Historically when a physician had completed several years of post-graduate training (residency) in a chosen field, the director of an approved program would sign the required documents allowing that doctor to “take the boards”. Certification by the various boards under the auspices of The American Board of Medical Specialties was a rite of passage, and for many an indication that a physician had mastered the material and was now prepared to enter independent practice in their chosen field. It had been understood by physicians, and the norm for several decades, that lifelong continuing education would be necessary to keep up to date. This was generally accomplished by participating in Continuing Medical Education (CME). High quality CME is approved by the Accreditation Council for Continuing Medical Education (ACCME) and is required by most states for medical licensing and license renewal. In addition, most hospital credentialing committees and many third party payment plans require documentation of participation in CME to attain and maintain staff privileges or to be included as an approved provider of services for insurance plans.
During the 1980s, many of the member boards of the ABMS began requiring their diplomates (doctors who passed the boards and hold board certificates) to periodically recertify. This involved taking a written examination every seven to ten years, depending on the initial board certification. While many physicians were not pleased with this change in the historic permanency of their board certification status, most understood that there was some value inherent in the periodic review of advances in their fields. Opposition to periodic recertification was limited and mild.
Many professional organizations began to offer recertification review courses. The requirement was an incentive for the CME industry to grow and expand which is exactly what occurred during the 90s and the first decade of this century. Physicians began spending a lot more time and more of their money attending these courses which many felt was essential to them passing a required recertification examination. All of these efforts were presented as being necessary to assure that diplomates of the respective boards were maintaining quality in their practices. During the first decade of this century the idea of Maintenance of Certification was developed and promulgated by The American Board of Medical Specialties and these programs were rapidly adopted in various formats by all 24 board affiliates who began requiring that all physicians holding board certification would now be required to participate in the ABMS MOC programs to maintain their continuous certification.
It is important to note here that the ABMS is a private organization, however it has had tremendous influence, especially at the national level, including the introduction of language within the Affordable Care Act (ACA) directing the Secretary of Health and Human Services to require that physicians participation in the Medicare and Medicaid programs be dependent upon their active participation in Maintenance of Certification. This was further solidified this year when the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was passed. Hailed by many as a “success” because the act repealed the flawed CMS payment formula for physicians…the Sustainable Growth Rate(SGR), MACRA once again contains language cementing MOC programs for all participating physicians beginning in 2019 when the new payment models are scheduled to begin.
Why is this an issue for physicians? There are several reasons, but one of the main concerns for practicing physicians is the time and expense that it takes to participate in these mandated programs, especially in this age of rapidly escalating regulation in other areas of medical practice. In addition, when physicians are being trained to require evidence that their medical and surgical practices are based upon scientific principles…”evidence based medicine”, the evidence that participation in MOC programs results in improvement in practice quality is simply not there.
These facts led to the development of the website Change Board Recertification which has served to educate physicians and others concerning this ongoing problem as well as to offer viable solutions and other resources. As The Docs 4 Patient Care Foundation developed The Physician’s Prescription For Health Care Reform we were quite concerned and very aware of this ongoing issue, which is why we included section #9 which deals with the recertification and MOC issue.
In 2014, Dr. Paul Teirstein, Chief of Cardiology at the Scripps Clinic, became frustrated with the ABIM MOC process and began communicating with his fellow academic cardiologists around the country. He found the level of frustration among his colleagues was incredible and began a petition to the ABMS to stop the MOC program. During this same time frame others were uncovering facts related to the financial benefits accruing to the American Board of Internal Medicine as a result of revenue generated by physicians mandated participation in their MOC activities. This was brought to the attention of the public by Kurt Eichenwald from Newsweek in the article The Ugly Civil War in American Medicine and the follow-up article A Certified Medical Controversy which shined a bright light on the fiscal conflicts of interest plaguing the ABIM and the ABMS.
Dr. Teirstein’s colleagues in cardiology began to ask him what he was going to do about it, and he responded by forming a new board, The National Board of Physicians and Surgeons, along with many academic colleagues from around the country who shared his view. Dr. Teirstein’s comments can be viewed at this debate on maintenance of certification which occurred at the Association of Professors on Medicine (APM) winter meeting in Laguna, CA on February 26, 2015.
Since the founding of the NBPAS, Dr. Hal Scherz, the Secretary of the Board of The Docs 4 Patient Care Foundation has joined the board of the NBPAS and continues to work toward NBPAS certification being accepted by the credentialing bodies of both hospitals and insurance plans. It is our opinion that lifelong learning in a physician’s chosen field has always been a necessary part of a responsible practice; however we feel strongly that no one educational entity should hold a monopoly on “approved” learning programs. Continuing Medical Education is available to physicians in many dynamic formats which are currently expanding. Old models of static testing and secure examinations which are expensive and treat physicians unprofessionally are outdated and should be re-evaluated based upon solid evidence.
The Docs 4 Patient Care Foundation is pleased to see the recent statements by the American Association of Clinical Endocrinologists and the American College of Rheumatology concerning this ongoing and rapidly developing issue. We encourage all specialty organizations to thoughtfully examine their positions on MOC and recertification as we work with the NBPAS and other organizations on common sense evidence based alternatives to the cumbersome and unproven ABMS MOC program.