Docs sound off, question MOC

Among the many challenges primary care physicians face in their work, few trigger more anger or frustration than maintaining board certification.

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Most physicians understand and agree with the overall goals of the maintenance of certification (MOC) process, which are to ensure that physicians are keeping their knowledge and skills up-to-date. But many also feel that the benefits of MOC, as most specialties apply it, don’t outweigh what it costs physicians in time, money and anxiety. And just as they would with an ill patient, they have ideas on how to cure what they believe ails MOC. 

While MOC detractors can probably be found among all the 24 certifying boards under the umbrella of the American Board of Medical Specialties, the American Board of Internal Medicine (ABIM) has come under especially harsh criticism. Much of it stems from the ABIM’s 2014 decision to expand MOC requirements to include new practice- and safety-related activities in addition to its existing 10-year recertification exam. Moreover, doctors had to complete a certain number of these activities every two years to maintain their board-certified status.

Faced with a torrent of criticism, the board backtracked. Early in 2015 it apologized for instituting the changes and said that the new activity requirements were being suspended through 2017. (The suspension was later extended through 2018.)

The board subsequently announced that beginning in 2018 it will offer a new testing option, consisting of shorter, open-book tests-what it calls “knowledge check-ins”- available more frequently than the once-a-decade written exam it now requires as part of MOC. Doctors can take the shorter tests wherever they choose, rather than having to travel to a secure testing location, and those who score well on these will be allowed to test out of the 10-year exams.

(The knowledge check-in option will be offered first to doctors recertifying in internal medicine and nephrology, and expanded to the other subspecialties covered by ABIM in 2019 and 2020.) 

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These changes have lessened, but by no means ended, physicians’ complaints about the ABIM’s process for maintaining certification. For its part, the board maintains that the tests and other activities it requires can help doctors identify gaps in their medical knowledge and improve how they run their practices.

At the American College of Physician’s 2017 internal medicine meeting, ABIM President and Chief Executive Officer Richard Baron, MD, MACP, offered another justification for MOC: keeping patients’ trust in their physicians in an era of “fake news.”

“I don’t think we can assume as individuals or as a profession that deference and trust is a given for doctors,” Baron said during a conference session. “I think we all have to think about how trust is built in the new world.”

To get a better sense of physicians’ views of MOC, Medical Economics spoke with physicians around the country to find out how they view the costs and benefits of MOC, and what they would do to change the process if the opportunity arose. Here’s what doctors had to say.

Alan Aboaf, MD

Type of practice: General internal medicine 

Practice location: Centennial, Colorado

Years in practice:  24

Most recent board certification: 2012

Recent MOC-related financial costs:
Purchase of Medical Knowledge Self Assessment Program (MKSAP), $620; attending meeting of Colorado chapter of ACP for MOC points, $765 ($200 for lodging, $565 for meeting costs); annual MOC fees, $194 ($1,940 over 10-year cycle) 

MOC-related time costs:
Two days out of office for attending annual meeting of Colorado chapter of ACP for MOC points, one day for taking MOC exam 

ACP/ABIM affiliation(s): none

Q: Where are you in the MOC process now? 

A: I sit for the exam again in 2022. I’ve been doing activities steadily along, just to make sure I don’t have to cram it all in at the end. Mostly those consist of going to [local ACP] meetings.

Q: Do you think MOC has benefitted you in any way? 

A: It’s always good to review. Medicine is an area that’s so fluid that if you don’t keep up you can end up practicing medicine that’s 20 years old. So I think there’s a benefit in that. The question is, should you be taking a proctored exam that’s so rigid and doesn’t reflect what you normally do? Also, you can’t get on the medical staff of a hospital without being board-certified, so it kind of hangs over your head as something you need to do.

Q: How would you design the MOC process if it were up to you? 

A: I’d just require regular CME in the discipline you practice in. I don’t think taking a proctored exam is something I would require. But if it is required, then the issue is how long do you make physicians do it? I’ve done it three times and am getting ready to do it a fourth time. I think at some point they could say you don’t have to do it anymore. 

Next: 'There can be significant improvement in the process'

David Hoffman, DO

Type of practice: Cardiology 

Practice location: Youngstown, Ohio

Years in practice: 38

Most recent board certification: 2007

Recent MOC-related financial costs: $194 for annual MOC fees

MOC-related time costs: One day for taking exam

Q: Where are you now in the MOC process? 

A: I have to complete it before September, somehow, and I’ll figure out some weekend soon what I have to do.

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Q: What will that involve? 

A: Reviewing whatever I need to review. The problem is, everywhere you turn they want to charge you a lot of money [for review materials.] To me that seems self-defeating. There’s so much information available now for free online they should just guide you to that. 

Q: Will you need to travel to take the exam? 

A: No, we have a testing site around here. So for me there’s no additional cost to prepare for MOC other than the cost of taking the exam.

Q: Do you think you’ve gotten any benefits out of the MOC process? 

A: My personal feeling is no. I think anyone can obtain up-to-date information in their field. You can go to [CME] websites that link to articles with good information.  And that’s what I do.

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Q:  How would you design the MOC process if it were up to you? 

A: I do like the idea that they’re changing the requirements of taking the boards to allow you to do it a little more frequently. My thought would be for each specialty to have the option of taking an open-book exam maybe every five years. And in doing so you must review important articles in your field chosen by a board of that specialty’s representatives. And be able to do it online. 

Obviously, people like Paul Teirstein [founder and president of the National Board of Physicians and Surgeons, which was founded in 2014 to provide physicians with an alternative path to maintaining certification] who’s highly respected, feel that there can be significant improvement in the process, and I’m in full agreement. 

Mike Tracy, MD

Type of practice: Internal medicine, pediatrics (double-boarded)

Practice location: Powell, Wyoming

Years in practice: 19

Most recent board certifications: 2016 for pediatrics, 2008 for internal medicine

Recent MOC-related financial costs: Overnight hotel stay prior to taking exam, $120; MKSAP review materials, $690; annual MOC fees (for double-boarding), $454

MOC-related time costs: None. Practice uses direct care payment model, so physicians’ income is not affected by not seeing patients every day 

ACP/ABIM affiliation(s): Governor of ACP Wyoming chapter

Next:  ‘board-certification industrial complex’

Q: Where are you now in the MOC process?

A: I take the internal medicine exam again next year. I got my MKSAP book, which is a great resource, and I’m trying to get through that this year. There are also a lot of paying courses available to help you with the exam but I don’t think I’ll do any of those. For me to go in person just about anywhere takes a lot of time. It’s possible I might do a video course. 

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Q: Have you benefitted from the MOC process in any way? 

A: Definitely. When I did my practice improvement module for diabetes I pulled 25 charts and looked at the results [for blood pressure levels] and remember thinking, ‘that’s much higher than I expected, there must be a mistake in that sample.’ So I pulled 25 more and got the exact same numbers. We were on paper records at the time, so I decided to make a paper registry. It sounds archaic, but it was really helpful. It really mapped out the problem for me. I attribute that to the practice improvement module.

Q: What do you think about the requirement for doing a certain number of MOC activities every two years?

A: To me, that’s an attempt to say, ‘let’s not put this off until the last minute.’ If MOC is really about keeping up-to-date then putting it off until the ninth year doesn’t make any sense.

Q: Are there any changes you would make to the MOC process if it were up to you? 

A: It seems like they should be able to develop a test that’s open book. After all, medical practice is open book. If a patient is in the exam room with me and I don’t know the answer to something I’m going to start looking at all the available resources.

I also think if you can get the process to where MOC isn’t a separate thing, but is part of the workflow like CME, then that’s ideal. I think we’re moving in that direction. We’re a lot closer than we were in 1998, I can promise you that.

Christopher Unrein, DO

Type of practice: Internal medicine/palliative care

Practice location: Parker, Colorado

Years in practice: 26

Most recent board certifications: 2008 for allopathic internal medicine; 2012 for osteopathic internal medicine; 2013 for osteopathic palliative medicine

Recent MOC-related financial costs: Week-long review course in Arlington, Virginia (including cost of course, travel and lodging), about $2,300; MKSAP, $690; annual fees for double-boarding, $256 

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MOC-related time costs:  Five days away for review course, one day each for allopathic and osteopathic exam 

ACP/ABIM affiliation(s): none

Q: Where are you now in the MOC process?

A: I finished my most recent cycle of certification for internal medicine in 2008, even though I didn’t have to finish until 2012. So I’ll do it again sometime in the 2021-2022 timeframe. Hopefully that will be my last one. In the meantime I’m getting credit for MKSAP and CME.  

Q: What are the costs of MOC to you?

A: The ABIM charges $2,560 over the 10-year cycle, $256 per year, to renew both certifications [internal medicine and palliative/hospice care]. I don’t have to travel to take the exam because there’s a test site less than a mile from my home. But MKSAP costs almost $1,000, and the ABIM review courses are usually in distant locations and they can last five or six days. So you’ve got airfare, five or six nights in a hotel, and meals to pay for. And the review courses themselves usually cost somewhere around $700 to $1,000.

I use the term ‘board-certification industrial complex’ to describe it all. There’s this whole industry of people selling you stuff, because they know we’re all scared to death if we don’t pass this exam we can’t get hospital privileges and we’ll get kicked off insurance panels. 

Next: 'I don’t think it’s that helpful'

Q: Do you think anything you’ve done through the MOC process has helped you? 

A: No more than being a conscientious doctor and getting a lot of CME credits. And to that end, there’s also the NBPAS. I got certified through them when they first got started. The credential doesn’t do me any good, but I think if we have enough people getting behind them it may eventually mean something.

Q: How would you design the MOC process if it were up to you?

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A: Why can’t we just continue to take good CME? It either reaffirms you in what you’re doing and that you’re doing it well, or you learn some new things. And these guys at the ACP conferences are really the experts in their fields and at the cutting edge of a lot of stuff. 

There are always going to be people who try to cheat the system, but we’re all supposed to be adults here. We prescribe dangerous medications, we cut people open. So we’re given all this responsibility then treated with this parochial mentality when it comes to MOC. Why can’t we be trusted as the professionals that we are?

Maria Chandler, MD

Type of practice:  Pediatrics, clinical professor at the University of California-Irvine and chief medical officer for The Children’s Clinic, a system of nonprofit clinics affiliated with UC-Irvine

Location: Long Beach, California

Years in practice: 25

Most recent board certification: 2007

Recent MOC-related financial costs: Review course, $1,000; annual MOC fees, $240

MOC-related time costs: None; time away covered by employer

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Editorial Advisory Board

Q: Where are you now in the MOC process? 

A: I’m recertifying right now, after taking a review course. I’m very fortunate that in 2017 people were offered a pilot program. They [the American Board of Pediatrics] send me a batch of questions every quarter this year. You can look things up, but you only get five minutes to answer each question. You can do it at home and you can start and stop. I took the first two quarters worth of questions and I really liked it compared to going to a test center.

The questions are very different from what I’ve seen in the past. You used to see questions like, ‘you’re in Uganda, and you see a puffy nodule, what insect bit you?’ Well, I don’t practice in Uganda. But now the questions are like ‘a 13-year-old girl comes in. Her grades are dropping and she cries when you ask her questions.’ So it’s a lot more practical.  

Q: What have been the costs of MOC to you?

A: The review course cost about $1100, but I was able to use the $1,200 I get from my employer for CME activities to pay for it. I stayed in Los Angeles [where the course was held] for five nights. The room was about $140, so I probably paid around $1,000 when you include meals and everything. 

Q: Do you feel you’ve gotten any benefits from the MOC process?

A: It made me go to a review course, but that was so esoteric it didn’t really help me. I also don’t know that I’ve really learned anything from the exam questions. I think I proved to them I’m still capable of seeing patients, but it has nothing to do with skills like bedside manner. So I don’t think it’s that helpful, but I understand they feel they have to do something.

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Q: What would your ideal MOC process look like? 

A: Here in the real world, I have to prove that we provide quality clinical care. I have to send outcome measures on all 50,000 of our patients, and we’re graded on those. I think that is a much better measurement of what kind of care you’re giving. I don’t know that sitting for a test proves much about your patients. And that’s the whole point: how are your patients doing? So if I designed something, I think I’d go more toward the pay-for- performance side where you have to prove your patients had good outcomes.

Next: 'A MOC process that says the majority of you folks are doing fine'

Eric Green, MD

Type of practice: General internist and director, internal medicine residency program, Mercy Catholic Medical Center

Location: Philadelphia/Darby, Pennsylvania

Years in practice: 16

Most recent board certification: 2011

Recent MOC-related financial costs: Review course (including cost of course and travel and hotel expenses), about $1,600; MKSAP, $690; review books, $600; annual MOC dues, $194

MOC-related time costs: Three days for review course, one day for taking exam

ACP/ABIM affiliation: Member of the ABIM Liaison Committee on Certification and Recertification

Q: Where are you currently in the MOC process?

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A: I get MOC points from going to live meetings of various types and using the online product UpToDate. 

Q: Were you doing any of the patient engagement or practice improvement activities before they suspended those requirements?

A: I was, but I found them to be very low-yield. I thought it was a poor use of my time.  and I resented that. 

Q: What has been the cost of MOC to you? 

A: I spent roughly $600 over three years on book of preparation materials. The review  course was about $1,000, I think, and I spent three nights in a hotel at roughly $200 per night. Then with the prep course and a day for the exam that’s four days I wasn’t seeing patients and there’s a time and opportunity cost to that. But if you’re looking at it as one work week out of 52 every 10 years, it’s not that much. 

A lot of times when I talk with my peers about this they ask what they’re getting for their money with MOC. I say I don’t know what I get every time I pay my automobile registration to the state of Pennsylvania. I view the money I pay to the ABIM as it lets me make the statement that I’m board-certified. The $200 or whatever we pay the board every year is nothing. People like accountants spend a lot more for their annual professional licensure. 

Q: What benefits do you derive from the MOC process? 

A: My overall feeling is that the MOC concept is a good one, which doesn’t always make me popular among my peers. The issue is that in day-to-day practice it’s easy to miss something that may have changed, that’s new. You get busy, you miss a journal or two. The point is, if you don’t know something, you’re never going to think about it, or diagnose it. That’s just the bottom line. So pushing docs a little out of their comfort zone is good. 

Q: If you could design your ideal MOC process, what would it look like?

A: I would love it if we had a MOC process that says the majority of you folks are doing fine, you’re demonstrating in some way that’s not burdensome to you that you’re keeping up. Then the people who don’t keep up, we’re going to say you need to do a little more active work to demonstrate that you’re keeping up.