Wednesday, March 12, 2014

No MOC for Me: Why I'm Not Signing Up For Maintenance of Certification

By the end of this month, holders of ABIM (American Board of Internal Medicine) and ABMS (American Board of Medical Specialties) board certifications are supposed to sign up for "Maintenance of Certification" a requirement that costs a bunch of fees and poses a bunch of busywork problems for physicians.  In general all I have heard in terms of reactions from colleagues are frustrated groans and begrudging acquiescence.  But I refuse to sign up for MOC.  Here are the reasons why.

Firstly, I am not required, for my employment, to have a board certification.  Nor am I for any other reason.  The only institution which can "force" you to have board certification is your employer or a hospital credentialing committee.  So, if somebody's gonna be the guinea pig, it may as well be me.



What do I save?  I save the hassle of yet another hoop to jump through, and yet another tariff on my already costly education and other dues, fees and memberships (I pay several thousands of dollars a year to belong to various specialty societies and to receive numerous medical journals [which I read]).   Pulmonary boards were going to cost over $2000 not including preparation materials and opportunity costs.  I let them expire.  Same with general internal medicine boards.  Indeed, I only got Critical Care certified after I briefly signed with a local hospital that required certification.

What do I gain from refusing to do MOC  (assuming you're the kind of person who has separate tallies for gains and losses)?  The main thing is satisfaction that finally I'm not bowing to ABIM which has become akin to a corporate juggernaut.  And maybe I'll start something.  Like what?

Besides a mass revolt, which is unlikely because most physicians ARE required to be board certified, I suspect that in the next 5-10 years some industrious young physician is going to make an alternative certifying agency to the ABIM.  Heck, maybe it will be me.  In a similar vein, the ABIM is leaving it up to hospitals what to do with MOC (their website will list me as certified but not up to date on MOC.). Well, I sit on the credentialing committee.  Surely the fact that one of their own is not participating in MOC will color perceptions of its relevance for that committee.

What do I lose?  Here's a misconception - I do not lose the "eligibility" (by the way "board eligibility" is not a term recognized by ABIM according to the representative I spoke to six years ago to clarify if I would lose eligibility to take boards if I did not take them within a certain time after completing fellowship) to take pulmonary or internal medicine or any boards that I'm currently eligible for in the future.  Once eligible always eligible.  By letting boards expire you do not lose the ability to take them in the future.  By not enrolling in MOC, It means that should I wish to recertify in critical care or any other expired boards in the future, I will have to then first go back and do the MOC requirements.  Here's where economic thinking comes into play.

Doing MOC now means sinking in money and effort that I can't get back later.  If I do MOC and don't renew boards, I have incurred sunk cost.  Plus, there is uncertainty about the future.  What if MOC is scaled back?  What if, by 2021, there is indeed an alternative to ABIM?  Well, then I will have wasted my MOC investment.  You should never pay up front for something you can pay for later without penalty.

What about nuance?  What if your education suffers Dr. Scott?  What if people lose confidence in you because you're not certified?

Here is some nuance:  Board questions are dumb.  I spent the last 15 years mastering how to answer those questions and score high, and I can say with confidence (especially after taking some NEJM CME last night which were starkly reminiscent of board questions) that board questions are not designed in a way that tests knowledge that is relevant to practice.  They are designed by "experts" within niches who, in addition to writing questions about rudimentary knowledge, wish also to exalt minutiae knowledge with no practical import, to force us to recognize their esoterica or their piddling odds ratio in a flawed study in an obscure journal.  (If you bought the proprietary exam study preparation materials, written by the same pedants who wrote the questions, you would know about that odds ratio without ever having to crack a journal, let alone the obscure one from which it was dredged.)

I don't wish to turn this into a debate about the merits of board certification in general, but suffice it to say that if I were confident that they had great meaning or even symbolism I would not take the position I have.  I am not a person who has ever had a problem passing boards.  Indeed, I think we should report actual scores not pass/fail dichotomies.  If the public deserves to know how smart and well trained their doctor is, hell, show them the scores and whether or not s/he has ever failed and had to retake the test!  But this is not about quality and education, it's about bureaucracy run amok (aMOC) and profiteering by an organization that is supposed to be serving physicians, not preying upon them.


26 comments:

  1. THANK YOU!! I could not have said it better myself. I have long ago stopped believing that the incremental piling up of these requirements have anything to do with ensuring physician quality, rather than simply making profits. Unfortunately the group that employs me requires board certification, otherwise I would have joined your revolt.

    Another example in medical education is adding the clinical skills portion of Step 2 USMLE (thankfully I just barely missed the implementation of that). Not only do medical students (who are already heavily in debt), have to pay the exorbitant exam fee (north of $1200) , they often have to pay airfare and room/board to travel to one of the few testing sites. If you come from a relatively well-to-do family, you can ask for help to pay the costs. If not, deeper into debt you go. So much for social mobility!

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  2. It seems from your comments that you lean towards a prediction that board certification and MOC might become less important over time. I wish I could say I shared this view, but I am more pessimisticCMS just made me jump through the hoop of declaring hat I would do MOC even more frequently than required in order to qualify for bonus reimbursement. With the degree to which beuracracy in the name of quality has become more prevalent in recent years, I don't see an end in site. I will just grumble and take the stupid test.

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    1. Josh-and if you do MOC, they will only increase the time and cost commitments-which do not even reach to offset the PQRS-MOC TAX should you not comply. See this URL from the ABA who NEVER wanted to go down the road of MOC, just pushed into this by the ABMS. READ the docuement at: http://www.theaba.org/pdf/MOC_PQRS.pdf
      see the grey box at the bottom! MOC is an extortion scam!

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  3. I am on call every other week and every 3 weekends. I don't have interns or residents. This is the last year to take my IM MOC. I don't have time or desire to study and take the test. I m sure our colleagues behind the test have "protected" time for education of research, but the great majority don't. If don't take my IM MOC will I lost the right to practice IM, if let's say I cannot longer practice critical care or pulmonary in the future for whatever
    reason?

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    1. As far as I know, if you don't have housestaff, IM doesn't matter (depending on the policy at various hospitals). However, if you ever go to a hospital that has a training program that has IM residents staffing the ICU, you have to be certified in IM in order to round in the ICU (one of my colleagues was in this situation).

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  4. www.changeboardrecert.com

    Mass MOC Noncompliance

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    1. Agreed and will be noncompliant as of 3/31/14! Fight the power!

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    2. The MOC should be renamed "MOE" MAINTENANCE OF EXTORTION!!!!

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    3. Agreed..........The more thought I give this topic, the more convinced I am that MOC is excessive in its scope and far too costly. What is to become of the physician in our society who has become over regulated, seconded-guessed and forced to jump through so many hoops he/she hardily has the time to lay hands on his/her patients.

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  5. I am a strong believer in the Oath of Maimonides. It reads:

    “Grant me the strength, time and opportunity always to correct what I have acquired, always to extend its domain; for knowledge is immense and the spirit of man can extend indefinitely to enrich itself daily with new requirements. Today he can discover his errors of yesterday and tomorrow he can obtain a new light on what he thinks himself sure of today…”

    I also embrace the parallel concept of satyagraha, loosely translated as "insistence on truth" (satya 'truth'; agraha 'insistence') coined and developed by Mahatma Gandhi.1,2,3,4

    Among others, I have previously published that MOC has never been proven to improve the quality of medical practice. To the contrary, it has been associated with the decreased collegiality of our profession as well as decreased involvement in local as well as national medical societies.5,6,7,8,9,10,11,12,13,14,15,16 Most practicing physicians find MOC to be clinically irrelevant 6,7,16 , and polling of physicians in clinical practice showed that only 1.6% wished to maintain the current system – whereas 4.7% supported reform and 93.7% voted to abolish requirements altogether.9

    The American Board of Medical Specialties has published that the quality of research on MOC does not meet commonly accepted research standards17 and that certification does not “guarantee performance or positive outcomes”.18

    As respected professionals, we as obstetrician/gynecologists believe in our own continued education and quality improvement. Accordingly, if MOC has not been empirically proven to improve our practices, or be clinically relevant for most of us, than why is it being forced down upon us?

    Veritas vos liberabit – Shouldn’t we insist on truth? If MOC is inadvertently decreasing attendance at scholarly and collegial meetings, shouldn’t we consider that detrimental to the medical profession? With 50% of the counties in America lacking an obstetrician to deliver babies, won’t the early retirements MOC could provoke worsen the health access crisis?

    The AMA House of Delegates study on the impact of MOC on physicians concluded, in a resounding consensus at their June 2013 meeting, that these programs were “burdensome, costly, and have little known positive impact on patient outcomes”11. You might also be aware that resolutions against MOC have recently been enacted by the American Medical Association and the state medical societies of New Jersey, Michigan, Ohio, Oklahoma, New York and North Carolina.

    As you should know, ABMS is currently involved in civil litigation with the Association of Physicians and Surgeons (US District Court No. 3:13-cv-2609-PGS-LHG) – as an apparent co-conspirator in “an unlawful conspiracy in restraint of trade in violation of Section 1 of the Sherman Act”. Furthermore, previous US Courts have favored antitrust provisions against other monopolistic professional certification processes19. In the words of Thomas Paine,
    “He that in defense of reason rebels against tyranny has a better title to Defender of the Faith.”
    With respect and satyagraha,
    Howard C. Mandel M.D., FACOG

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  6. Ref from above:
    1) McKay, John P.; Hill, Bennett D.; Buckler, John; Ebrey, Patricia Buckley; Beck, Roger B.; Crowston, Clare Haru; Wiesner-Hanks, Merry E. A History of World Societies: From 1775 to Present . Eighth edition. Volume C – From 1775 to the Present. (2009). Bedford/St. Martin's: Boston/New York. ISBN 978-0-312-68298-9. ISBN 0-312-68298-0. Page 859
    2) Uma Majmudar (2005). Gandhi's pilgrimage of faith: from darkness to light. SUNY Press. p. 138. ISBN 9780791464052.
    3) M.K. Gandhi, Satyagraha in South Africa, Navajivan, Ahmedabad, 1111, pp. 109–10.
    4) Mohandas K. Gandhi, letter to P. Kodanda Rao, 10 September 1935; in Collected Works of Mahatma Gandhi, electronic edition, vol. 67, p. 400. www.Ghandiserve.org
    5) Not Until Proven to Improve Health Care Practice, Mandel HC. N Engl J Med 2013:368 1261-1263
    6) Dubravic M. Board certification/recertification/maintenance of certification—a malignant growth. J Am Phys Surg 2011;16:52-53
    7) Orient JM. AAPS survey: physicians skeptical of recertification. Evaluating the quality of care provided by graduates of international medical schools.
    J Am Phys Surg 2009;14:17-18
    8) Norcini JJ, Boulet JR, Dauphinee WD, et al. Evaluating the quality of care provided by graduates of international medical schools. Health Affairs 2010;29(8):1461-1468
    9) Change Board Recertification. Website poll. Available at http://www.changeboardrecert.com/vote.html. Accessed December 30, 2012
    10) MOC doesn’t create better physicians, Mandel HC. Med Econ Sep 25, 2013
    11) AMA House Disses Recertification Programs, Pittman D www.medpagetoday.com/meeting coverage/AMA/39949 June 18, 2013
    12) Recertification and Maintenance of Certification. Mandel HC; J Am Phys Surg:16;3,65 Fall 2011
    13) Why don’t lawyers have to be recertified? Mandel HC, Med Econ Feb 10, 2012
    14) Recertification and Maintenance of Certification. Sharon, GE; J Am Phys Surg:16:3,66 Fall 2011
    15) Recertification and Maintenance of Certification. Mackel JV; J Am Phys Surg:16:3,66 Fall 2011
    16) Kempen PM: Maintenance of Certificiation—important and to whom? Journal of Community Hospital Internal Medicine Perspectives,Issue 1, 2013 Pages 1-4
    17) Sharp LK, Bashook PG et al. Acad. Med. 2002;77:534–542
    18) www.abms.org/maintenance_of_certification/pdfs/ABMS¬_MOCMythsFacts_3-20-13.pdf
    19) Havighurst CC, King NM. Private credentialing of health care personnel: an antirust perspective. Part Two. Amer J Law Medicine 1983; 9:263-334


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  7. I have been fighting MOC and Maintence of Licensure (MOL) from the FSMB for over 3 years in Ohio and the physicians here have been staunch opponents of MOC and MOL. The state medical society fought and WON, including seeing the FSMB allied State Medical Board executive fired!
    Physicians can and MUST make a difference using the state organizations, as the national specialty societies have aligned with the ABMS boards to cash in on the money making juggernaut! Please follow me and that battle against MOC at http://paulmdphd.blogspot.com/ and WWW.changeboardrecert.com !! The national organization Association of American Physicians and Surgeons has filed a lawsuit against the ABMS/ABIM MOC organizations and welcome your support at http://www.aapsonline.org/index.php/article/aaps_takes_moc_to_court . As long as physicians continue to act like sheep they will be fleeced to the slaughterhouse!

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  8. End MOC Now! The extortion must be stopped.

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  9. NO MORE. I will not recertify.

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  10. ANTI MOC Webinar on March 23, 2014-please join us!
    I would like to point out there will be a Webinar on March 23, 2014 and the particulars are viewable at:
    http://www.aapsonline.org/index.php/event/webinar_moc_update
    1.5 CME credits are available and NO MOC Points!

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  11. Would a better system be attendance at CME instead of the exam? What do other countries do?
    How would you handle the touchy issue of possible cogniitive impairment?

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  12. All good questions, and I'm not sure I know the answers.....

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  13. I've never set for the IM Boards and I do not plan to -- MOC caps it. Board Certification is voluntary and if it were not the ABMS would face anti-trust monopoly violations. Ironically by not taking the boards I am protecting them from prosecution.

    When I finished residency in 1985 I settled in an area that didn't know what an internist was, so I saw kids and adults. Years later when managed care came along when I told them I was IM, they said I couldn't see kids which were 1/3 of my practice at the time. Since I was not board certified I was considered General Practice and could continue seeing kids as I had for years, and I see them to this day.

    In 29 years of very busy practice I have not lost a single opportunity because of the lack of board certification. In fact it has been a plus -- the hospital I admitted to kept making me Chief of Medicine until the JCAH required a BC doc head departments.

    I do find it interesting that so many docs who insist on being board certified cry in outrage when the same boards that granted them certification tell them that they need MOC. By embracing one they invite the other. Every insurance company that has insisted on board certification has came back to the table and credentialed me without restriction. I wish some of them wouldn't, I really need a break.

    Prediction -- MOC will win the day. As the BC for life crowd dies out the young ones won't know any better. Increasingly the best the brightest, the real go getters go into other fields -- this will just drive more of the people we really want practicing away. But those who remain will have nice certificates to show their patients. That's something at least.

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  14. The new doctors are all brainwashed about board certification. I know because years ago I wanted to get mine. It was the thing to do. Also, I was told I would need it for insurance.

    MOC, Re-certification. All useless.

    I for one am tired of being ripped off. Tired of being threatened by insurance companies and my own organization that are suppose to have my back.

    I say let the administrators and the insurance company executives see the patients.

    If your a new resident or young attending and you bow down to these organization then you are blind and are ignoring your demise in the very near future. If you want to spend the rest of your life taking test after test and your evening doing MOC after MOC then have a nice time and don't ever complain about it because you get to chose NOW, RIGHT HERE TODAY WHAT WILL HAPPEN TO YOU FROM THIS POINT ON.

    Like they say CHOOSE WISELY.

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  15. Physicians - are fat moneybags. They make WAY too much money. Every businessman should try to squeeze as much money out of physicians, as they can. We should charge them for their education, certification, re certification, malpractice insurance, health insurance, life insurance, disability insurance, maintenance of insurance, maintenance of certification, maintenance of maintenance of maintenance of certification, maintenance of maintenance of licensure and maintenance of the right to breath. This way all our patients will get so much better, cheaper, and easily accessible health care!

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    1. Yep. Almost forgot medical license ($600-$1200 every 3 years), DEA fees to support drug addicts ($730 every three years), pharmacy license ($300 for three years), lawyer fees, billing fees. Did I forget anything?

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    2. Yes, the nervous breakdown fees and the fees to get the other certifications so that you can pay the fees for certifications that led to the nervous breakdown fees. I think that about covers it. Or maybe not. Is there a fee for guessing?

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  16. As ACA takes hold, the doctor shortage is becoming acute. I've seen different numbers, but somewhere between 10 and 20% of docs are not board certified and who knows how many are not current with MOC. Is our system insane enough to take them out of patient care? Probably. And I am looking forward to it. My BE holds out until 2018, so the temptation to sit for the IM boards will be there until then. My employer has no qualms letting the window close -- my job is mine for as long as I want it.

    The nurse pracitioners are taking over anyway, and they can have it.

    No boards, no MOC -- it is time for someone to make a futile gesture, it might as well be me.

    OSU offers an 18 month CNP program -- I could do that, become 'board certified' and skip this MOC nonsense. They take zero call in training, no weekends, and while their curriculum is not a gimme by any means but neither is it medical school. Bet I could skip the classes, just take the tests and pass the thing.

    And I would rather do that than cede a penny or a moment to the ABMS.

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  17. Now, the hospital is making me get board certified because it is linked to the insurance company and if I want to be on the insurance I have to be certified. I let it lapse last year due to a busy practice.

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  18. Sometimes when we couldn't get the desired results to our hands then we have to look forward to such kind of the essentials merely considered more important so this will indeed be a very good field of instructions to follow instead. pulmonology fellowship

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