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PERS PE C T IV E Maintenance of Certification 2.

standards could be further refined and assessment by the boards. throughout their careers. We be-
to reflect the changing education- They also encourage innovation. lieve that high standards of spe-
al and practice environments and In the area of lifelong learning, cialty certification are important
address the needs of the physi- for example, some boards are to health care, and we hope our
cians it is intended to support. emailing questions of the week medical-community partners will
The recently approved 2015 to stimulate learning through work with us to continue to
ABMS standards for MOC are the self-assessment activities. Thanks evolve our certification systems
result of this refinement process. to technological advances, some to ensure that the standards they
These standards (available at www boards are investigating the pos- set continue to be highly valued
.abms.org) include general stan- sibility of developing a secure ex- in the future.
dards pertaining to the member amination that can be delivered Disclosure forms provided by the au-
boards themselves, outlining ex- in various settings and for ex- thors are available with the full text of this
article at NEJM.org.
pectations for them to incorpo- panding access to approved refer-
rate all six ABMSACGME core ence materials during the exami- From the American Board of Medical Spe-
competencies throughout their nation process. Under the new cialties, Chicago.

MOC programs, to enhance the standards, boards are also ex- 1. Davis DA, Mazmanian PE, Fordis M, Van
value and relevance of their MOC pected to provide feedback from Harrison R, Thorpe KE, Perrier L. Accuracy of
programs for their diplomates by the examination to guide physi- physician self-assessment compared with
observed measures of competence: a sys-
being sensitive to time, adminis- cians self-assessment and indi- tematic review. JAMA 2006;296:1094-102.
trative burden, and cost, and to vidual learning; they are also 2. Wittich CM, Reed DA, Ting HH, et al.
engage in continuous quality im- expected to provide MOC credit Measuring reflection on participation in
quality improvement activities for mainte-
provement of their MOC pro- for meaningful participation in nance of certification. Acad Med 2014;89:
grams, in part through regular system- and team-based quality- 1392-7.
review incorporating input from improvement activities in physi- 3. Peterson LE, Blackburn BE, Puffer JC,
Phillips RL Jr. Family physicians quality inter-
diplomates and the public. The cians practice settings. ventions and performance improvement
new standards place greater em- We see the 2015 MOC stan- through the ABFM diabetes performance in
phasis on profes- dards as providing the medical practice module. Ann Fam Med 2014;12:
An audio interview 17-20.
on MOC with Steven sionalism and pa- community, the member boards, 4. Vernacchio L, Francis ME, Epstein DM, et
Weinberger of the American tient safety, and and ABMS with an opportunity al. Effectiveness of an asthma quality im-
College of Physicians is they include a re- to work together to positively af- provement program designed for mainte-
available at NEJM.org nance of certification. Pediatrics 2014;134(1):
quirement that ex- fect the care of patients and e242-e248.
aminations assess physicians communities, to support the so- 5. Gorzkowski JA, Klein JD, Harris DL, et al.
judgment as well as knowledge. cial compact between the public Maintenance of Certification Part 4 Credit
and recruitment for practice-based research.
The 2015 standards retain pro- and the profession, and thereby Pediatrics 2014;134:747-53.
gram elements that incorporate to help maintain medicine as a DOI: 10.1056/NEJMp1409923
both physician self-assessment profession and support physicians Copyright 2015 Massachusetts Medical Society.

Boarded to Death Why Maintenance of Certification


Is Bad for Doctors and Patients
Paul S. Teirstein, M.D.

I n January 2014, the American


Board of Internal Medicine
(ABIM) changed its certification
listed as certified, meeting main-
tenance of certification (MOC)
requirements or certified, not
knowledge, practice-assessment,
and patient-safety activities, on
which physicians are assessed
policies for physicians. Instead meeting MOC requirements. every 2 years, and passage of a
of being listed by the ABIM as MOC requirements include ongo- secure exam in ones specialty
certified, physicians are now ing engagement in various medical every 10 years.

106 n engl j med 372;2nejm.orgjanuary 8, 2015

The New England Journal of Medicine


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Copyright 2015 Massachusetts Medical Society. All rights reserved.
PE R S PE C T IV E Why MOC Is Bad for Doctors and Patients

My personal frustration in try- level A data, and these findings 10 years, others strongly believe
ing to fulfill the new MOC re- relate only to recertification, not that the exam questions are not
quirements ultimately led me to the controversial new MOC re- relevant to their practice or a re-
create a Web-based petition that quirements. liable gauge of physicians knowl-
now has more than 19,000 anti- The ABIM claims that a ma- edge. The ABIM describes its
MOC signatures and contains jority of certified physicians have tests as using psychometrics
thousands of comments against already signed up for MOC, leading to high reliability and
the new MOC requirements which they interpret as support reproducibility,2 but no clear cor-
(www.nomoc.org). A recent sec- for the program, but MOC is relation between these test re-
ond petition with nearly 6000 mandated by the ABIM for re- sults and patient outcomes has
signatures advocates taking a cently certified physicians and been documented. Furthermore,
pledge of noncompliance with perceived as a job-security require- many physicians believe that
the requirements. ment by many others physi- closed-book tests are no longer
Although the ABIM argues cian interest is either required or relevant, since physicians can now
that there is evidence supporting motivated by fear. Indeed, in a easily turn to online resources,
the value of MOC, high-quality 2010 Journal feature that allowed as well as their colleagues, while
data supporting the efficacy of physicians to express their opin- caring for patients.
the program will be very hard, if ions on MOC, many respondents The ABIM has grown into a
not impossible, to obtain. In commented that the exercise large business enterprise. The eco-
fact, close examination of the re- was only marginally relevant to nomics of certification are ex-
ports cited by the ABIM reveals their day-to-day practice and that posed on the ABIMs Internal
that the data are ambiguous at it took their time away from pa- Revenue Service Form 990, which
best: in a meta-analysis of 33 tients and other learning activi- is required of all not-for-profit or-
studies, 16 described a signifi- ties.5 These problems are espe- ganizations (www.guidestar.org).
cant association between certifi- cially frustrating in light of other In 2012, the year of its latest fil-
cation status and positive clinical ongoing tasks that hospital- ing, the ABIM received more
outcomes, 14 found no associa- based physicians are required to than $55 million in fees from
tion, and 3 found a negative as- complete. For example, to main- physicians seeking certification.
sociation. Moreover, the authors tain my hospital privileges I must Several of its board members and
of the meta-analysis concluded complete 14 separate computer its chief executive officer are
that the research methods of modules on various subjects ei- highly compensated. Many re-
most published studies on this ther annually or every 2 years. In spondents to the Journal feature
topic are inadequate.1 Almost all addition, my annual bonus is tied expressed the view that the MOC
published studies evaluate initial to my performance on practice- program was essentially a money-
board certification, not recertifi- improvement activities, including generating activity for the ABIM.5
cation or MOC,2 and the rigorous formal surveys of patient satis- Much of the U.S. health care sys-
requirements for initial certifica- faction, low-density lipopro tein tem is now focused on value, and
tion should not be equated with cholesterol control, blood-pressure physicians are working hard to
the busywork required for the control, and various core mea- provide better patient care at lower
MOC every 2 years. One of the sures for hospitalized patients. cost. MOC provides the opposite
few studies examining lapsed Adding continuous ABIM MOC an activity with no proven ef-
certification showed no effect of activities, which have no docu- ficacy, at a high cost. MOC fees
physicians certification status mented efficacy, to this already range from $2,715 to $3,335 every
on patient outcomes after coro- overwhelming list is onerous and 10 years; on top of these are
nary intervention.3 Two very re- diminishes the time physicians costs for travel to testing centers,
cent studies found no association have for patient care. review courses, and time spent
between recertification and per- Although some members of away from practice. I believe that,
formance or quality measures; the medical community believe like the rest of the medical com-
one, conducted by ABIM mem- that its not unreasonable to ask munity, the ABIM should focus
bers, found a minor reduction in physicians to formally document on efficacy while cutting its costs
cost of care.4 No study provided their fund of knowledge every and lowering its fees.

n engl j med 372;2nejm.orgjanuary 8, 2015 107


The New England Journal of Medicine
Downloaded from nejm.org on December 5, 2017. For personal use only. No other uses without permission.
Copyright 2015 Massachusetts Medical Society. All rights reserved.
PERS PE C T IV E Why MOC Is Bad for Doctors and Patients

We all support lifelong learn- sicians annual CME attendance. ABIM is a private, self-appointed
ing, but an excellent alternative I also believe that the ABIM web- certifying organization. Although
to MOC already exists: continu- site should be vastly simplified it has made important contribu-
ing medical education (CME). so that administrative tasks be- tions to patient care, it has also
Currently, medical licensure for come less onerous. Finally, I be- grown into a $55-million-per-
physicians requires an annual lieve that the ABIM should work year business, unfettered by com-
minimum of approximately 25 to cut its costs and, correspond- petition, selling proprietary, copy-
hours of CME, depending on the ingly, substantially reduce the righted products. I believe we
state. Physicians accept this re- initial certification and recertifi- would all benefit if other organi-
quirement because they perceive cation fees paid by physicians. zations stepped up to compete
it as having value. Organizations The ABIM is now under fire. with the ABIM, offering alterna-
providing recognized CME pro- Some 63% of respondents to the tive certification options.
grams are regulated by the Ac- 2010 Journal feature opposed More broadly, many physicians
creditation Council for Continuing MOC.5 In a survey by the Ameri- are waking up to the fact that
Medical Education, which requires can College of Cardiology (ACC), our profession is increasingly
each CME offering to provide an nearly 90% of the respondents controlled by people not directly
educational gap analysis, a opposed the new MOC require- involved in patient care who have
needs assessment, information ments, and ACC leaders are now lost contact with the realities of
about speakers potential conflicts engaged in discussions with the day-to-day clinical practice. Per-
of interest, and course evalua- ABIM to change MOC. The ABIM haps its time for practicing phy-
tions, as well as meeting other has been formally criticized for sicians to take back the leader-
performance standards. CME of- the new requirements by several ship of medicine.
ferings must compete with one important physician groups, in- Disclosure forms provided by the author
another, and they therefore pro- cluding the American College of are available with the full text of this article
vide choice. If physicians do not Physicians and the American As- at NEJM.org.
perceive value in a particular sociation of Clinical Endocrinol-
From the Scripps Clinic and the Scripps Pre-
CME offering, they will go else- ogists (which has formally asked bys Cardiovascular Institute, La Jolla, CA.
where a situation in stark the ABIM to suspend its new
contrast with the ABIM monopo- MOC requirements). The Associ- 1. Sharp LK, Bashook PG, Lipsky MS,
ly on MOC. ation of American Physicians and Horowitz SD, Miller SH. Specialty board cer-
tification and clinical outcomes: the missing
There are many opinions about Surgeons filed a lawsuit against link. Acad Med 2002;77:534-42.
how MOC should be changed. the American Board of Medical 2. Holmboe ES, Lipner R, Greiner A. Assess-
My main recommendation would Specialties (the parent organiza- ing quality of care: knowledge matters. JAMA
2008;299:338-40.
be to allow 25 annual hours of tion of the ABIM) for restraining 3. Fiorilli PN, Minges K, Herrin J, et al. As-
CME to be substituted for the trade and causing a reduction in sociation of Interventional Cardiology board
current MOC requirements that patient access to physicians. At a certification and in-hospital outcomes of pa-
tients undergoing percutaneous coronary
need to be met every 2 years. Do- recent American Medical Asso- interventions. J Am Coll Cardiol 2014;63:
ing so would eliminate, or make ciation meeting in Chicago, dele- 2904-5.
optional, the busywork modules gates voted to oppose making 4. Lee T. Certifying the good physician, a
work in progress. JAMA 2014;312:2340-2.
that have little practical value, in- MOC mandatory as a condition 5. Kritek PA, Drazen JM. Clinical decisions:
cluding all medical knowledge, of medical licensure. American Board of Internal Medicine main-
practice-improvement, and pa- Regardless of how the MOC tenance of certification program polling
results. N Engl J Med 2010;362(15):e54.
tient-safety modules. The charg- issue is resolved, the recent focus
es for these new MOC activities on the ABIM has shed a bright DOI: 10.1056/NEJMp1407422
should be nominal perhaps light on how medicine is regu- Copyright 2015 Massachusetts Medical Society.

$100 per year for tracking a phy- lated in the United States. The

108 n engl j med 372;2nejm.orgjanuary 8, 2015

The New England Journal of Medicine


Downloaded from nejm.org on December 5, 2017. For personal use only. No other uses without permission.
Copyright 2015 Massachusetts Medical Society. All rights reserved.

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