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Maintenance of Certification: Beauty Is in the Eyes of the BeholderMaintenance of Certification

Robert M. Centor, MD; David A. Fleming, MD, MA; and Darilyn V. Moyer, MD
[+] Article, Author, and Disclosure Information

This article was published online first at www.annals.org on 13 May 2014.

From University of Alabama at Birmingham Huntsville Regional Medical Campus, Huntsville, Alabama; University of Missouri Center for Health Ethics, University of Missouri School of Medicine, Columbia, Missouri; and Temple University School of Medicine, Philadelphia, Pennsylvania.

Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-1014.

Requests for Single Reprints: Robert M. Centor, MD, University of Alabama at Birmingham Huntsville Regional Medical Campus, 301 Governors Drive, Huntsville, AL 35801; e-mail, rcentor@uab.edu.

Current Author Addresses: Dr. Centor: University of Alabama at Birmingham Huntsville Regional Medical Campus, 301 Governors Drive, Huntsville, AL 35801.

Dr. Fleming: University of Missouri Center for Health Ethics, University of Missouri School of Medicine, MA412 Medical Science Building,1 Hospital Drive, Columbia, MO 65212.

Dr. Moyer: Temple University School of Medicine, 3401 North Broad Street, 8 Parkinson Pavilion, Philadelphia, PA 19140.

Ann Intern Med. 2014;161(3):226-227. doi:10.7326/M14-1014
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In this issue, American Board of Internal Medicine leaders discussed recent changes in the certification process. The editorialists describe why many believe that the current process is burdensome and not beneficial and offer suggestions for an assessment process that better reflects the skills necessary to be a good internist.

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Submit a Comment/Letter
Why can't MOC be more like FOAM in ER medicine?
Posted on May 17, 2014
michael kelley
zayed military hospital UAE
Conflict of Interest: None Declared
I am a Med/Peds guy who quit my private practice of 18 years to work overseas. Largely by accident I ended up working in a mid sized ED. For that reason I have been spending many hours reviewing ED material. Besides being big into using ultrasound as part of the patient exam the other interesting thing these ED folks have is FOAMED,free open access emergency department educational learning materials. Bright docs put together pod casts, literature reviews, practice tips, and post it on a web site. Feed back form ED docs reading it helps promote or debunk the postings. Ratings/feed back help rank articles in importance and impact on practice. Information that is sub par is devalued.
MOC has none of this. There is little incentive to make learning interesting or valuable or relevant to practice. There is no user feed back. There is no survival of the fittest competition to boost quality. ABIM has a captive audience and like any other monopoly that gives them the freedom to ignore their constituents.
As with most internists, I want to stay up to date. I do not want the quality of my million dollar education to fade. I would love to have a high quality source of succinct relevant learning. Instead I get boring irrelevant and often pointless "modules" that do precious little to keep my skill set tuned.
I concur
Posted on May 17, 2014
David L. Keller, MD
Conflict of Interest: None Declared
I agree with this editorial and would only add the following specific criticisms:

1) It is degrading and unprofessional to force mature, respected physicians and surgeons to take examinations at "secure testing centers" alongside crowds of sweaty, nervous teenagers taking their college board exams. We have earned the trust to take the exam in the familiar comfort of our offices, where we actually practice, and where we interact with patients in ways which affect their lives.

2) The re-certification exam should not test us on esoteric information about rarely-encountered conditions, for which we would consult with specialists in real life. Every question must clearly test for knowledge or problem-solving ability which every internist must have. The test is graded pass-fail - there is no reason or purpose to have any question which a large percentage of competent practicing internist cannot answer. I am not calling for a dumbing-down of the test, but rather for making it 100% relevant to the practice of the typical general internist; if that is done, the questions will seem much easier and no last-minute cramming or crash courses will be needed. As long as these "test preparation" businesses are thriving, you will know that the ABIM test has not been perfected yet.

3) The "secure test" should be open-book, just like the practice of medicine is in real life. As it is, the re-certification test encourages rote memorization, which is dangerous for many reasons. It encourages us to rely on memorized facts, rather than looking them up. This is a habit which can lead to disaster when memory fails or the facts change. Another dangerous habit encouraged by the closed-book exam is reliance on memorized facts without questioning them. Our state of understanding is not advanced by such blind obedience to authority. We should be encouraged to question authority, "thought-leaders", guidelines and recommendations, rather than swallowing them whole so that we can regurgitate them intact during the secure exam. The skeptical and questioning state of mind we should be maintaining as science-based professionals is not compatible with the need for rote memorization to pass the secure exam.

If the Maintenance of Certification process is allowed to continue as it now exists, we are admitting before the world that physicians have not earned any more trust or respect than the crowds of teenagers taking their college board exams alongside us at the "secure test centers".
Maintenance of Certification, Love it or leave it
Posted on May 27, 2014
David Silverman
Consultant Physician, Lakes District Health Board, Rotorua Public Hospital, Rotorua, New Zealand
Conflict of Interest: None Declared
I am an American trained and ABIM certified internist permanently working in New Zealand and, as a Fellow of the Royal Australasian College of Physicians, enrolled in their Continued Professional Development Program. I wrote to the ABIM asking if an exception could be made for overseas practicing physicians working under a different system where no one has even heard of this process. The answer I got was formulaic and seemingly spit out by a vending machine with not a bit of real thought--in other words "no way, why do you even dare to ask Stupid." Fortunately MOC holds no cards here (same as the standard system of measurement) so I can kindly reply to the ABIM to go fly a kite. This is yet another benefit of working abroad.
Exploitable loophole for physicians near retirement undermines the program
Posted on June 5, 2014
Edward Ringel, MD FACP
MaineGeneral Medical Center Augusta, Maine
Conflict of Interest: None Declared
I'm 61 years old and keep up with the literature, attend conferences, and try my best to apply thoughtful care to my patients. I plan to retire at 65. I have grandfathered IM and Pulmonary certificates, and I let my Critical Care lapse because mercifully I don't do critical care any more. I did want to maintain my MOC so that when internet searched by prospective patients I passed that criterion. It's also useful for recredentialing and insurance purposes. I also have a basic pride in my work and it was important for me personally to remain (to my mind, at least) fully credentialled.

Let's look at how this plays out. Reading the requirements carefully, I needed to do two MOC activities to buy two years of sufficient activity to remain MOC+. I then had to complete a second module, including one of the self-assessment modules, by the end of another two years. This creates an interval of slightly under four years where I remain MOC+ for having done a single activity. The way it works out with my birthday, I'll have about 1/2 year practicing without the benefit of being MOC+. At that point, I'm not going to worry about it.

To reiterate: by completing a single ABIM MOC module I will remain MOC compliant for four years. (As an aside, I completed the MOC module as a beta tester so I was able to provide feedback about the utter irrelevancy of a number of the questions.) In my case, I've gotten the requirement out of the way and I can move on to useful CME. I pay the MOC upkeep fee on a yearly basis so I'm paying a couple of hundred dollars a year to look like I'm doing what I'm doing anyway.

If I were not diligent, this process would present an easy way for me to slither away from this MOC stuff and do my "CME" on a cruise ship.

I feel mostly like I am paying for an imprimatur that has little or no incremental value. Worst of all, for those of us closer to retirement than others, it's easy to stay MOC+ while doing very little, and arguably we would be one of the groups that might warrant closer attention. I had hoped for a program that would have made me feel engaged, and it does not.
The ABIM and misplaced priorities
Posted on June 5, 2014
Paula Bononi MD FACP
Conflict of Interest: None Declared
The ABIM has misplaced its priorities. I hold lifetime certification. However, I signed up for MOC due to the ABIM's stated intention of designating me as "not meeting maintenance requirements" if I did not comply. That request was onerous, but the deal breaker for me was an invitation to take the recertification exam by December 31, 2023.

Dr Baron, by December 31, 2023, I plan to be enjoying my retirement.
Different MOC Exam Passing Rates by different ABMS Boards
Posted on June 10, 2014
Donald Trainor MD FAAP FACP
HealthNet Inc.
Conflict of Interest: None Declared
As a generalist Med/Peds Physician Board Certified by both the Amer. Board of Pediatrics and the ABIM for over 20 years with non-lifetime certification for both, I have always found the ABP exams to be much more primary care focused than either the initial or subsequent MOC ABIM General IM exams. In fact, it was particularly galling when attending an IM MOC Prep course 3 years ago to have the faculty cardiology lecturer say that we needed to memorize some information being presented based on ABIM core content even though he had never seen a case in his 20+ years in cardiology practice. He explained however that the ABIM likes to ask questions about it on the exam nonetheless.
On my most recent ABIM exam, the 1st time pass rate for the already Board Certified Internists taking it was 84%. This contrasts with my recent ABP Pediatric MOC Exam which had a ~95% pass rate for the Board Certified Pediatricians taking it. My ObGyn wife's recent ABOG MOC exam also had a >90% pass rate. Who does the ABIM think they have to be so hard on practicing Board Certified Internists? What about those Physicians practicing Internal Medicine who never have been Board Certified? An argument can be made that maybe the ABIM should focus on testing them rather than "punishing" practicing Internists who have always been Board Certified, are Physician Leaders of their clinical organizations and delivery systems, have never been sanctioned by their State Licensing Board or Medicare/Medicaid, and WHO have been recognized by 3rd party payors for their clinical quality.
MOC secure exams, particularly for ABIM because of their higher fail rate, have turned into a cottage industry where MOC Prep courses proliferate and which cost thousands of dollars for registration, travel, hotel, and time away from practice, let alone to pay for the MOC processes and secure exam.
Again, the ABIM MOC exam process was more onerous that the one I took for ABP. The latter did not require fingerprints or palm prints, for example. It also was only 2 modules instead of 3, making it a 1/2 day exam instead of an all-day exam. And why does a computerized exam take weeks, even months to tell the testers the outcome of their exam? The actual taking of the ABIM secure exam feels like I was being booked for a minimum security prison. Again, we are all already Board Certified, have not been charged with anything more than a traffic violation for 99+% of us, but this feels threatening and demeaning.
MOC as administered by ABMS Boards is intended to ensure clinical knowledge and allegedly competency (although I am not aware of any study that clearly demonstrates that the latter is true). However, Insurance Payors are increasingly using it to determine participation in their plans, never an intended end result of Board Certification, I don't believe.
Let's put the fun back into MOC and clinical lifelong learning. I would much rather, if there is to be a "corrective action" from a MOC secure exam (rather than lose my Board Certification), have to take a certain number of CME credits in the clinical areas in which my exam indicated I am not as knowledgeable. Or even retake an exam in the areas I didn't perform as well in to meet a predetermined pass rate, kind of like CPA exams.
Thanks for the comments
Posted on June 13, 2014
Robert M Centor, MD
Conflict of Interest: Editorial writer
Thanks for your comments. Your thoughts are important and reinforce the idea that the objections to the current MOC processes are not rejections of ongoing education. As I read the comments, internists want to maintain and expand knowledge. We want processes that help us grow. Many internists believe that alternate strategies would help them succeed.
Not alone
Posted on July 16, 2014
Robert B. Copeland, MD, MACP, FACC, FRCP
West Georgia Physicians
Conflict of Interest: None Declared
Multiple ACP mailings, e-mails and phone calls make me well aware that I am not alone in my concern with ABIM’s position on maintenance of certification.

The current generic ABIM statement for those Internists without time limited certification is, “certified, not meeting maintenance of certification requirements.” The ABIM does not know what those of us who consider professionalism and lifelong scholarship a critical personal obligation may be doing. I consider the statement an insult. Patients, employers and insurers may well read, “certified but not meeting maintenance of certification requirements,” as unfit to practice medicine!

I have successfully taken five ABIM certification and recertification examinations without paying for spoon feeding or subscribing to any ABIM Program. At age 77, I continue to practice, study, teach, run a free clinic and medically direct a complex regional hospital department. The maintenance of medical knowledge and diagnostic skills is very, very important to me.

I have corresponded with Dr. Baron, President and CEO of ABIM. He was respectful but it seemed to me terribly out of touch. He did suggest that I visit the ABIM Foundation website to read the physician charter on professionalism. I had to inform him that it was my high personal privilege to have been a part of the group which wrote that charter.

Some twenty-five years ago, Holly Smith chided the leadership of ABIM about its proclivity to, “chew on more than it had bitten off”. Their current opaque position on maintenance of certification using their my way or no way program seems to show they are still at it. It also raises the question of whether the ABIM is our principled setter of standards or is becoming a toll collector on the road to dwindling health in America.

I have proudly served both ABIM’s Board of Governors and ACP’s Board of Regents. The last thing I want to do now is promote adversarial positions. However, when the best efforts of well-intended people proves to be more capricious than constructive, it is time to reconsider.

How is MOC helping our patients?
Posted on August 5, 2014
Leonard Johnson MD
St. John Hospital and Medical Center
Conflict of Interest: None Declared
At the end of the day, what the ABIM must answer as it figures out how to respond to the loud chorus of criticism from internists and subspecialists is how the "evolving" process of MOC has helped our patients. As internists, we concern ourselves with the time and costs involved in the process but as a society I believe we can agree that if all of these changes lead to improved patient outcomes, we could accept our individual burden. In particular, at a time of a shortage of primary care physicians with shortages projected to increase, how does increasing the proportion who are no longer certified (a consequence of increasing recertification failure rates) help the population in general? Furthermore, as 60+ year old physicians try to decide whether to continue practice or now face the additional time and costs associated with MOC, are we encouraging them to stay in practice to serve their patients or rather retire? As a patient who is attempting to contact a physician's office for an appointment and refill, would I rather his/her office staff busy themselves with reaching out to patients to complete surveys to meet MOC requirements or take care of my medical needs? If the physician practice is large, the need to complete large volumes of surveys along with all the requisite insurance information make the time spent on direct patient care even smaller. Have any of our patients ever complained about their inability to answer surveys to our certifying organization or do they more frequently complain about wait times as they try to schedule and get refills? Their ultimate approval of our care comes when they decide to see us again. If a physician remains busy throughout their practice, what is the additional benefit of a patient survey through the ABIM to confirm their ability?

If the ABIM cannot answer how the current MOC process (including the actual test content itself) has improved patient care using actual peer-reviewed data, I suggest they commission some of the $70 million in the ABIM Foundation for such research demonstrating its actual practical value. In medicine, we do not produce treatment guidelines based on the principle of "we believe" but rather based on "studies demonstrate". It is past time for the ABIM to start using the rules of evidence to support their current MOC or re-focus the process on how to better serve our patients. I commend the ACP leadership for pushing this issue further over the last several months and would suggest that we continue to remind the ABIM who they serve.
To the Editor
Posted on August 12, 2014
Edward Volpintesta, MD
Bethel, CT
Conflict of Interest: None Declared
I am not an internist. I am a family physician in practice for 40 years and until several years ago had consistently and successfully re-certified. But my comments have relevance to the criticisms recently discussed.
The authors raised several good points, but there are a few that were not mentioned and should be.
The boards were never meant to be mandatory. They started out as voluntary exams. Physicians would never have supported them if they had known that eventually they would attain the de facto mandatory status that they now have.
The punitive nature of the exams is counter-productive to learning whatever the board may be because the pass/fail approach forces examinees to cram and engorge themselves with information a large part of which they do not need. This is taxing and actually it is dishonest.
Because of their punitive nature, a large industry of board preparation courses has grown to take advantage of the fears of those examinees who are not good test takers or who shudder at the thought of not getting a passing grade. I have seen some board preparation courses actually guarantee a passing grade.
For example, like many other family physicians and general internists, I have customized my practice over the years. Once I did office surgery, gynecology, and treated patients in the ICU and on the hospital floors. I also did pediatrics and took care of patients in the nursing home.
Now, however, I now use hospitalists for my in-patients and delegate the care of my nursing home patients as well. I no longer do gynecology or pediatrics. I rarely do suturing.
The great majority of my patients are the same ones that I started out with in my practice because I have practiced in the same town and office.
When I last took my Family Medicine boards at least 30% of the questions were unrelated to my practice. My colleagues in internal medicine say the same.
Continuing education must not be punitive. For doctors who have already been certified, education should adopt more of a self-assessment type approach.
More important, the board preps cannot accurately assess the totality of a doctor’s talents and capabilities.
Furthermore, maintenance of certification cannot measure personal qualities like honesty, the ability to connect with patients in a personal and humane way, working well with one’s consultants, serving on hospital committees and participating in medical affairs in one’s state and county medical association.
Clearly, in addition to its shortcomings MOC should never be used, as it is, as a single factor to judge a physician’s capabilities. Yet by singling out doctors as MOC-certified or not, this is exactly what the ABMS is doing.
Al things considered, I doubt very much that psychometricians who are the experts in the goals and benefits of continuing medical education and testing, unanimously approve of the methods that are at the core of the American Board of Medical Specialties’ approach.
This debate is incomplete without hearing from them.

I would like to add the most important is that by making MOC mandatory the American Board of Medical Specialties (ABMS) eliminates the voluntary basis without which our medical organizations would not have supported the creation of the ABMS in the in the first place.
Is it any wonder that many physicians feel betrayed by the ABMS and that they are provoked and that they believe that the actions of the ABMS are deliberately unjustified and cannot go unchecked and unchallenged?

1. Centor RM. Ann Intern Med. 2014;161:226-227.

MOC - a pathway to maintaining knowlege and delivering current patient care
Posted on August 28, 2014
Antoinette Spevetz, MD
Cooper University Hospital
Conflict of Interest: None Declared
To the Editor:
I have been following the discussions regarding the changes in the American Board of Internal Medicine (ABIM) Maintenance of Certification (MOC) program that went into effect in January 2014. In contrast to the article by Drs. Baron and Johnson in support of the changes, the accompanying editorial by Drs. Centor, Fleming, and Moyer suggests that heuristics are at play resulting in a disconnect between the intentions of ABIM and the perceptions of the internal medicine community for whom MOC is one of many mounting stressors. Medicine and the external influences on physicians have certainly changed dramatically since the 1990s when I started to practice. Electronic medical records, the rigors of documentation, and pay-for-performance measures that we may or may not agree with all eat up our professional as well as personal time.

What strikes me here is that if we physicians want to take a stand against these infringements on our time, why did we choose MOC to rebel against? Is it because “they”, the ABIM, is us? The ABIM is governed by physicians. Can we say that of some of these other external entities? Have we chosen this fight because ABIM is an easier target than CMS or other agencies?

I think we should be careful. If we look at what MOC seeks to accomplish it is education. It provides a mechanism for all of us to keep up with our specialties and to remain current. I was recently at the meeting ABIM held in Philadelphia to hear feedback from the societies. Most everyone who spoke up was from a major medical institution. That is not where the bulk of medicine is practiced. It is practiced in small hospitals around the country where physicians do not have the benefit of training programs and residents to keep current every day. I have worked in private practice and understand the challenges in keeping current. Sometimes we all need an impetus to devote time and energy to a solid, focused review of our specialty. Our patients demand it, as does the oath we all took upon graduation from medical school.

I am completely supportive of streamlining the process, participating in activities that are relevant to our practice and making MOC as easy to work into our days as possible. I must say that reading some of the things written against the MOC does not necessarily make us look good as physicians. When non-physicians ask me why we are complaining about keeping current and paying $200 per year, I find it a difficult question to answer. We are entrusted with people’s lives. I don’t enjoy spending time and money and taking the secure exam any more than anyone else. Nor do I have a higher salary than anyone else. I do, however, think it is the right thing to do and support it.

Antoinette Spevetz, MD
Author's Response
Posted on October 10, 2014
Robert M. Centor, MD, MACP, David Fleming, MD, MACP, Darilyn Moyer, MD, FACP
University of Alabama Birmingham
Conflict of Interest: None Declared

Thank you for the comments. These thoughts are important and reinforce the idea that the objections to the current MOC processes are not rejections of ongoing education or professional development. As we read the comments, it is clear that internists want to maintain competency and expand knowledge for the sake of their profession and the welfare of patients. We want processes that help us grow at many levels. Many internists believe that alternate strategies would help them succeed in this effort.

Dr. Kelley challenged the MOC process to be more like FOAM in ER medicine. He raises an important concern about continuing education. We can imagine changes in MOC that would enhance learning enjoyment. We hope that the ABIM Assessment 2020 project will help transform MOC from merely a summative examination to a formative process. http://www.abim.org/news/abim-initiative-seek-input-on-physician-knowledge-skill-assessment-approaches.aspx

Dr. Ringel has concerns about an “exploitable loophole”. Dr. Ringel makes explicit what many older physicians are doing in their engagement of MOC. We do not view this as a loophole, and hope that ABIM will change their reporting to make this behavior unnecessary - http://www.abim.org/news/abim-leadership-explore-change-to-language-indicating-moc-status-on-website.aspx We who hold lifetime certificates are encouraged but not required to participate in MOC for certification.

Dr. Trainor raises a critical concern - differing initial MOC pass rates across specialty boards. We have raised this issue repeatedly, and hope that ABIM will respond. We agree that the progressively lower initial pass rate for the secure internal medicine board exam continues to be an unavoidable problem that needs to be addressed.

Dr. Copeland speaks with wisdom as a former ACP leader and former ABIM leader. We respect his opinions.

Dr. Johnson asks how MOC is helping our patients? In the current climate that asks physicians to base decisions on the best evidence available, what evidence exists that the MOC process helps patients? Anecdotal and subjective validity will not suffice in the modern era.

Dr. Spevetz worries that the internal medicine community is rebelling against ABIM. This may be true. Internists opine about the problems of EHRs, prior authorization, the current payment structure, and other administrative burdens that distract from patient care and practice enjoyment. The concern about MOC is not about goals but rather process. We agree with the intent of requiring physicians to maintain competence in their profession, but have concerns about the current recertification exam and other aspects of MOC that are logistically burdensome for practicing internists with there being no evidence that patient care will be improved. The ABIM is now listening to our concerns and is making change, which hopefully will encourage acceptance by internists and allow MOC to achieve its patient centered goals.

We thank all who have commented for reconfirming the importance of lifelong learning and maintaining professional competence, while also asking legitimate questions about how best to reach those goals. We believe that the ABIM is now working to improve their MOC processes and applaud the strides they have made. We look forward to continued joint efforts with ABIM to foster ongoing improvements in MOC.

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