MOC: A view from the trenches

This article's views do not necessarily reflect those of Contemporary Pediatrics. -The Editors

I took my pediatric boards in 1984. Board certification back then consisted of both written and oral exams. While I was raising my young family, it wasn’t easy to allocate the funds needed to fly across the country to take my “oral” board exam. We somehow found the money and I completed my “orals” (after reading through the Nelson Textbook of Pediatrics a few times). I remember the sense of accomplishment I felt weeks later when I opened the letter indicating that I was “Board Certified” in Pediatrics, and I hung my framed certificate in my office with pride. To me, board certification marked the end of a long road beginning with premedical studies, medical school, residency, and medical practice. After more than a decade devoted to becoming a pediatrician, board certification meant that I had the skills and knowledge I needed to become a good pediatrician and do well by my patients.

The rules change

As you can imagine, I was disheartened to learn that at the turn of the millennium, the American Board of Medical Specialties (ABMS) was introducing a new Maintenance of Certification (MOC) program that did away with permanent certification. Although young pediatricians could become board certified, it was only a temporary designation and one that required “recertification” every 10 years.

By changing the rules abruptly, the ABMS had denigrated my wonderful post-residency achievement by mandating participating in MOC in order to continue to demonstrate pediatric expertise. Because I was “grandfathered,” I had not intended to recertify, until I left private practice and my employer indicated participation in MOC was a condition of employment.

Like many of my colleagues in clinical pediatric practice, I hold the MOC program in low esteem-even more so after managing to finish my Part 4 projects in the nick of time to complete my first 5-year cycle. After investigating the controversies surrounding MOC certification (see “The MOC controversy: Issues and answers“), I believe MOC is an unnecessary program, and one that only adds to our workload.

Real world pediatrics

As I have asserted time and again in my Peds v2.0 articles, there is a striking disconnect between real-world pediatric practice and the perception of pediatric practice by those who have sought to regulate and “improve” medical care. So many impediments have been placed in our path by extraneous bureaucracies that it is becoming very difficult to take care of patients these days. For these reasons, many pediatricians are retiring early or abandoning private practice. In my view, pediatricians, long considered the most timid of physicians (it’s in our nature that we must have a tolerant disposition to be a good pediatrician), should stop accepting these impositions and begin to rally to improve our working conditions. By doing so, we will improve our quality of life as well as the care we provide our patients.

Two months ago, I suggested that we “just say no” to stage 2 meaningful use. Perhaps it’s also time to try to improve the MOC process and “just say no” to the current MOC program.

A hot topic

Today MOC is a very hot topic among my pediatrician colleagues. I honestly have not encountered a pediatrician in clinical practice who has anything good to say about the program, with most vigorously expressing that MOC does not improve the quality of care we provide patients. Many tell me that it takes time away from medical practice; it’s too expensive; and it adds to the office overhead of providing care. They also express that MOC Part 4 projects have little bearing on clinical practice and should be eliminated.

Many who oppose MOC believe that the ABMS has reinvented itself and its relevance to medical practice primarily for financial purposes, claiming that the public needs to be reassured that American physicians continue to be well trained and educated. Many physicians feel betrayed by academic institutions, medical think tanks, medical societies, and the government, all of which have supported MOC without evidence that it is necessary or that it can even achieve its intended purposes.

We suspect there may be dark forces at work because the ABMS and its member Boards were conceived as nonprofits but today have assets in the millions of dollars, and their executives are extremely well paid. In addition, continuing medical education (CME) organizations including the American Academy of Pediatrics (AAP) have generated lots of money providing self-assessment and quality assurance (QA) modules for MOC, so they have little reason to challenge the status quo.

We are lifelong learners

One of the joys of pediatrics is that I learn at least 1 new thing every day. Pediatricians put up with complicated electronic health records, meaningful use, and insurance company requests for medication authorizations-all because we enjoy taking care of patients. We are used to participating in CME, and most states and hospitals require CME each year in order to maintain our medical licenses. Few physicians would disagree because most feel that CME of our own choosing can be enormously beneficial. State medical boards and hospitals have mechanisms in place for identifying problem physicians and also have numerous remedies for rehabilitation. Even without MOC, current processes already identify the very few physicians who do not provide quality care.

Medical care is not just about “knowing stuff” but also providing good patient care. It means knowing how to communicate with patients and provide options; how to educate and reassure; and how to be honest and forthright when we face diagnostic dilemmas. We do not practice in a vacuum and it is more than appropriate to discuss cases with colleagues or specialists or to provide referrals when indicated. Although we can try to teach how to provide quality care, this often comes via experience, and more often than not our patients turn out to be the best teachers of all.

How to fix MOC

At a time when we are becoming more focused on evidence-based medical care, it is time that we challenge ABMS mandates as having no scientific merit and start to discuss developing evidence-based guidelines regarding how to practice medicine. This would mean suspending current MOC practices with the exception of the 10-year exam, and retaining the yearly CME requirement of state medical boards.

I would like to receive credit for the self-education I do every day, be it looking up topics via UpToDate or Medscape, communicating with specialists, or reviewing a case with colleagues. This is the kind of real-world education that truly improves the quality of care we provide patients. I’d also like to receive credit for projects involving analyzing the accuracy of new devices I integrate into medical practice.

I recently performed an in-office study regarding the sensitivity of a rapid strep test, determining that because we had few false negatives compared with culture, we could stop doing backup cultures. When submitted to the American Board of Pediatrics for MOC Part 4 credit, the study was rejected because it did not adhere to QA project requirements. Nonetheless, the project is now saving our clinic and patients money, and expediting patient care.

It is long past due that we join with those colleagues who have signed petitions protesting MOC mandates. We should also encourage our AAP chapter representative to request that the AAP investigate the MOC process.

I am hopeful that eventually someone begins listening to those of us practicing in the trenches of medical care. While I bide my time, I am joining the American Association of Physicians and Surgeons, which has the stones to sue the ABMS in an attempt to overturn the MOC process.

FYI

By completing my MOC, I can pay the American Medical Association $75 to get 60 CME category-1 credits. This satisfies 1 year of CME requirement in my home state of New Hampshire and most other states. -Andrew J Schuman, MD, FAAP

Dr Schuman, section editor for Pediatrics 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.