The Boards Have Exceeded Their Bounds

In the interests of full disclosure, I acknowledge with delight that I have a non-time limited board certificate from the American Board of Anesthesiology (ABA), issued before the year 2000. I can just say “no” to recertification.

The more I learn about the American Board of Medical Specialties (ABMS) and its highly paid board members, the more disillusioned I’ve become. It’s easy to see why so many physicians today have concluded that ABMS Maintenance of Certification (MOC) is a program designed to perpetuate the existence of boards and maximize their income, at the expense primarily of younger physicians.

Lifelong continuing education is an obligation that we accepted when we became physicians, recognizing that we owe it to ourselves and our patients. That is not at issue here. We have an implicit duty to read the literature, keep up with new developments, and update our technical skills.

The real danger of MOC is this:  It is rapidly evolving into a compulsory badge that you might soon need to wear if you want to renew your medical license, maintain hospital privileges, and even keep your status as a participating physician in insurance networks. If physicians don’t act now to prevent this evolution from going further, as a profession we will be caught in a costly, career-long MOC trap. The only other choice will be to leave the practice of medicine altogether, as many already are doing.

What can be done?

The American Medical Association (AMA), to its credit, passed a resolution this year calling for the “immediate end of any mandatory, recertifying examination by the American Board of Medical Specialties (ABMS) or other certifying organizations as part of the recertification process.” Further, AMA policy states:

Any changes to the MOC process should not result in significantly increased cost or burden to physician participants (such as systems that mandate continuous documentation or require annual milestones).

The MOC program should not be a mandated requirement for state licensure, credentialing, reimbursement, insurance panel participation, medical staff membership, or employment.

Many physicians have rebelled against compulsory MOC and have succeeded in getting the attention of their state legislatures. The state of Oklahoma passed a law in April, 2016, stating that nothing in its laws concerning medical practice shall be construed to make MOC “a condition of licensure, reimbursement, employment, or admitting privileges at a hospital in this state.” Kentucky’s governor signed a more limited measure that forbids making MOC a condition of state licensure. Other states are considering joining Oklahoma as “Right to Care” states.

The California Medical Association (CMA) considered but didn’t pass an anti-MOC resolution at its October meeting. However, there is enthusiasm for pursuing the resolution again in 2017, and it appears to have a strong chance of passing. The title of the resolution is, “Maintenance of Certification should not be used as criteria to assess physician competence”, and it would direct CMA to work with the Medical Board of California to promote legislation prohibiting MOC “as a mandated requirement for physician licensure, credentialing, reimbursement, network participation, or employment.”

NBPAS: An alternative to the ABMS monopoly

If there were unquestioned proof that the MOC process improves patient care and outcomes, then the expense and time would be more justifiable. However, no such data exist. Initial board certification is associated with higher-quality practice, but recertification with MOC programs is not. As Paul Mathew, MD, commented in the November/December 2016 issue of Practical Neurology, “Literature regarding the evidence supporting recertification with MOC programs is weak at best, and most is written by conflicted authors who are executive board members of ABMS boards.”

A good example proving Dr. Mathew’s point is a recent editorial defending MOC in the New England Journal of Medicine (NEJM). The co-authors have close ties to the American Board of Internal Medicine (ABIM) and its foundation, which have been mired in financial scandal. It would be hard to defend a claim to scholarly objectivity.

Dr. Mathew and I are both unpaid, voluntary board members of the National Board of Physicians and Surgeons (NBPAS), an organization founded two years ago by Paul Teirstein, MD, a cardiologist at the Scripps Clinic in La Jolla. Dr. Teirstein’s frustration with ABIM’s expensive MOC requirements led him first to create a web-based petition that rapidly accumulated more than 19,000 physician signatures. He then founded NPBAS as a grass-roots physicians’ organization, offering a cost-effective alternative pathway for board-certified physicians to demonstrate their commitment to continuing medical education (CME) while bypassing the ABMS and MOC.

The challenge, of course, for NBPAS is to achieve recognition by hospitals and insurers, which is a slow process. But progress has been made, as thousands of board-certified physicians (myself included) have earned two-year NBPAS certificates, and thousands more are in the process.

The anti-MOC movement shows no signs of abating. An October, 2016 article in the Mayo Clinic Proceedings concluded that only 24 percent of physicians agreed that MOC activities are relevant to their patients, only 15 percent thought they were worth the time and effort, and 81 percent believed that they were a burden. These results were “pervasive, and not localized to specific sectors or specialties.”

The ABA and MOCA 2.0

To the credit of the American Board of Anesthesiology (ABA), it was one of the first boards to pay attention to the discontent of its diplomates. In May, 2015, it convened a two-day summit to consider redesign of its Maintenance of Certification in Anesthesiology Program (MOCA), and concluded that its ten-year “high-stakes MOC exam is not the most effective way to help its board-certified physicians learn and retain medical knowledge.” The ABA decided to embrace “multiple learning techniques”, and introduced the “MOCA Minute” program, where physicians must answer 30 online questions each calendar quarter or 120 questions annually. This new approach has not brought with it any decrease in cost to participants.

I might be tempted to enroll in the “MOCA Minute” program if I didn’t think that it would be equivalent to stepping in quicksand, and that extrication would be impossible.

After watching residents doing practice multiple-choice questions for years, I’ve reached the conclusion that their time would be better spent reading a good basic anesthesiology textbook and review articles in major journals. The inherent problem with all the multiple-choice questions is that the resident ends up reading three or four wrong answers for every correct one. No wonder they become confused. They would be better off reading only correct information.

I have a fundamental objection also to the ABMS “Six Core Competencies” as the bedrock of the MOC program. Some of them – practice-based learning, patient care, procedural skills, medical knowledge – are fine. But the last two are another matter:

“Interpersonal and Communication Skills: Demonstrate skills that result in effective information exchange and teaming with patients, their families and professional associates (e.g. fostering a therapeutic relationship that is ethically sound, uses effective listening skills with non-verbal and verbal communication; working as both a team member and at times as a leader).

Professionalism: Demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles and sensitivity to diverse patient populations.”

These are qualities that we all needed to learn and incorporate into our daily practice long before we were board-certified. If you didn’t have an inherent sense of ethical conduct and personal responsibility before you left elementary school, nothing the ABA does is going to change you. If you can’t communicate, a multiple-choice test won’t help. These topics are not properly the business of continuing medical education.

If MOCA is truly valuable, then the ABA should have enough confidence in its product not to make it mandatory. It should compete in the CME marketplace with meetings, journals, online materials, and every other CME product. Board-certified physicians should be able to choose among all these to demonstrate “lifelong learning” and renew their time-limited certification.

It’s time to make it clear to the ABMS that we’re not its indentured servants. The time to do that is now, before it gains any more ground in making our right to work dependent on surrender to MOC.

8 COMMENTS

Andrew

I agree. I also have non-time limited board certification, but feel that my younger colleagues are subjected to an overly burdensome, costly and ineffective process. Let’s make our voices heard.

[Reply]

Oren Bernstein

I could not agree more. I faithfully did my MOCA 2.0 activities for the past year to honestly judge their utility to me as a physician and to my patients.

I thought the MOCA minute was a poorly-executed, low-quality activity. The ASA already publishes the ACE and SEE programs which seem to serve the same purpose.

MOC has never been proven to improve outcomes. I stay current out of duty to the community I serve, not because a paternalistic board holds a financial gun to my head and tells me to comply and pay it my practice tax of $210/year. That is extortion, pure and simple.

I will not be participating in MOCA any longer, and am proud of my ongoing boards certification by NBPAS.

Thank you, Dr. Sibert, for calling attention to this issue.

[Reply]

I believe that the ABMS Boards have stepped outside their ethical and maybe also legal limits as 501-c-3 organizations. Officer and key employee remuneration is too high for dues alone — so selling courses, exams, and tying same to insurance reimbursement and hospital privileges is necessary to keep the cash income flowing. That’s why ABMS and its assorted associations and academies favor MOC — it could be the ABMS boards’ lifeline. The ABMS boards are obliged to file Form 990 with IRS — physicians should look these over and decide to what extent their favored boards may be acting like ordinary taxable businesses. — robert L. weinmann, MD, Editor, The Weinmann Report, http://www.politicsofhealthcare.com

[Reply]

Aaron

I also agree. My certification is not time-delimited and unless somebody holds a loaded gun to my head I will never sign up for MOC.

It’s also interesting the AMA finally has taken a position I agree with. I resigned the AMA as a medical student after they provided their biographical data tapes to DOD effectively registering me for a draft I had no statutory requirement to register for being born in the latter part of 1959. Every decision they’ve promulgated until now specifically including the ACA has reinforced that my judgement before I even became a doctor was and still is sound. Every so often I get a “dues statement” from them that goes to the circular file.

NBPAS is an interesting alternative and I’ll look into it.

[Reply]

I do applaud Dr Sibert for the article, she is spot-on. I, too, am a BC Anesthesiologist who is not time limited, but until 12.31.2016 was also BC in Pain Management as well. I did a lot of soul seaching on whether I wanted to re-certify, and was more than a little perturbed that had my pain certification expired on 1.1.2017, I would have been eligible for the more CME-based program to maintain certification. As a consequence, I elected to join the NBPAS, which requires precisely that…a CME-based program.
As I’ve explained to colleagues about my decision, I like many of them, took written then oral anesthesia boards, then written pain boards in 1996/2006, and then took the AmBoard of Pain Medicine boards in 1998 (non time limited). I think I’ve proven that I can write a $2100 check for the exam, another $1100 for a review course, take countless hours away from my family/personal time to study, close my private practice a week to get holed up alone in a hotel to study just before the exam, then pass an exam. And, in a few months, forget everything I’ve learn about a given drugs effect on the rat hippocampus. The thought that members of the ABMS board are collecting huge salaries, while exempting themselves from the pain they are inflicting on me, only adds insult to injury.
So unless I am coerced by hospital to be BC Pain, or I face further drop in reimbursement by insurance by not being BC Pain, as of now, I am choosing not to get (what would be my third time) BC in pain again…at least by the ABMS.

[Reply]

Adam Collins

Hi Karen, I think you raise some excellent points and it is good to question. As a participant in MOCA and as someone who runs simulation courses for MOCA and there purposes I have a reasonable insiders perspective (as well as an obvious conflict of interest). I participated in MOCA 1 for a cycle before MOCA 2.0. MOCA 2.0 is not very expensive and, for the most part, it doesn’t go beyond what it takes to maintain a state medical license or hospital credentials. Admitedly, MOCA minute and MOCA part 4 add a fair amount of burden, but it is ripe with professional development opportunity. In my experience MOCA minute is a valuable way to probe for actionable knowledge deficits. The questions have a short commentary and reference list that I have used more than once. I have implemented change around new practices that were in direct conflict with the dogma of my training years. Personally, I appreciate a little curated content in the world of information overload.

MOCA part 4 is another story. Now there are many opportunities for earning MOCA part 4 credit, and many or them will grant credit for improvement projects that one is already doing. It can also be done in teams. Some of the opportunities cost nothing, but others, such as simulation are costly.

I am not looking for more regulation, but I would defend MOCA as regulation that produces positive results. I’d also rather we as a community of physicians police ourselves instead of creating a void for other external bodies to step in and take it to the next level.

[Reply]

Karen,

Thanks for your excellent review of the ABMS Maintenance of Certification (MOC) program. Not only have the Board exceeded their bounds, they are, in my opinion, corrupt, using the money to inure the leadership of these unelected officers of these organizations for political and financial gain far outside their private 501(c)(3) designation. See http://www.medtees.com/content/PPADC2Feb2017.pdf

Physicians are organizing and will be moving toward exposing the corruption and self-dealing of these organizations that have led to anti-trust actions, We will request investigations by the IRS, OIG of the Department of Health and Human Services, and Department of Justice.

Westby G. Fisher, MD
President and Co-Founder of Practicing Physicians of America
http://www.practicingphysician.org

[Reply]

I think if the Boards wish to continue to have the power to certify us, they should stop picking out articles for us to read. Seeing patients and being in the operating room 80-100 hours a week and then going to a computer screen to figure out tables and graphs is NOT EDUCATIONAL. MOC becomes the enemy of whatever time you have left for your family, living a life and paying bills, being a friend and relative. Soon, the objective becomes looking for answers to complete the test as fast as possible.
Those on the Board should read the articles and then write a summary of what they think is important and what they think we should know. I would complete this. Then click “summary read” and move on to the next summary.
Personally, I like the idea of having multiple venues of Cme to choose from, allowing some of us to get away from the practice for 2-3 days to attend lectures, if that’s our choice.
In the end, the Medical societies could have done a lot more to protect us from this government and third party invasion into medicine, but they didn’t. They rolled over and gave up control. Bureaucrats running medicine and it’s finances has given them all our authority and none of our responsibility.

[Reply]

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