Physicians Taking Back Medicine: Is MOC contributing to the physician shortage?

Editor’s Note: Welcome to Physicians Taking Back Medicine, a podcast from Medical Economics. Hosted by Dr. Rebekah Bernard, each episode dives into the real-world challenges facing today’s doctors. The show will explore how doctors can reclaim their autonomy and shape the future of health care with candid interviews and actionable insights. Join Dr. Bernard and her guests each month as she guides you toward an empowered and sustainable medical career. The views expressed in the episode do not necessarily reflect the views of Medical Economics or MJH Life Sciences. Scroll to the bottom for show notes, including topics and timestamps,music credits and more.

Rebekah Bernard, M.D.

Host, Physicians Taking Back Medicine

In 1989, Mark Lopatin, MD completed his fellowship training in rheumatology and applied to take his certifying board examination. Since the American College of Rheumatology only offered board certification exams every two years, Lopatin had to wait until 1990—a year of major changes to the American Board of Medical Specialties (ABMS) certification process. Had Lopatin been able to take his exam in 1989, he would have been ‘grandfathered’ into lifetime certification—no more tests, no more fees, and no maintenance of certification modules. But beginning in 1990, the American Board of Internal Medicine (ABIM), an ABMS member branch that certifies rheumatologists, instituted a new requirement: Physicians would need to pass an exam every ten years to remain board certified. In 2000, the ABIM instituted further changes to the board certification process, introducing a new program called “Maintenance of Certification” (MOC).

Mark Lopatin recalled how the program began. “Physicians had to acquire a hundred ‘maintenance of certification’ points every 10 years. To acquire these points, doctors had to purchase products sold by the ABIM—other continuing medical education programs were not initially deemed adequate. As far as I’m concerned, it was a money grab.”

ABIM continued to expand the MOC program, increasing the number of points required. “It really hit the fan in 2014, when the ABIM decided that instead of earning a hundred points every ten years, physicians had to earn a hundred points every five years,” said Lopatin. “This led to all kinds of revolts—online petitions with thousands of signatures, a vote of ‘no confidence’ by the Pennsylvania Medical Society, and a Newsweek series expose of the finances of the organization.” Lopatin said that he personally communicated multiple times with the CEO of ABIM both in writing and in person, penned op-eds to the media, and testified listening sessions hosted by ABMS in Washington D.C.

Frustrated by what he perceived as a lack of adequate response from the ABIM, Mark Lopatin took the ultimate step: In 2020, he retired from clinical medicine at 63 rather than recertifying for the third time. “I refused to submit to what the ABIM was pushing on me,” said Lopatin. “After speaking out against MOC so many times, in so many ways, I had to put my money where my mouth was. I refused to bow down on bended knee to an organization that was not acting in the best interest of physicians, and more importantly, in the best interest of patients.” After his retirement, Lopatin authored a book about his work fighting for physicians and patients, including an entire chapter on MOC.

Study shows that anti-MOC laws may increase physician supply

While ABMS officials represent board certification as ‘optional,’ most hospitals and insurance companies require physicians to maintain certification with either ABMS or the American Osteopathic Association (AOA) to be credentialed, making MOC a condition of employment. In the last decade, several states have instituted laws that prohibit organizations from tying employment to participation in MOC, including North Carolina (2016), Oklahoma (2016), Tennessee (2016), Georgia (2017), Texas (2018), and Arkansas (2019). Now, a new study shows that states with anti-MOC laws have a larger supply of older physicians, implying that physicians who are not forced to participate in the burdensome recertification process are working longer rather than retiring early.

Mark Lopatin said that he was not surprised to hear the results of this study, noting that if he had not been required to recertify, he may have continued working for at least a few more years as a rheumatologist. “If I had been able to take that initial exam in 1989 and been granted lifetime certification, I likely would still be seeing patients today,” he said. “MOC put a time limit on me, because insurance companies were not going to reimburse me if I wasn’t board certified.”

Physician leaders created an alternative to ABMS and MOC

Mark Lopatin is not alone in his concerns about the recertification process. Neurologist Paul G. Mathew, MD, DNBPAS, FAAN, FAHS has been fighting to improve the model since he first learned about a MOC update to his branch of ABMS—the American Board of Psychiatry and Neurology (ABPN)—in 2014. “I was sitting in an ABPN session at an American Academy of Neurology meeting, and the speaker was going on and on about the new MOC requirements, such as modules that needed to be completed, and surveys that had to be administered to patients and colleagues,” said Mathew. “Everybody in the room just looked around at each other saying, ‘Why are we doing this? This seems like a lot of busy work, and we're paying to do it.’”

Mathew said he and others in the audience asked ABPN officials these questions but failed to receive a satisfactory answer. He decided to put his advocacy training into action. “I created a petition to show the ABPN that neurologists felt the new MOC modules did not improve patient care or improve clinical knowledge,” Mathew said. “Thousands of doctors signed this petition, and believe it or not, I never received a single response from the ABPN.”

While the organization failed to respond, physician leaders were paying attention. “Paul Teirstein, a cardiologist in California, had created a new board re-certification organization to offer an alternative to ABMS—the National Board of Physicians and Surgeons (NBPAS), and he invited me to join the Board of Directors,” said Mathew, who points out that the group of founders of NBPAS are not just a rogue group of disgruntled physicians. “There are some pretty big names there—Harvard, Mayo Clinic, UCLA, NYU, Columbia, and Dartmouth.”

Mathews said that NBPAS is not an initial certifying body. “We still require physicians to complete initial certification with ABMS or AOA,” he said. But rather than requiring MOC modules or high-stakes examinations, NBPAS recertifies physicians based on completing CME relevant to their specialties. “Everybody should be playing by the same rules,” said Mathew. “We feel that if some physicians are grandfathered into lifetime certification and only need to complete continuing medical education (CME), then that’s the standard we should all be subjected to.”

The board of NBPAS are volunteers. “None of the board members collect a salary,” said Mathew. “The cost of board recertification with NBPAS pays for the administrative staff who review submitted CME to make sure it's relevant, and a fraction is spent on advocacy to try to expand access for physicians who are boarded by NBPAS.”

Increasing acceptance of NBPAS recertification

One of the limiting factors to NBPAS recertification has been acceptance by credentialing organizations such as hospitals and insurance companies. NBPAS Board Member Paul Mathew said that this is gradually changing. “More and more hospitals and medical facilities are realizing that it’s not good for there to be a monopoly for board recertification,” he said. “In fact, white papers have been released by organizations including the Federal Trade Commission noting the negative impact of monopolies on healthcare markets.” Mathew said that NBPAS is now recognized by the Joint Commission and the National Committee of Quality Assurance and meets the standards for primary source verification for insurance credentialing.

Another barrier to NBPAS are regulations in three states—California, Florida, and Texas—that restrict how and when physicians can represent themselves as board certified. In these states, physicians may only advertise as board certified if they are currently certified or grandfathered in by the ABMS or AOA. Once physicians decline to participate in MOC, ABMS immediately removes the label of ‘board certified,’ regardless of how many times physicians previously took and passed the certification exam. Some states are rejecting ABMS’s monopoly on board recertification, including Oklahoma, where the Board of Medicine decided in January 2025 to allow physicians to continue to be recognized as board certified even if they choose to re-certify with NBPAS.

Challenges to alternate recertification pathways

During his work with NBPAS, Paul Mathews said he has seen ABMS work hard to maintain its status as the sole recredentialing body for physicians. “ABMS is a very wealthy organization with a large war chest,” he said. “Any time bills are brought before legislators, there are lobbyists aggressively feeding false narratives.”

For example, Mathew said that ABMS advocates argue that physician skills deteriorate over time, and that failure to participate in MOC programs results in lower quality care.Mathew rejects that argument, noting that physicians are required to complete CME to maintain licensure and that technology has made it easier to stay current. “No physician practices without access to greater knowledge,” said Mathew. “If we have a question in clinic, we look at the medical literature to see what's up and coming—with a pocket computer that we call smartphones, the access to that data is unlimited.”

Mathews also challenges the ABMS model of being tested on material that may have no relevance to a physician’s current practice. For example, Family physicians may be required to answer questions about obstetrics, even though they may not practice in the field after residency. “For a person who practices zero obstetrics, does it make sense for that person to be reading articles and taking quizzes on obstetrics?” said Mathew. “Likewise, as a neurologist, I can assure you that in no point in my clinic day do I take a muscle biopsy, stain it, put it under a microscope, and identify the pathology. This is the type of irrelevant force feeding of knowledge embedded in MOC programs that does not improve patient care.”

Retired rheumatologist Mark Lopatin said that the unnecessary study time required for board recertification with ABMS was a factor in his decision to retire. “Prep time for a board recertification exam is months of preparation,” he said. “That's time away from family, time away from practice, taking a course, travel to a different city. There are all kinds of things that physicians have to do to prepare for a board exam, and it's one of the contributing factors to physician burnout.”

Impact of alternate certification on physician recruitment

Advocates for anti-MOC laws say that the burdensome recertification process takes a toll on physician wellness, potentially contributing to the physician shortage. “Patients put their trust in a physician’s hands—their lives depend on us,” said Rheumatologist Mark Lopatin. “And to imply that physicians won’t stay current without the American Board of Internal Medicine’s enforcement is insulting.”

Lopatin is referring to a Community Insights blog from ABMS that stated: ‘Board preparation is the most important driver of medical education.’“This is a stunning statement regarding how little the ABMS thinks of physicians and the lack of trust they place in us,” said Lopatin. “Never mind my patients, the legal ramifications, the license ramifications. They believe that it is only because of them that I maintained my education and my knowledge of medicine.”

While Lopatin opposes the ABMS MOC process, he believes that physicians should prove their knowledge and expertise through initial board certification and continuing medical education. “They should be testing my due diligence by showing that I’ve followed through on my CME,” said Lopatin. “They can measure that and prove to the public that physicians are staying current.”

This is the mechanism that NBPAS utilizes for recertification. Paul Mathew said that allowing physicians to choose this pathway can reduce physician burnout by allowing doctors to focus on clinical areas of importance to their patients and practice. In addition, Mathew notes that recertification through NBPAS can save organizations money. “Physicians will be seeing patients rather than spending time doing board prep work, and they won’t be using their CME budget to pay for MOC modules.” Mathew said that allowing the option of NBPAS recertification is a value-add for physician recruitment and retention.

Rebekah Bernard, MD is a Family physician in Fort Myers, Florida and the author of several books on healthcare, including Physician Wellness: The Rock Star Doctor’s Guide.

Music Credits

Medical Education by Art Media - stock.adobe.com

Episode timestamps generated using AI tools

Introduction to the Episode (00:00:14) Host introduces the topic of Maintenance of Certification (MOC) and the guests.

Dr. Paul Mathew's Background and MOC Advocacy (00:00:30) Dr. Mathew shares his background and initial experiences with MOC requirements.

Founding of NBPAS and Early Advocacy (00:00:50) Dr. Mathew describes the founding of NBPAS and his advocacy efforts against traditional MOC.

Joining the NBPAS Board (00:02:33) Dr. Mathew explains how he joined the NBPAS board and its mission.

NBPAS Founders and Certification Philosophy (00:02:48) Discussion of NBPAS founders, their credentials, and the organization's approach to certification.

Host’s Personal Experience with MOC (00:03:36) Host shares personal frustrations with MOC and the appeal of NBPAS.

Challenges with NBPAS Acceptance (00:04:36) Discussion about initial resistance to NBPAS by hospitals and insurers.

Recognition by Accrediting Institutions (00:04:46) NBPAS gains recognition from major accrediting bodies, improving acceptance.

Primary Source Verification Explained (00:05:44) Explanation of primary source verification and its importance in credentialing.

State Board Recognition Issues (00:06:41) Host discusses state-level barriers to advertising board certification with NBPAS.

Oklahoma’s Legislative Progress (00:07:38) Oklahoma passes a law recognizing NBPAS for board certification advertising.

Broader Certification and Title Issues (00:07:48) Comparison of physician and non-physician board certification standards.

ABMS Lobbying and MOC Narratives (00:09:03) Discussion of ABMS lobbying and arguments about physician skill decay.

Irrelevance of Some MOC Requirements (00:10:04) Critique of irrelevant MOC content for certain specialties and practices.

Impact of MOC on Physician Workforce (00:10:50) MOC’s negative effect on physician retention and the physician shortage.

Study on Anti-MOC Laws and Older Physicians (00:11:06) Recent study shows anti-MOC laws increase supply of older physicians.

Introduction of Dr. Mark Lopatin (00:12:22) Host introduces Dr. Mark Lopatin, a retired rheumatologist affected by MOC.

Dr. Lopatin's Certification Journey (00:12:30) Dr. Lopatin recounts his board certification timeline and the shift to time-limited certification.

Escalation of MOC Requirements and Backlash (00:13:36) Description of increasing MOC demands, physician backlash, and public exposure.

Dr. Lopatin's Advocacy and ABIM Response (00:15:05) Dr. Lopatin's efforts to reform MOC and ABIM’s limited changes.

Real-World Practice vs. Timed Exams (00:16:25) Dr. Lopatin contrasts real clinical problem-solving with the constraints of timed board exams.

MOC’s Contribution to Burnout and Retirement (00:17:36) Dr. Lopatin explains how MOC contributed to his decision to retire.

Would Dr. Lopatin Have Continued Practicing? (00:18:26) Dr. Lopatin confirms he would have worked longer if not for MOC burdens.

Impact of Anti-MOC Laws on Physician Supply (00:19:34) Host cites studies showing anti-MOC laws help retain experienced physicians.

MOC as a Barrier to Patient Care (00:20:11) Discussion of how MOC restricts patient access to experienced physicians.

MOC as the Final Straw for Physicians (00:20:24) Dr. Lopatin describes MOC as an additional burden leading to physician burnout.

NBPAS as an Alternative Solution (00:20:55) Host introduces NBPAS as a response to physician concerns about MOC.

NBPAS Operations and Benefits (00:21:10) Dr. Mathew explains NBPAS’s volunteer structure, cost, and benefits for physicians and institutions.

Encouragement for Physician Advocacy (00:22:44) Dr. Mathew encourages physicians to get involved in advocacy for change.

Conclusion and Call to Action (00:23:02) Host wraps up the episode, encouraging listeners to continue working for healthcare improvement.