MOC controversy: Issues and answers

The August 2014 issue of Contemporary Pediatrics featured an article titled “Maintenance of Certification: Myths, facts, and FAQs,” written by Virginia A. Moyer, MD, MPH, vice president for Maintenance of Certification (MOC) and quality for the American Board of Pediatrics (ABP). The editors received dozens of responses from pediatricians, all critical of the MOC process and questioning the necessity of the program. In this Peds v2.0 article, I describe the transition from permanent board certification to MOC and detail the many controversies surrounding the current program. Elsewhere in this issue, I don my “pediatrician” hat and express my own opinions regarding MOC (“MOC: A view from the trenches”).

History of board certification

To put MOC in perspective for pediatricians, it is important to understand the origin of the board certification process. As you will see, today’s MOC program represents a radical departure from the board certification program as originally developed by specialty boards.

In the early part of the 20th century, there were no requirements to prevent untrained physicians from calling themselves ophthalmologists, dermatologists, or pediatricians. Anyone who had a “special interest” in narrowing his or her practice focus could be listed as a specialist in the directory of the American Medical Association (AMA). The need to distinguish physicians who completed specialty training gave rise to the creation of specialty boards such as the American Boards of Ophthalmology, founded in 1917; Otolaryngology in 1924; Obstetrics and Gynecology in 1930; and Dermatology in 1932.

The American Academy of Pediatrics (AAP) was formed in 1931, but it did not see its role being that of a specialty board. One of its first actions was to task a Committee on Medical Education to investigate the need for a distinct ABP whose role was to certify physicians who had completed a pediatric internship and residency as board-certified pediatricians.

Through the cooperative efforts of the AAP, the American Pediatric Society, and the AMA Section on Pediatrics, the ABP was formed in 1933. Its purpose was straightforward-to certify pediatricians for practice. Members received no salary and paid no dues, and were responsible for developing an examination and certification process. Pediatricians could apply for certification after completing 1 year of internship, 2 years of residency, and 2 years of practice or further training. Interestingly, board certification in pediatrics received significant pushback from many academic institutions, and it took nearly 20 years for certification to gain widespread acceptance among virtually all American pediatricians.¹

In 1933, the same year the ABP was founded, the American Board of Medical Specialties (ABMS) was formed whose membership consisted of the 5 existing boards-ophthalmology, otolaryngology, obstetrics and gynecology, dermatology, and pediatrics. Its role was simply to develop guidelines and regulations for all its member boards. Today there are 24 member boards under the ABMS, including the ABP.

Evolution from board certification to MOC

In 1989, the ABP stopped issuing a “permanent” certification in pediatrics, and began issuing time-limited certification that would require periodic recertification for pediatricians to claim board certification status. Several years later in 2010, the ABMS drastically changed the model of certification, from one based on a lifelong certification to today’s model that is based on continuous “maintenance” of certification.

As a consequence, in 2010 the ABP began issuing certificates with no end dates. Figure 1 illustrates the ABP’s most recent data on the certification status of pediatricians practicing in this country. According to a recent article by Paul Kempen, currently 25% of all licensed physicians in the United States are not board certified. Additionally, he reports that less than 1% of physicians with lifelong certificates have recertified, and in 2010 the ABMS indicated that less than half of American physicians were participating in MOC.²

MOC today

In creating MOC, the ABMS transformed itself from an organization whose purpose was to qualify physicians to practice in their specialty, to one whose role was to assure the public that physicians are of the highest quality by virtue of their continued participating in educational and testing programs. To accomplish this, the ABMS outlined 6 core competencies for physicians that include:

1. Professionalism;

2. Patient care and procedural skills;

3. Medical knowledge;

4. Practice-based learning and improvement;

5. Interpersonal and communication skills;

6. Systems-based practice.

Currently, the ABMS and its member boards require physicians to satisfy 4 components in order to achieve MOC. These are:

·      MOC part 1: Licensure and professional standing

·      MOC part 2: Lifelong learning and self-assessment

·      MOC part 3: Cognitive expertise

·      MOC part 4: Practice performance assessment

Pediatricians who are familiar with the MOC process know that MOC part 3 requires taking an examination every 10 years. Part 2 participation requires taking ABP-approved educational continuing medical education (CME) self-assessment activities and part 4 requires participating in ABP-approved Quality Assurance projects. Currently, pediatricians are expected to complete requirements in parts 2 and 4 every 5 years. It is generally believed that most physicians wait until the last year of the 5-year cycle (and sometimes the last quarter of the last year) to complete these requirements.

New MOC mandates

In an effort to encourage its members to become more diligent in participating in MOC on a regular basis, the American Board of Internal Medicine (ABIM), whose members include 200,000 internists and subspecialists, last year mandated that its members must complete at least 10 MOC CME credits every 2 years. Additionally, grandfathered ABIM physicians began to be listed as "certified, not meeting MOC requirements" if they didn’t register for continuous MOC. Concerned that MOC participation status may result in lost hospital privileges or expulsion from insurance plans, ABIM physicians have been enrolling in MOC by the droves. The new mandates have resulted in a dramatic increase in the number of ABIM physicians enrolled in MOC (77% of its members), and now 21% of ABIM-grandfathered physicians are now MOC participants.

The 2014 ABIM mandates have met with widespread and much publicized resistance. There is an online petition protesting the ABIM action, that as of this writing has garnered over 19,000 physicians’ signatures (www.petitionbuzz.com/petitions/recallmoc). In June 2014, the AMA House of Delegates voted to solicit an independent third party to evaluate the effects of MOC on the physician workforce, physicians' practice costs, patient outcomes, patient safety, and patient access.

Controversy: Does MOC improve outcomes?

The ABMS has sponsored many studies that indicate that MOC improves the quality of care American physicians provide patients. Conclusions reached by these studies imply that a physician’s skills deteriorate as he or she get older, and physicians in solo and rural practices perform more poorly on certain measures involving patient outcomes.³ For a comprehensive list of these articles, download this document from the ABIM website: www.abim.org/pdf/publications/articles-about-certification-values.pdf.

It has been noted by critics of these pro-MOC studies that many, if not most, were authored by members of specialty boards or were solicited by member boards of the ABMS. Sharp and colleagues critiqued these studies and found that many have not used proven scientific methods to demonstrate their outcomes^.4 Grosch published a detailed analysis of Sharp’s data, and concluded these studies fail to indicate that MOC is associated with better clinical outcomes. ⁵

Interestingly, Gary Freed (a member of Contemporary Pediatrics’ Editorial Advisory Board) authored an excellent study indicating that when surveyed parents were informed about the particulars of “maintenance of certification,” they indicated that they would prefer a certified pediatrician care for their child.⁶ However, many physicians report that unless patients are given such information, few are familiar with board certification or MOC. In 30 years of pediatric practice, not one parent has ever asked me my board certification status!

The “Empire” strikes back

Many physicians have expressed frustration and acrimony at the current MOC situation. In 2011 10 of the 16 members of the editorial board of Clinical Pediatrics (including the editor-in-chief) supported an article critical of MOC, in which author Victor Strasberger asserted that: “Maintenance of certification is broken. It needs to be fixed. And the powers behind MOC-the American Board of Pediatrics and the American Academy of Pediatrics-need to understand and accept the fact that criticism of MOC is warranted, needed, and well intentioned.”⁷ The article made the following points:

·      MOC has never been adequately tested.

·      MOC is expensive.

·      Parts 2 and 4 of the MOC are cumbersome and do not always apply to pediatricians.

·      The MOC recertification exams are not an accurate or reasonable assessment of pediatricians’ skill or their practices.

·      The ABP was originally developed as a not-for-profit. Now the assets of the ABP are listed by the Internal Revenue Service as exceeding $40 million and its top officers make 5 times as much as most pediatricians

Maintenance of Certification has been the subject of several physician focus groups, which have concluded that the program needs to be reevaluated and restructured. In particular, most physicians believe that part 4 of MOC has little relevance to physicians in clinical practice.^8,9

The organization most opposed to MOC has been the Association of American Physicians and Surgeons (AAPS). The AAPS is a small physician advocacy group with over 3000 members. In 2014, the organization sued the ABMS to stop continuous MOC and revert to a program requiring just a written exam every 10 years (Figure 2). The AAPS points out that MOC has never been shown to improve outcomes; it has generated billions of dollars for years for organizations that provide medical CME; it imposes severe time compliance constraints on physicians; and patient care actually suffers as a result.

Not yet the last word

No doubt you have your own opinions about MOC. To read mine, see "MOC: A view from the trenches." We do live in interesting times, and everyone is curious about what form MOC will take in the years to come. Please write back to us and let us know what you think!

REFERENCES

1. Brownlee RC. The American Board of Pediatrics: its origin and early history. Pediatrics. 1994;94(5):732-735.

2. Kempen PM. Maintenance of certification and licensure: regulatory capture of medicine. Anesth Analg. 2014;118(6):1378-1386.

3. 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.

4. Sharp LK, Bashook PG, Lipsky MS, Horowitz SD, Miller SH. Specialty board certification and clinical outcomes: the missing link. Acad Med. 2002;77(6):534-542.

5. Grosch EN. Does specialty board certification influence clinical outcomes? J Eval Clin Pract. 2006;12(5):473-481. Erratum in: J Eval Clin Pract. 2006;12(6):704.

6. Freed GL, Dunham KM, Clark SJ, et al; 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(5):841-845.

7. Strasburger VC. Ain’t misbehavin’: is it possible to criticize maintenance of certification (MOC)? Clin Pediatr (Phila). 2011;50(7) 587-590.

8. 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.

9. Cook DA, Holmboe ES, Sorensen KJ, Berger RA, Wilkinson JM. Getting Maintenance of Certification to work: a grounded theory study of physicians’ perceptions. JAMA Intern Med. November 3, 2014. Epub ahead of print.

Dr Schuman, section editor for Peds v2.0, is clinical assistant professor of pediatrics, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, and editorial advisory board member of Contemporary Pediatrics. He has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.