As a physician who recently completed training, I have only taken my board certification exam— I am yet to start the arduous process of maintenance of certification (MOC). The process, overseen by the American Board of Medical Specialties (ABMS), entails a four-level framework that most physicians have submitted to since the early 1990s. Based on conversations with other physicians— and pending lawsuits— it seems that I am not alone in my trepidation for the road to come.

The background of MOC— a complicated issue

The largest certifying board for physicians, the American Board of Internal Medicine (ABIM), is responsible for certifying over 200,000 physicians. The vast majority— 85% of practicing physicians elect to become board certified. Not obtaining board certification— or maintaining it— is a tremendous faux-pas. The majority of patients and hospitals consider uncertified physicians near incompetent, despite an average of a decade of training and the multiple standardized tests necessary to obtain the MD designation.

Of course, there is a noble cause behind MOC. Physicians have committed to life-long learning and need to keep abreast of innovations in patient care. Additionally, the ABIM cites that the value of the MOC was designed with the input of physicians and quotes benefits such as adherence to guidelines, improved patient care and decreased health care costs. While some studies show an association between improved patient care and board certification, the high percentage of board-certified physicians and the many confounding real life factors, like fatigue, short clinic appointments, and administrative load make it difficult to ascertain causality.

A critical look at MOC

Our current MOC process does not always achieve these lofty goals. The recurrent ten-year MOC is not inexpensive; it requires time off work and lost pay, as well as fees totaling thousands of dollars.  Of course, this does not include travel expense or study costs associated with the exam.

The consequences go beyond financial concerns, as physicians who do jump through the hoops have learned the difficult way. A group of physicians sued the ABIM in December 2018, citing

• Lost jobs and patients as many hospital and insurance require board certification to obtain hospital privileges and reimbursement
• Defamation, as physicians not maintaining ABIM certification, can be “red-flagged,” even if they voluntarily adhere to other certification processes
• Monopolization of physicians certification and concerns regarding transparency and ulterior motivations of monetary gain

In response to the lawsuit, the ABIM put out a call to its members in January 2019, called the Vision for the Future Commission, to evaluate general opinion regarding MOC. Astonishingly, only 12% of members indicated that they valued MOC, 46% had mixed feelings, and 41% did not value it at all. Most participants called MOD “burdensome” with 43% noting that it did “not help their [medical] practice in any meaningful way.”

Changes are Coming to MOC

To its credit, the ABIM has made some changes following physician outrage. It began to roll out the Knowledge Check-In in 2018, an alternative to the 10-year MOC in which physicians can take a biennial exam in the comfort of their own home or office. It simulates real-world situations, such as the ability to refer to the reference tool UpToDate that many physicians utilize during patient care.

Other specialty boards look to ABIM and refine their policies based accordingly.  For example, the American Boards of Pediatrics (ABP), Surgery (ABS) and Plastic Surgery (ABPS) have all begun implementation of similar alternatives to the ten-year MOC exams that are “open book,” don’t require travel to test centers and take place more often than every ten years. The ABP is completely transitioning to this model.

Also, the pediatric exam— the MOCA-Ped— provides real-time answers so that physicians can learn from their mistakes in an educational setting and pass on the benefit to their patients. Others, like the American Boards of Obstetrics & Gynecology (ABOG) and Psychiatry and Neurology (ABPN), encourage their members to stay current on their specialty’s literature by testing physicians on innovative research as a way to maintain certification.

Furthermore, some boards are beginning to take the high stakes out of MOC. Physicians who do not pass the MOC can repeat the exam so they won’t automatically lose their certification, as is the case for ABIM physicians at the end of their ten-year cycle. Additionally, the ABP is making its MOC more relevant, allowing, real-world practices, like the development of quality, innovative programs in the workplaces to fill requirements for MOC.

Is it too little too late?

Despite the efforts taken by ABMS, some physicians suggest it is too little too late, and they are ready to walk away from the MOC as it stands. The alternative certifying board, The National Board of Physicians and Surgeons (NBPAS), has been vocal in calls to effect change in the current practice of MOC. The NBPS certifies non-surgical medical specialties and osteopathic physicians and identifies itself as a “grassroots organization.”

The criteria for certification are much more straightforward than for ABMS specialties:

• Prior certification by ABMS or AOA boards
• A valid medical license
• 50-100 hours of CME over the past two years
• Active hospital privileges and medical staff appointment

However, only a minority of physicians (7000) is certified by NBMS, and only 108 hospitals nationwide accept certification from NBMS to obtain hospital privileges. Just as important, many insurance companies do not acknowledge NBMS certification. It is unclear how widespread NBPAS certification will become overtime and if it will rival or even replace ABMS. It is significantly cheaper, with the fee just under $169 for MDs and $189 for DOs with renewal fees $15 cheaper and no recurrent test required.

While the NBPAS and alternatives to ABMS make up a small proportion of the MOC options for physicians, the fact remains that they exist and as such, ABMS cannot turn a blind eye to physician concerns. Only time will tell if physicians are frustrated enough to increasingly switch to these alternatives to ensure the best care of their patients, without undue burden to themselves and their practices physicians.

Whatever the future holds, we physicians have the leverage to make our voices heard.