Do Recertification Demands Waste Doctors' Time and Money?
"A Useless Waste of Precious Time"
The increasingly tough maintenance of certification (MOC) requirements are the latest emergency facing today's physicians, many of whom feel that they are hemorrhaging money and time for no valid reason.
The American Board of Internal Medicine (ABIM) "has made unreasonable changes in MOC requiring more frequent participation and higher fees" and MOC activities are "complex, have questionable value, and detract from more worthwhile pursuits, including patient care and other educational activities, ie, CME," according to a recent petition initiated by Paul Teirstein, Chief of Cardiology and Director of Interventional Cardiology, Scripps Clinic, La Jolla, California. It calls upon ABIM to institute "a simple pathway consisting of a test every ten years." The petition has accumulated over 15,740 signatures since its launch on March 10, 2014.
Even the 10-year exam has been challenged. Change Board Recertification, a national movement of physicians committed to reforming the board recertification process, conducted a survey of 3000 physicians in 2011 and found that 93.7% of respondents voted to abolish all MOC requirements, including the exam, converting all certifications to lifetime status.
But proponents of the new requirements say they ensure ongoing growth of physician knowledge, professionalism, procedural skills, and practice-based improvement, assuring quality patient care -- and that they're much less costly and burdensome than they seem.
"MOC is quite manageable," says Lois Margaret Nora, MD, JD, MBA, President and Chief Executive Officer of the American Board of Medical Specialties (ABMS).
"There are many ways for physicians to integrate the process into their practice so the burden is minimized." Dr. Nora says that the benefits of MOC make the effort worthwhile, although many doctors disagree.
A large proportion of internists have chosen to engage in the American Board of Internal Medicine's (ABIM) newly revised MOC program by the May 1 deadline to be reported as "Meeting MOC Requirements." As of May 1, nearly 150,000 physicians had enrolled in ABIM's MOC program.
The 10-year recertification exam has drawn stinging criticism from physicians who feel that it's unfair, irrelevant to practice, and not a reliable gauge of physicians' knowledge. Indeed, although numbers of exam-takers are increasing, pass rates are dropping. In 2009, 90% of 4526 first-time internal medicine recertification exam-takers passed. In 2013, of 5772 internal medicine first-time exam-takers, only 78% passed. Many physicians feel that this points to serious flaws in the exam.
Jonathan Weiss, MD, a Monticello, New York-based physician who is board-certified in internal medicine, pulmonary medicine, and critical care medicine, is one of them. He describes the exams as a "useless waste of precious time" because they tested material that was irrelevant to his practice and siphoned off time he could have spent with patients.
Additionally, he says, "in this day and age, when physicians are encouraged to look things up rather than to rely on memory, a closed-book 'cognitive' exam is even more absurd and potentially harmful to patients. And there's no real evidence that these exams have improved the quality of patient care."
Lesley Fein, MD, a West Caldwell, New Jersey-based rheumatologist, is similarly indignant. "Imagine if lawyers had to pass the bar exam every 10 years. They wouldn't stand for it," she observes.
Dr. Nora defends the necessity and fairness of the exam, which "is intended to be an assessment of a physician's knowledge, judgment, skills, and familiarity with new standards." She says the exams "are subjected to rigorous psychometric evaluation to make sure questions are reliable and valid."
She also commiserates with exam-takers. "I know the time before the exam involves stress for many physicians, and I just want to cry for them. But it comes back to serving the public trust, making sure physicians are as competent and up-to-date as they need to be."
How MOC Came to Exist
Board certification dates back over 75 years and "grew out of the need to ensure that physicians claiming to be specialists did, in fact, have the appropriate training and knowledge," Dr. Nora recounts.
Although certification was originally conceived as a once-in-a-lifetime event, "patients became concerned because medicine has evolved dramatically," Dr. Nora explains. So by the 1990s, specialty boards had instituted a recertification process, consisting of an exam taken every 10 years by anyone who completed training after 1990. Those who completed training earlier were "grandfathered" into the system. But, "now we understand that every 10 years is no longer appropriate because medical science is changing so rapidly, so more frequent activities are necessary."
Each specialty board has its own set of MOC requirements and timetable in which these requirements must be met. But all boards require four components:
• Licensure and good professional standing;
• Cognitive expertise, measured through a formal closed-book examination;
• Lifelong learning and self-assessment; and
• Practice performance assessment.
These are specific to each board but include a combination of educational activities (including CME), patient safety modules, open-book tests, self-assessment of some practice metric, and patient/colleague surveys.
Dr. Nora describes her own recertification experience. "I'm a neurologist. I finished my fellowship in 1987, so I was a 'grandparent' and didn't need to recertify." She decided to recertify because she realized she "needed ongoing learning and self-assessment to stay abreast of the astronomical changes in medicine."
But opponents of MOC insist that physicians don't need MOC to ensure lifelong learning.
"Sincere physicians are dedicated to keeping up with new developments in their field, even without these complicated requirements," says Paul Kempen, MD, PhD, an anesthesiologist based in Weirton, West Virginia, and Steubenville, Ohio.
Dr. Kempen, who received his medical degree at Albert-Ludwigs University of Freiburg, Germany, notes that in Europe, "there is no comparable formal structure to MOC, although continuing education is emphasized and there's a high standard of excellence in medicine."
How are physicians expected to remain current without formalized MOC?
CME is designed to accomplish just that, says Kenneth Christman, MD, a Dayton, Ohio-based plastic surgeon. "We all recognize that we don't know everything, and CME is a structured way to further our knowledge. MOC is redundant, expensive, and intrusive."
Adds Dr. Christman, "I'm a board-certified plastic surgeon, and I'm proud of it. But there are equally fine doctors who aren't board-certified. In fact, when I myself needed surgery, I went to a highly qualified surgeon who wasn't board-certified because I thought he was the most competent surgeon I could choose for my condition."
Dr. Nora thinks the current CME requirements aren't enough. "MOC isn't only about the acquisition of information," she explains. "It's a four-part framework focusing on professionalism, practice improvement, and self-assessment. MOC is CME, only it incorporates other things as well." Additionally, she notes, many CME activities can be counted toward MOC points, and vice versa.
Useful Activity or 'Annoying Busywork'?
Some doctors detest the MOC; others feel much more positive about it.
Dr. Weiss regards MOC modules as "annoying, time-consuming busywork inflicted on doctors who already are drowning in paperwork." Like the exam, these modules "harm patients by robbing them of my time and attention."
But other physicians are enthusiastic.
"The purpose of these requirements isn't to meet some meaningless bureaucratic standard but to improve patient care," says Marie Brown, MD, an Oak Park, Illinois-based internist and geriatrician.
The key, according to Dr. Brown, is choosing a relevant practice parameter, such as smoking cessation counseling or foot care for diabetics, and taking a close look at your practice patterns.
Dr. Brown chose to assess her patients' immunization rates and was surprised to discover that she was falling behind in immunizing patients against tetanus every 10 years. She distributed an anonymous questionnaire to the staff in her office (another internist, two LPNs, and two clerical staff), asking what could be done.
"We brainstormed and the receptionist came up with a solution. Now, instead of my asking about immunizations at the end of a visit as a kind of afterthought, the receptionist gives the patients information to read in the waiting room. And I have standing orders for all vaccinations. This has increased the vaccine rate by 20% to 30%."
The cost of MOC has been met with anger and resentment. The exam fee is $1365 for internal medicine and between $2200 and $2830 for certain subspecialties, which can be paid in annual installments. However, annual payments may be subject to fee increases, and certification status may change if one falls behind on payments. And the ABIM states that it makes no exceptions to its financial policies, even in extenuating circumstances.
"This is legalized extortion, plain and simple," says Dr. Kempen. "The exorbitant cost of the exams comes off the backs of already financially strapped physicians and lines the pockets of the executives of ABMS and boards, as well as the exam facilities."
He notes that physicians also incur indirect costs, such as paying for tutorials and travel to the exam. And one of the most serious costs is the reduction in patient load necessary to create extra time for MOC requirements.
Some physicians regard these costs as a necessary evil that goes with the territory of being a doctor, like office staff salaries or malpractice insurance. "Everything in medicine is based on risk-benefit analysis, and in this case the benefits outweigh the drawbacks," says Dr. Brown, who is the ACP governor for the Northern Illinois chapter.
Other physicians are furious. "I'm devastated by these new regulations," says Dr. Fein. "I'm in solo practice and can't afford to take time away from my patients or close my practice for weeks of studying or completion of other tasks. I don't know what to do."
Dr. Nora states that t exam costs are "in the ballpark" of "other professions with similar requirements, such as accountants, pilots, or lawyers." She acknowledges that "there are costs involved with quality education and quality assessment," but says they're necessary and "money well spent."
How Optional Is MOC?
Everyone agrees: From a strictly legal point of view, MOC is optional. "The only thing required to practice medicine in this country is a valid license," says Dr. Nora. "Board certification is a choice. And if you're a 'grandparent,' recertification is also a choice."
But "choice" isn't always black and white. MOC is increasingly tied to hospital privileges, reimbursements, and network participation. MOC participation is one way that physicians can meet requirements of the Centers for Medicare & Medicaid Services (CMS) Physician Quality Reporting System (PQRS). And an increasing number of medical associations support MOC, including the American Hospital Association, the American Medical Association, the Joint Commission, and the Federation of State Medical Boards, which is looking at incorporating aspects of MOC into licensing requirements.
Moreover, the push for MOC is being taken directly to patients. The ABIM Website urges patients to ask their physician if they are participating in MOC. "If the answer is no, you may want to encourage them to do so." Patients can also verify that their physician is MOC-compliant.
"Calling this 'voluntary' is a farce," comments Dr. Kempen. "These pressure tactics eliminate a physician's freedom to choose."
"I call this 'regulatory capture' -- when special-interest groups use legislation to force purchase of their products under the guise of betterment of society," Dr. Kempen says. "Physicians are forced to submit to the authority of the boards because legal and governmental entities have been talked into demanding it." He adds, "MOC isn't a response to public demand, as ABMS would have us believe. It's the reverse. ABMS and the boards are pushing the public into demanding MOC."
In 2013, the Association of American Physicians and Surgeons (AAPS) filed an antitrust suit in New Jersey federal court, claiming that MOC is a "moneymaking, self-enrichment scheme" that "restrains trade and causes a reduction in access by patients to their physicians." The lawsuit focused on a New Jersey-based physician who was denied hospital privileges because he had not recertified. According to AAPS, "there is no justification for requiring the purchase of [ABMS's] product as a condition of practicing medicine or being on hospital medical staffs."
"AAPS feels that the medical recertification industry is a monopoly whose net keeps widening," comments Dr. Christman, a past president of AAPS. He mentions that AAPS has received many complaints from physicians who have been forced into retirement because they didn't comply with MOC or they failed the exam. "In light of the physician shortage, this is alarming."
Dr. Nora states that she is not at liberty to discuss the lawsuit but believes the claims are "without merit."
Making MOC Manageable
Opponents of MOC urge physicians to "stand up to the tyranny" of ABMS and the MOC requirements of the specialty boards. "I call it 'civil disobedience' and regard myself as part of an incipient mass-noncompliance movement," says Dr. Weiss, who has decided not to recertify.
But many physicians will sign up for MOC because they think it's valuable or are afraid of the consequences if they refuse.
If you've decided to recertify, here are some tips to make the process more manageable.
• Don't wait until the last minute. Stay abreast of the literature. Some boards (such as the American Board of Obstetrics and Gynecology) regularly recommend specific studies and articles.
• Make use of online tutorials. Check your board's Website for tutorials with practice exams. The ABIM, for example, offers a free tutorial. The American College of Physicians (ACP) offers a paid tutorial, the MKSAP16. ACP recently piloted a project called MKSAP Study Hall, consisting of weekly one-hour Webinars incorporating humor to make the material engaging.
• Attend an in-person review course. The ACP, for example, offers two- to three-day courses prior to the exam.
• Collaborate with colleagues. Cover each other's practices during MOC-related activities. Create a study group to review, exchange tips, and provide mutual encouragement.
• Work with staff support for practice improvement modules. For example, a nurse can review charts to see how many patients were vaccinated.
The decision to recertify isn't one-size-fits-all, so educate yourself about both sides of this complex issue. Whichever path you choose will require courage. MOC isn't for the faint of heart; it requires determination to overcome its stresses and challenges. And avoiding MOC requires the commitment and strength to swim against the current. But courage and dedication are not foreign to physicians. They're prerequisites for the practice of medicine.