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.