do not define the programs. CMS does require physicians to report on quality measures. We believe MOC can offer physicians an avenue to satisfy these requirements by providing performance data that is clinically meaningful and relevant to their practices. Aligning MOC with other performance assessment measures, where it makes sense to do so, reduces burden on physicians. That is a goal we all have in common.

    Thank you again for your responses. The comment period on the Proposed Standards for Programs for MOC ends tonight; please comment if you have not.

  50. Dr. Nora’s opinions on board certification are expected as one who is now at the helm of ABMS. While I am board certified, I do not feel that this designation has been of benefit to me or to my patients. The program has been expensive, time consuming and coercive. The changes that have been implemented to start in January 2014 do not materially change these facts. The forces in play here and the agenda go beyond the stated mission of increasing physicians’ performance and verifying that a certain standard has been reached. I take my responsibility for lifelong education and professional development very seriously. Board re certification and MOC requirement to not contribute to this success. Indeed, they consume time and resources that could have been devoted to educational activities that would perform a true educational function.

    Most of us who are familiar with practicing according to medical evidence recognize how thin the ‘evidence’ is supporting MOC. I’ll wager that if a truly independent group studies this issue, that the conclusion would confirm what most actual practicing physicians already know. If this study rejected the value of MOC, would Dr. Nora and colleagues, d/c the MOC program or criticize the study?

  51. Dr Nora’s very convenient answer “Questions range from “I know you’re old enough to have grandmother status – do YOU do MOC?” (Yes)” is a gross misrepresentation of facts, as are the vast majority of the ABMS self produced “science” listed above in the references. THE ABMS itself attempted a meta-analysis of the data and published this as a complete FAILURE to enable support of their certificatiion (see:Acad. Med. 2002;77:534–542) stating: “Conclusions. Few published studies (5%) used research methods appropriate for the research question”
    Dr Nora certified in 1987 and only in early 2013 recertified, for the very first time-to fulfill her “ABMS job requirements”. This “commitment” underlines the dishonesty prevalent throughout ABMS and all Boards ranks regrading the importance of recertification int heir own lives (read:http://dx.doi.org/10.3402/jchimp.v2i4.19753). IF this MOC program were such a great thing, physicians would have flocked to comply and the ABIM Task Force on Recertification would never have declared the impossibility of voluntary recertification programs-which was published BY THE ABIM (and see table P 203!) in Ann Intern Med. 2000;133:202-208: “In 1986, ABIM reluctantly concluded that the concept of voluntary recertification, no matter how well-conceived, was unlikely to be successful.”
    Dr Nora’s statement that ” more than 450,000 physicians currently participate in MOC programs”, is as disingenuous as her and many ABMS leader’s personal recertification history- that 450K represents only that 1/2 of all US physicians who ARE intimidated by the fear of MOC requirements to stay in practice, while 25% of ALL us physicians NEVER certified with the ABMS! There is NO significant ABMS penetration into non-US markets and Europe is known for medical excellence without ANY ABMS presence! The ABMS is a confidence scam selling “confidence” to physicians, patients, bureaucrats and the non-suspecting general public at great cost and NO value.
    “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 PQRS-MOC program.” Thanks ABMS for introducing this 2% PENALTY, due to force physicians to submit to the ABMS corporate program by 2016 or LOSE 2% of all CMS payments-just another tax on physicians and sold to congress personally by the ABMS to get their program to FORCE physicians to subscribe.
    The biggest problem is that the ABMS MOC programs ASSUME there is some problem with physician’s care and they are the ONLY ones who have the answer to this lie.
    Dr Nora, the ABIM and ABMS FAILED to appear upon open invitation in THEIR HOMETOWN of Philadelphia this year to debate the merits of recertification (see: http://www.youtube.com/watch?v=AetMD0OYVkY&feature=youtu.be). Scroll to minute 15 to start debate after introductions. Dr Nora-I invite YOU and any ABMS/ABIM leaders to openly debate this topic before a general collection of practicing physicians-anytime, anyplace on your turf. The arguments against this confidence scheme are overwhelming and in print or presented in that video produced on neutral ground!

  52. “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.” No Dr. Nora, it is untenable that ABMS forces this expensive MOC nonsense on unwilling participants. It is fine to “offer” MOC, but to force it on overburdened physicians is untenable. Offer MOC and let participants freely choose whether they want to participate. Then we can truly assess how useful physicians feel about MOC. Lifetime certification and lifelong learning is the recipe for success. Anything else is all about obnoxious ABMS revenue and ABMS control

  53. MOC is a money making scheme for the ABIM. Please disclose the compensation to its leaders, to include monetary and “benefits”, such as paid travel and luxury hotels and dinners.

  54. Asking scared physicians for their opinions of MOC just before receiving their test results is not the appropriate way to poll. Why not ask physicians what they think of the MOC process 1 year after they have received their test results? I venture to say the results would be FAR different. Another example of ABMS data manipulation and manufactured “evidence” to force this monstrosity on unwilling subjects.

  55. Can multiple choice questions really assess one’s ability as a physician? Can this process really “improve….interpersonal and communication skills?”
    Doesn’t being a physician mean more than what can be measured by taking a multiple choice test? I think MOC just measures our ability to comply with increasingly outrageous, expensive, and non-reimbursed regulation.

  56. Really Dr. Nora? MOC is a “young” program? We know recertification has been around for decades. With the revenue raised by the ABMS member boards, there has been plenty of time and revenue to document any utility of this farce. Please stop using “young program” as an excuse to foist this expensive process on those who have no input into its development. We know better. We recognize the hypocrisy of using ABIM employees to do retrospective chart reviews of dubious merit to provide some pathetic “evidence” that MOC accomplishes anything worthwhile except revenue generation to the specialty boards. We are smarter than that, Dr. Nora

  57. As a profession, physicians need to collectively look at all the policies, regulations, mandates, financial arrangements and such that impact the patient-physician relationship and our autonomy, the evidence that these have any clinical validity, and the (perverse) incentives of those who promote these. While I respect many of the various Boards members, and certainly mine, any thinking physician would have great trouble accepting
    Dr. Nora’s points for anything other than a fable, pushed by bureaucrats
    who wish to protect their financial arrangements and power. There is little
    evidence that any of her points have validity; certainly no surgeon or
    internist would adopt a new treatment or procedure based on the flimsy evidence the ABMS uses to attempt to justify their cause. It is also telling that Recert, then MOC was constructed over the past 25-30 yrs, behind closed doors and c little input from the practicing physicians it affects, and c no evidence base. Sadly, our profession is beat up, c many physicians bright, but PC, risk adverse, test takers. And acolytes to those who
    choose to conscript them.
    As we watch another poorly construed policy (PPACA), that also has the potential to hurt the patient-physician relationship, fail; one may wish to observe the talking points and narratives used to first promote it, then rationalize its reasons for failure. Very similar to what is used as ‘fact’ to support MOC and the ABMS agenda.
    Our hope is that physicians will begin to wake up and push back to protect our profession and the patient-physician relationship that is being threatened at many levels, and by many powers and false prophets; the govt, insurers, trial bar, now MOC. As CS Lewis said- ‘Of all tyrannies, one exercised for the ‘good’ of its people is the most oppressive.’
    Let’s hope that Drs Nora, Casel, Wachter, Holmboe, Choudry, et al will join
    us in dvlping a true program of Lifelong Learning that we all support, rather
    than the sham of MOC and lifelong testing. This could begin by a series of open discussions and planning c practicing physicians.
    I think we are all tiring of bureaucrats, theorists and social engineers telling us how medicine should be practiced, what quality entails, and what makes a ‘good’ physician. And the attendant ppwk and time spent on complying c these processes of little clinical value.
    Thank you and let’s keep this discussion going as we work together for a better future. Check out ChangeBoardRecert.com and join AAPS.

    It is time for all to say – Enough is Enough

  58. Credentials: Board certified x 3 in IM, pulm and CCM 20 years ago; recertified x 3 ten years ago. Recertified again x 1 (in IM) one year ago, at which point I had a revelation, and that revelation was as follows. MOC is a costly onerous scam. It makes a select few very wealthy (Board members, etc). NO PART of my medical practice has ever been improved by my participation in MOC. In fact, as my time is limited, my medical practice may well have been somewhat harmed by my participation in MOC, as I was forced to waste time memorizing useless irrelevant minutiae regarding esoteric medical issues I will never see, taking valuable time away from learning opportunities of my choosing focused on medical issues that are part of my actual medical practice. There is no credible evidence to support the benefit of MOC. This is yet another example of the over-regulation of medicine and is a direct contributor to the worsening doctor shortage, as utterly capable physicians retire far earlier than necessary rather than deal with the ugly beast known as MOC. Politicians and regulators are only too happy to buy into and promote a process that the vast majority of physicians hate and feel is useless and which the public could care less about,but which lines their pockets with cash.

  59. Frankly, I’m tired of the commercialization of lifelong learning. Dr. Nora, we are professionals, and deserve better than one-size fits all bureaucratic, score-keeping education. It is not right to ignore the massive profits of the ABMS member boards and the obnoxiously inflated salaries paid to the board chairs. This information is publicly available for all to see and should be an embarrassment to member boards. We should be able to guide our own lifelong learning and should not have to seek and pay for ABMS approval of our lifelong learning. This MOC is clearly a money and power grab by the greedy ABMS and member boards and has little to do with education. Please be more honest with us, Dr. Nora

  60. My experience with things like this is that the feedback period is to give the masses the illusion that they have a voice. Regulatory groups like the boards and the ACGME then just go right ahead with their plans.

  61. I appreciate Dr. Nora’s invitation to dialogue. I completely agree that physicians should have ongoing education and training to maintain their expertise and keep current on what is new in the field. MOC is a good idea. A couple of concerns: first, the research that Dr. Nora cites involves mostly self-reports on specific outcomes. I understand that the process of MOC is too new to evaluate for effectiveness. Second, a lot of the MOC programs look like web-based modules that are completed independently. I have my doubts about how carefully or completely those things are generally done. There is also the considerable and uncompensated time and cost, as Dr. Nora mentioned.

    Here’s the bigger problem: the educational criteria for each specialty is not based on actual clinical practice, but on CMS practice guidelines and quality outcomes. This would be fine except we all know that CMS quality measures measure only those things easily quantified and not necessarily those linked with better care for the individual. It is particularly concerning that independent boards have linked their assessments to PQRS, basically requiring doctors to cooperate with the government to collect quality improvement data. From what I’ve read today, MOC seems to be a government initiative in disguise.

    I appreciate the efforts of the ABMS. I don’t think it’s initiatives will improve the quality of care substantially. What will? Giving doctors more time with patients. Providing doctors with an open-access, curated website for all the latest relevant clinical research. Providing meaningful and useful lectures in grand rounds and other venues. Compensating doctors for “professional development” time, the time that even my pre-schooler’s teachers take for themselves once a month. Allowing “mini-residencies” for deficiencies. For example, if an anesthesiologist is rusty on fiberoptic skills, doing a month- or week-long intensive airway “rotation” would go a lot further in increasing skills than an on-line course.

  62. Dear Dr. Nora,

    Thank you for an excellent piece in an increasingly complex area, how to maintain each physician’s knowledge base and skill set. The continued development of sophisticated teaching and testing so that MOC does indeed help guarantee the best in care is not only reassuring, but also exciting.

    I wonder whether you foresee a near future where MOC will be more closely attached to the constant daily practice of medicine, as apposed to a separate time to study and develop knowledge? Specifically, do you believe we should be looking at tying EMR records and orders directly to academic and educational database sets, to monitor and “judge” care on a continuous basis? This would allow not only improved medical care on a moment-by-moment basis, but would also allow instant, real-time feedback and education of the physician. Instead of turning “to the side” to consult a reference, such as “UpToDate”, the database would be constantly watching my decisions and observations, and suggesting ways to “correct” or enhance the care I deliver in a way that would benefit not only the patient, but would better educate me, each day and each moment.

    Thank you again for your hard work building the foundation for the delivery of quality care,

    jcs

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