MOC, or maintenance of certification, is the requirement used by medical specialty boards for physicians to maintain board certification. But do we really need board certification MOC?
The American Board of Medical Specialties is a non-profit organization consisting of 24 member board organizations. These include the American Board of Internal Medicine (ABIM), American Board of Pediatrics, American Board of Surgery, American Board of Family Medicine, among others. Each board determines the requirements for board certification in its specialty, which is generally completion of an appropriate residency or fellowship followed by successfully passing a board examination in that speciality.
After a physician successfully completes a residency or fellowship, they are then “board-eligible” in that specialty. To become board-certified, the physician must take and pass a board examination in that specialty. These board examinations consist of a 1-day written test and some specialty boards additionally require an oral examination. In the 1970’s becoming board-certified was considered optional and most hospitals did not require a physician to take a board examination in order to practice in that particular specialty. By the 1980’s, many hospitals began to require new physicians to be board-certified in order to have hospital privileges in any given specialty but older, non-certified physicians were generally grandfathered in for hospital privileging. Until 1990, physicians only had to take and pass a specialty board examination once and then they had lifetime board certification. However, after 1990, the specialty board organizations moved to a time-limited board certification and required physicians to re-take the specialty board examination every 10 years in order to maintain their certification.
Although taking and passing the board examination periodically initially sounded like a good idea, it became immediately apparent that this created a problem for many physicians. For example, an internal medicine hospitalist had to take the general internal medicine recertification exam that largely focused on outpatient medicine topics which were irrelevant to inpatient hospitalist practice. Or the oncologist who sub-specialized in prostate cancer treatment would have to take the general oncology recertification examination that tested about breast cancer, colon cancer, and lung cancer treatment, all of which were irrelevant to the prostate cancer subspecialist’s practice. The recertification tests were hard and many physicians had to take a week-long board review and preparation course in order to pass the tests.
In an attempt to maintain relevancy, specialty boards have added maintenance of certification modules in addition to or instead of the every 10-year recertification exam. These MOC modules are generally a series of annual open-book examinations that physicians could take at home, on their own time. The argument for open-book exams is that by making the physician research questions using medical references, the physician would learn about the topic in order to answer the question correctly. However, with the widespread availability of artificial intelligence resources, such as ChatGPT, a person would not even need to have a high school diploma to pass an open-book specialty board MOC module. Each module is worth a certain number of MOC points; as an example, the American Board of Internal Medicine requires a physician to have 100 points every 5 years to maintain certification.
MOC points can also be awarded for other activities, such as attending CME (continuing medical education) events. Thus, MOC points can be awarded for going to a medical conference, attending grand rounds, or viewing on-line medical education webcasts. MOC points can even be awarded for viewing on-line medical reference resources, such as UpToDate.
Physicians already have other educational requirements
Maintenance of certification by specialty boards is not the only on-going educational requirement that physicians face. Here are a few of those that I was required to do in order to practice at our hospital:
- Continuing medical education. The Ohio State Medical Board requires all physicians to have 50 hours of CME credits every 2 years to maintain licensure. CME credits are commonly acquired by attending hospital grand rounds or annual specialty medical conferences.
- Advanced cardiac life support. In our hospital, critical care medicine privileges and sedation privileges require ACLS certification. Re-certification is necessary every 2 years and consists of a four-hour course in-person course that includes a written examination. Prior to attending the re-certification course, attendees must first read and study the 202-page ACLS manual. Over my career, I took the ACLS course 19 times.
- Collaborative Institutional Training Initiative. The CITI course is required for any physician who is involved with clinical research and takes approximately 4 hours. This must be repeated every three years.
- Electronic medical record training. Initially, this takes about 10-20 hours. However, once you are facile with it, you just need to get trained on the periodic software updates – about 1 hour per year.
- Compliance training. At our hospital, we have a mandatory 2 hours per year for billing/coding compliance training to ensure that we are documenting our services and billing correctly. In addition, there is a 1-hour annual HIPAA compliance module requirement.
- Hospital training. These annual modules consist of on-line content with a post-test that requires a passing score of > 80%. They cover everything from what to do in a fire, to how to read a hazardous materials label, to the hospital’s sexual harassment policy. They vary in number from year to year but typically total about 10 hours per year.
The argument for MOC
Advances in medicine happen rapidly resulting in significant changes in medical practice every few years. For example, the way that we manage a patient with a myocardial infarction today is totally different than the way we did 20 years ago. The main argument for MOC is that it is a way to ensure that physicians keep up with the changes in their specialties.
The arguments against MOC
A petition to end the American Board of Internal Medicine’s MOC requirement started 2 weeks ago already has 10,500 signatures. The authors of the petition stated that signers “firmly believe that the MOC program has become burdensome, costly, and lacks evidence to support its effectiveness in improving patient care or physician competence.” So, what are the objections?
- Cost. The cost of the American Board of Internal Medicine initial specialty examination is $1,430 and subspecialty examinations are $2,325. The ABIM’s MOC program costs $220 per year to maintain board certification. Each additional subspecialty costs $120 per year. In my case, as an internist who subspecializes in pulmonary medicine and critical care medicine, the initial cost would be $6,080 and then $440 per year after that. Many physicians have expressed concern that the MOC programs are used by the subspecialty boards to increase their revenues and have pointed to the ABIM president’s annual salary of $1,031,924 for his 32-hour work week (more than four times the average salary of an internist).
- Redundancy. State medical boards already require 25 hours or more of continuing medical education per year in order to maintain a medical license. Most CME activities are also eligible for MOC points so many physicians say that they are paying the boards to keep track of education that they are already doing for their state medical boards.
- Irrelevancy. As physicians become more sub-specialized, MOC tests that cover diseases that the physicians do not treat in their regular medical practices are irrelevant. Because a physician does not normally manage a particular group of diseases, it takes much more time to prepare for unfamiliar subjects. An analogy would be to require a professor of 20th century American literature to pass an annual test covering 10th century Chinese literature. In my situation, I do not and have never practiced sleep medicine yet 10% of the pulmonary board recertification exam consists of sleep medicine questions. I can remember driving from Columbus to Cincinnati to take my 10-year pulmonary recertification exam and calling one of my colleagues from the car to tell me everything I needed to know about interpreting a sleep study.
- Unproven benefit. To date, there is no evidence that passing MOC tests and modules makes a specialist a better doctor. In an era where evidence-based medicine is championed, there is no evidence that MOC is effective in determining physician competency.
- Discriminatory. In the past, once a physician passed the board examination, the physician was board-certified for life and there was no requirement for MOC or re-certification. For hospitals that require board certification for credentialing, older physicians who are board certified for life do not need to do MOC but younger physicians whose board certifications are time-limited to 10 years do need to do MOC.
- Physician burnout. There is not a single physician in the U.S. who looks forward to taking a recertification examination. Many choose to take board exam review and prep courses (the course offered by the American College of Physicians to prepare for the ABIM exam costs $1,095). This requires time off work and creates anxiety about a tedious process that does not make them better doctors. Many physicians time their retirement to coincide with when their 10-year recertification expires just so they do not have to go through it another time.
So, what is the solution?
Board certification was initially created to document successful completion of a specialty residency or subspecialty fellowship. It was similar to the final exam for a college course. You completed a 3-year residency and then at the end, took the ABIM exam to certify that you learned what you needed to know to be an internist. The board exam should go back to being the final exam of a residency or fellowship. I believe that the specialty boards should not be involved with any form of recertification after that initial test. The practicing physician specializing in breast cancer oncology does not need to be held to the same knowledge level about colon cancer as a physician who just completed a general oncology fellowship.
Specialty board organizations need to be down-sized. Re-certification is big business. The ABIM alone has annual revenues exceeding $71 million. The increased income from recertification has resulted in bloated salaries for senior executives and expansion in the number of employees. These boards were created to serve the medical profession but now, the medical profession is increasingly serving the board organizations. They have become feudal lords over fiefdoms of medical specialists.
Health insurance companies should abandon recertification requirements for physicians. Currently, one of the main reasons that physicians spend so much time and money on board recertification is because it is a requirement to be paid by many health insurance companies. The insurance companies have no way to know whether or not a physician is competent so they have adopted board re-certification as a surrogate marker for competency. The problem is that it is not.
“Open book” MOC tests are no longer valid in an era of on-line artificial intelligence programs. All a physician has to do is copy and paste the question into an AI program and the program will tell you the correct answer. These take-home tests are now meaningless.
We should replace the concept of “maintenance of certification” with “maintenance of competency”. Competency determination should be left to the state medical boards and hospital credentials committees. There is no evidence that completing MOC modules ensures that a physician is competent in their area of practice. State medical boards should dictate the number of annual continuing medical education hours required for maintenance of licensure and continue to sanction or revoke licenses of physicians determined to not meet the standards of medical practice. Hospitals should use their credentials committee to confirm that specialists on the medical staff are practicing medicine and surgery competently. As a hospital medical director, I believe that the people who can best judge the competency of a physician are the other physicians who practice in the same hospital. Over the years, I have seen plenty of physicians who always passed their board re-certification exam but were kicked off of our hospital’s medical staff because they were incompetent.
So, is it time to do away with MOC?
August 7, 2023