Paul S. Teirstein, M.D.
N Engl J Med 2015; 372:106-108January 8, 2015
In January 2014, the American Board of Internal Medicine (ABIM) changed its certification policies for physicians. Instead of being listed by the ABIM as “certified,” physicians are now listed as “certified, meeting maintenance of certification (MOC) requirements” or “certified, not meeting MOC requirements.” MOC requirements include ongoing engagement in various medical knowledge, practice-assessment, and patient-safety activities, on which physicians are assessed every 2 years, and passage of a secure exam in one’s specialty every 10 years.
My personal frustration in trying to fulfill the new MOC requirements ultimately led me to create a Web-based petition that now has more than 19,000 anti-MOC signatures and contains thousands of comments against the new MOC requirements (www.nomoc.org). A recent second petition with nearly 6000 signatures advocates taking a “pledge of noncompliance” with the requirements.
Although the ABIM argues that there is evidence supporting the value of MOC, high-quality data supporting the efficacy of the program will be very hard, if not impossible, to obtain. In fact, close examination of the reports cited by the ABIM reveals that the data are ambiguous at best: in a meta-analysis of 33 studies, 16 described a significant association between certification status and positive clinical outcomes, 14 found no association, and 3 found a negative association. Moreover, the authors of the meta-analysis concluded that the research methods of most published studies on this topic are inadequate.1 Almost all published studies evaluate initial board certification, not recertification or MOC,2 and the rigorous requirements for initial certification should not be equated with the busywork required for the MOC every 2 years. One of the few studies examining lapsed certification showed no effect of physicians’ certification status on patient outcomes after coronary intervention.3 Two very recent studies found no association between recertification and performance or quality measures; one, conducted by ABIM members, found a minor reduction in cost of care.4 No study provided level A data, and these findings relate only to recertification, not the controversial new MOC requirements.
The ABIM claims that a majority of certified physicians have already signed up for MOC, which they interpret as support for the program, but MOC is mandated by the ABIM for recently certified physicians and perceived as a job-security requirement by many others — physician interest is either required or motivated by fear. Indeed, in a 2010 Journal feature that allowed physicians to express their opinions on MOC, many respondents commented that “the exercise was only marginally relevant to their day-to-day practice and that it took their time away from patients and other learning activities.”5 These problems are especially frustrating in light of other ongoing tasks that hospital-based physicians are required to complete. For example, to maintain my hospital privileges I must complete 14 separate computer modules on various subjects either annually or every 2 years. In addition, my annual bonus is tied to my performance on practice-improvement activities, including formal surveys of patient satisfaction, low-density lipoprotein cholesterol control, blood-pressure control, and various core measures for hospitalized patients. Adding continuous ABIM MOC activities, which have no documented efficacy, to this already overwhelming list is onerous and diminishes the time physicians have for patient care.
Although some members of the medical community believe that it’s not unreasonable to ask physicians to formally document their fund of knowledge every 10 years, others strongly believe that the exam questions are not relevant to their practice or a reliable gauge of physicians’ knowledge. The ABIM describes its tests as using “psychometrics” leading to “high reliability and reproducibility,”2 but no clear correlation between these test results and patient outcomes has been documented. Furthermore, many physicians believe that closed-book tests are no longer relevant, since physicians can now easily turn to online resources, as well as their colleagues, while caring for patients.
The ABIM has grown into a large business enterprise. The economics of certification are exposed on the ABIM’s Internal Revenue Service Form 990, which is required of all not-for-profit organizations (www.guidestar.org). In 2012, the year of its latest filing, the ABIM received more than $55 million in fees from physicians seeking certification. Several of its board members and its chief executive officer are highly compensated. Many respondents to the Journal feature expressed the view that “the MOC program was essentially a money-generating activity for the ABIM.”5 Much of the U.S. health care system is now focused on value, and physicians are working hard to provide better patient care at lower cost. MOC provides the opposite — an activity with no proven efficacy, at a high cost. MOC fees range from $2,715 to $3,335 every 10 years; on top of these are costs for travel to testing centers, review courses, and time spent away from practice. I believe that, like the rest of the medical community, the ABIM should focus on efficacy while cutting its costs and lowering its fees.
We all support lifelong learning, but an excellent alternative to MOC already exists: continuing medical education (CME). Currently, medical licensure for physicians requires an annual minimum of approximately 25 hours of CME, depending on the state. Physicians accept this requirement because they perceive it as having value. Organizations providing recognized CME programs are regulated by the Accreditation Council for Continuing Medical Education, which requires each CME offering to provide an “educational gap analysis,” a needs assessment, information about speakers’ potential conflicts of interest, and course evaluations, as well as meeting other performance standards. CME offerings must compete with one another, and they therefore provide choice. If physicians do not perceive value in a particular CME offering, they will go elsewhere — a situation in stark contrast with the ABIM monopoly on MOC.
There are many opinions about how MOC should be changed. My main recommendation would be to allow 25 annual hours of CME to be substituted for the current MOC requirements that need to be met every 2 years. Doing so would eliminate, or make optional, the busywork modules that have little practical value, including all medical knowledge, practice-improvement, and patient-safety modules. The charges for these new MOC activities should be nominal — perhaps $100 per year for tracking a physician’s annual CME attendance. I also believe that the ABIM website should be vastly simplified so that administrative tasks become less onerous. Finally, I believe that the ABIM should work to cut its costs and, correspondingly, substantially reduce the initial certification and recertification fees paid by physicians.
The ABIM is now under fire. Some 63% of respondents to the 2010 Journal feature opposed MOC.5 In a survey by the American College of Cardiology (ACC), nearly 90% of the respondents opposed the new MOC requirements, and ACC leaders are now engaged in discussions with the ABIM to change MOC. The ABIM has been formally criticized for the new requirements by several important physician groups, including the American College of Physicians and the American Association of Clinical Endocrinologists (which has formally asked the ABIM to “suspend its new MOC requirements”). The Association of American Physicians and Surgeons filed a lawsuit against the American Board of Medical Specialties (the parent organization of the ABIM) for restraining trade and causing a reduction in patient access to physicians. At a recent American Medical Association meeting in Chicago, delegates voted to oppose making MOC mandatory as a condition of medical licensure.
Regardless of how the MOC issue is resolved, the recent focus on the ABIM has shed a bright light on how medicine is regulated in the United States. The ABIM is a private, self-appointed certifying organization. Although it has made important contributions to patient care, it has also grown into a $55-million-per-year business, unfettered by competition, selling proprietary, copyrighted products. I believe we would all benefit if other organizations stepped up to compete with the ABIM, offering alternative certification options.
More broadly, many physicians are waking up to the fact that our profession is increasingly controlled by people not directly involved in patient care who have lost contact with the realities of day-to-day clinical practice. Perhaps it’s time for practicing physicians to take back the leadership of medicine.
Article link: http://www.nejm.org/doi/full/10.1056/NEJMp1407422