Prescribing insanity: Monopoly in continuous board certification drives costs up and physicians out

The largest board certification organization in the United States, the American Board of Medical Specialties (ABMS), recently announced a record-breaking number of ABMS-certified physicians in the United States – 988,737 out of 989,323 physicians to be exact – easily cementing its monopoly status for its physician certification enterprise. Amidst their highly profitable business model is a significant, but little known, driver that is exacerbating burnout and hastening the exit of physicians from clinical practice. ABMS Maintenance of Certification (MOC) is a proprietary continuing education product that to date has no high-quality evidence that it improves patient care. The cost and burden associated with MOC remains a significant factor driving physicians out of medicine.

MOC is undermining the foundation of the medical system – its physicians. Despite labeling MOC as voluntary, ABMS forces de facto compliance with its onerous and unproven continuing education product by successfully weaving MOC into the national credentialing landscape through its for-profit subsidiary, ABMS Solutions LLC. Employers and government entities – hospitals, health systems, residency programs, health insurers and state boards of medicine – purchase and rely on data from ABMS Solutions for necessary verification of physicians’ credentials. Physician data is big business, with ABMS Solutions reporting $8 million in revenue for 2022 with another $28 million held in assets. Because of ABMS Solutions’ intrinsic ties to parent company ABMS and its member boards’ physician data, ABMS Solutions reports physicians as “not certified” if they refuse to purchase MOC. As a result, physicians are stripped of their coveted board-certified status and risk their jobs for failing to comply. Physicians are responding as expected – by leaving medicine for good – a stinging consequence in the era of physician burnout and loss.

In close and exclusive collaborations with other arms of organized medicine, ABMS has created what amounts to a collective boycott against other certification bodies, entangling physicians in a monopoly that burdens dedicated physicians everywhere. In fact, a web of powerful “nonprofits” including the American Medical Association (AMA), the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Graduate Medical Education (ACGME), and the Federation of State Medical Boards (FSBM),work together, unchecked, and with intertwining and conflicted board relationships that arguably have no place in science or public policy. This exclusivity also stifles employment opportunities, imposes unnecessary barriers on highly qualified physicians and, worst of all, reduces access to critically needed medical care.

Board certified physicians are thus faced with a Hobson’s choice: continue spending significant time and money on MOC orjeopardize their job, future employment prospects, and academic appointments critical for teaching the next generation of physicians. This lose-lose situation is compounded by physicians’ acknowledgement of the superfluous and for-profit nature of the MOC process. A 2023 Survey of Clinical Oncologists found that an overwhelming majority (82%) felt that MOC was an unnecessary addition beyond typical Continuing Medical Education (CME) requirements, with additional, widespread agreement (74%) that MOC does not improve their clinically relevant knowledge or improve the quality of patient care. Rupa Dainer, MD, a former American Board of Anesthesiology board member, noted in conversation that, “ABMS and its member boards know that there are no strong data supporting their MOC programs yet continue to force MOC upon physicians, the public, and policymakers. This raised some very concerning ethical questions for me, and I could not in good consciencecontinue as part of their leadership.”

Similarly, a 2018 survey of U.S. rheumatologists found that 74.8% of respondents felt that MOC added “no clinical value beyond what is already achieved by studying CME.” The same survey found that the majority (73.4%) of respondents felt that the primary reason for ABMS creating MOC was either the financial well-being of board-certifying organizations or to satisfy administrative requirements in health systems. ABMS found little support even in its own survey with just over one in ten (12%) physicians finding value in ABMS MOC. This data begs the question of how and why this stranglehold of physicians and medicine persists, despite the existence of an innovative and much-demanded alternative. Dr. Dainer was not surprised by these survey results: “Dropping MOC often means leaving clinical practice and patients behind. That’s a choice that no physician should have to make.” There is no purpose in requiring physicians to jump through the burdensome and expensive hoops of MOC without appropriate scientific evidence to support its benefit, especially when quantitative and qualitative evidencedemands the opposite.

With each physician lost, patient wait times increase, critically needed care is delayed and overall patient access to care worsens, even in federally designated Healthcare Professional Shortage Areas (HPSAs). Recent data from the Health Resources and Services Administration (HRSA) shows that over 100 million people live in HPSAs for primary medical care. This population only sees a jarring 47.6% of health care needs met, with more than 17,000 physicians needed to serve these populations – statistics that are only worsening through unproven MOC requirements.

Discontent with MOC is nothing new, and the opposition continues to grow. Physicians have been calling out MOC ever since its rollout in the year 2000, and it is imperative that we listen. Forward-thinking hospitals, health systems, and payors are recognizing that offering choice and competition to MOC helps recruit and retain quality physicians, leaving more time for patient care. It is past time for everyone to leave status quo burdens behind.

No single entity should be able to wield an expensive, arduous, and unproven process that taxes U.S. health care, adds to physician burnout, and further exacerbates the known and growing physician shortage. Requiring physicians to adhere to ABMS’ Maintenance of Certification requirements upholds a flawed and profit-driven system that drives highly qualified, board-certified physicians out of medicine at a time when shortages are only worsening. Instead, we need to be looking at the solutions that contribute effectively to lifelong learning and keep physicians practicing medicine. At the end of the day, we are all patients. We must care for our physicians so that they are here to care for all of us.