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    MOC controversy: Issues and answers

    There has been much discussion both for and against Maintenance of Certification (MOC) requirements. This article explains how a permanent board certification program for physicians transitioned into MOC recertification and discusses the controversies surrounding the current program.

    The August 2014 issue of Contemporary Pediatrics featured an article titled “Maintenance of Certification: Myths, facts, and FAQs,” written by Virginia A. Moyer, MD, MPH, vice president for Maintenance of Certification (MOC) and quality for the American Board of Pediatrics (ABP). The editors received dozens of responses from pediatricians, all critical of the MOC process and questioning the necessity of the program. In this Peds v2.0 article, I describe the transition from permanent board certification to MOC and detail the many controversies surrounding the current program. Elsewhere in this issue, I don my “pediatrician” hat and express my own opinions regarding MOC (“MOC: A view from the trenches”).

    History of board certification

    To put MOC in perspective for pediatricians, it is important to understand the origin of the board certification process. As you will see, today’s MOC program represents a radical departure from the board certification program as originally developed by specialty boards.

    In the early part of the 20th century, there were no requirements to prevent untrained physicians from calling themselves ophthalmologists, dermatologists, or pediatricians. Anyone who had a “special interest” in narrowing his or her practice focus could be listed as a specialist in the directory of the American Medical Association (AMA). The need to distinguish physicians who completed specialty training gave rise to the creation of specialty boards such as the American Boards of Ophthalmology, founded in 1917; Otolaryngology in 1924; Obstetrics and Gynecology in 1930; and Dermatology in 1932.

    The American Academy of Pediatrics (AAP) was formed in 1931, but it did not see its role being that of a specialty board. One of its first actions was to task a Committee on Medical Education to investigate the need for a distinct ABP whose role was to certify physicians who had completed a pediatric internship and residency as board-certified pediatricians.

    Through the cooperative efforts of the AAP, the American Pediatric Society, and the AMA Section on Pediatrics, the ABP was formed in 1933. Its purpose was straightforward—to certify pediatricians for practice. Members received no salary and paid no dues, and were responsible for developing an examination and certification process. Pediatricians could apply for certification after completing 1 year of internship, 2 years of residency, and 2 years of practice or further training. Interestingly, board certification in pediatrics received significant pushback from many academic institutions, and it took nearly 20 years for certification to gain widespread acceptance among virtually all American pediatricians.1

    In 1933, the same year the ABP was founded, the American Board of Medical Specialties (ABMS) was formed whose membership consisted of the 5 existing boards—ophthalmology, otolaryngology, obstetrics and gynecology, dermatology, and pediatrics. Its role was simply to develop guidelines and regulations for all its member boards. Today there are 24 member boards under the ABMS, including the ABP.

    Evolution from board certification to MOC

    In 1989, the ABP stopped issuing a “permanent” certification in pediatrics, and began issuing time-limited certification that would require periodic recertification for pediatricians to claim board certification status. Several years later in 2010, the ABMS drastically changed the model of certification, from one based on a lifelong certification to today’s model that is based on continuous “maintenance” of certification.

    As a consequence, in 2010 the ABP began issuing certificates with no end dates. Figure 1 illustrates the ABP’s most recent data on the certification status of pediatricians practicing in this country. According to a recent article by Paul Kempen, currently 25% of all licensed physicians in the United States are not board certified. Additionally, he reports that less than 1% of physicians with lifelong certificates have recertified, and in 2010 the ABMS indicated that less than half of American physicians were participating in MOC.2

     

    Andrew J Schuman, MD, FAAP
    Dr Schuman, section editor for Peds v2.0, is clinical assistant professor of Pediatrics, Geisel School of Medicine at Dartmouth, ...

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    • Dr. Dr V
      I am fully trained Pediatrician that I can see the benefits of CME but not in the manner are conducted. These are more vacation than education. Very costly with minimal learning as the time is fragmented with VIEW the sponsors---Extra lunches and Dinners by Pharmacy industry, time with family. Then there is the cost of leaving the practice unattended or by a Lucum.Both very expensive. May I suggest: Older Physicians, retired or would like a different setting could become either voluntary or at lower cost to cover the practice and all of us would contribute a nominal PMT amount that would be less than total current expenses then we could every 3, 5, 7 and 10 years post practice a longer period to be determined and attend a Residency-Fellowship training facility and be like a fellow--last year resident--or special tailored category to attend patients, lectures, give lectures to junior residents and share experiences and same time learn new tricks, procedures, new treatments and Dx tests. We would be rested as would be education ONLY. Once I did within the US Army a mini-fellowship at my cost that gave more insight into what I wanted and needed at that time was Pediatric ID in the tropics. We would eliminate the cottage industry around CME, we would be better trained and educated physicians, our practice would be covered and would a less expensive item. I am not BC nor intent to but keep abreast of new things and am weary of such called "evidence based" medicine as almost never I am aware population that was based and people who did the conclusions. Most of the time do not reflect my population and lately most of them are on COST reduction but the liability for not testing or doing something always remains. Dr Villalta
    • Dr. klhark
      In 2009, in response to notices from the ABP, I sent the following letter to the president of the ABP. It went unanswered. THe comments are still pertinent, although the ABIM appears to have made even more onerous requirements. (see Dr. Schuman's commentary.) Two recent papers in JAMA hint at minimal cost saving by board certified physicians, but no better clinical outcomes. (Gray 2014, Hayes 2014) Dear Dr. Stockman III: Thank you for most recent of several updates on the implementation of the Maintenance of Certification (MOC) program. There is no question that provision of quality care is the goal of every practitioner. There is evidence that aging physicians may need help. In 2005, Choudhry, Fletcher and Soumerai concluded, “Physicians who have been in practice longer may be at risk for providing lower-quality care. Therefore, this subgroup of physicians "may" (emphasis added) need quality improvement interventions.” According to Dale (2007) [T]he drive toward recertification came from the recognition that physicians’ skills and knowledge usually decline over time, even though their experience steadily increases. On the other hand, it was recognized that the patient’s satisfaction with their physician depends largely upon their physician’s interpersonal skills, behaviours and sense of professional responsibility. Your letters hint (threaten?) that insurers and licensing agencies will be requiring MOC for participation. However, data collected by your own agency indicates that this is not true. (Freed et al, 2006a, Freed et al 2006b) The issue I take with you is your belief that recertification, continuing education or participation in quality improvement programs makes a difference in the delivery of quality care. I have yet to find any evidence of that recertification improves physician practice. I have searched PUBMED for any articles that document improved outcomes after recertification. I have queried the program directors of the Neonatal Resuscitation Program for evidence that the biannual recertification (as opposed to the initial training) makes a difference. I have received no reply, and interpret this mean that the evidence does not exist. From personal experience, I am no better (or worse) after NRP evaluation than before. I have successfully resuscitated hundreds of neonates over the years. Repetition in real life settings keeps me proficient. While there are studies using historical controls that suggest that NRP certification process is an effective teaching tool (for example in Illinois (Patel et al, 2001) and in the United Kingdom (Draycott et al 2006)) there are no studies addressing recertification in NRP programs. I have taught resuscitation using manikins and animal subjects. Success with either or both does not portend success with infants. I know physicians who pass the NRP and cannot resuscitate a newborn. In theory, there is a “best practice” for many medical conditions. The Vermont Oxford NICQ collaborative has attempted to identify better practices, but so far has found it difficult to transplant the good outcomes from better performing units to less successful units. Kilbride et al (2003) were able to reduce nosocomial infections in only 2 of 6 NICUs. (For more information on NICQ, see the supplement to Pediatrics found at http://pediatrics.aappublications.org/content/vol118/Supplement_2/index.... accessed 10/03/08) De Brantes et al (2008) evaluated 60 metrics that were considered as a tool to evaluate physicians for recertification. Only 20 were evidence based. “The discord that often exists between expert opinion and demonstrated clinical and economic evidence” suggests that we do not yet know how to evaluate a physician’s practice. Even when the AAP publishes a practice guideline, it attaches the disclaimer that the guideline does not represent the standard of care. Physicians are pummeled with practice regulations that require the expenditure of significant sums of money. Virginia, my current practice state, requires 60 CME hours every two years. Fees can exceed $60 per hour for face-to-face programs (see for example http://ColumbiaCME.org), or at least $1000 every two years. This does not include travel and lodging. In fact CME programs have become a cottage industry with the same names appearing on programs around the country. Licensure renewal fees can exceed $600 every two years. (Maryland) Your fee for recertification is $ 990. (At least in Canada, the expectation is that costs will come down. (CMAJ, 2004)) On top of that you are now requiring that we be “actively involved in measuring and improving the quality of care that you deliver.” I don’t know if anyone has estimated the costs of this activity in a private office. I do know that the annual membership fee for the Vermont Oxford Neonatal Network (VONN) was $2500 in 2000. VONN was a means of evaluating the care we provided in the NICU at Columbia Hospital for Women in Washington, D.C. Books outlining the AAP’s recommendations for selected areas of care (for example, school health, perinatal care, child abuse) are no longer a membership benefit but an additional charge. (www.AAP.org/bookstore) Rather than focus on testing, we should be focusing on identifying the better way to practice and on teaching the identified good practice. The Dutch (Schulpen, and Lombarts, 2007) have taken a much more labor-intensive approach (by both the accrediting agencies and the practices) with site visits to practices every 5 years including patient questionnaires, chart reviews, and process surveys. Site visits are just one of the 4 “pillars” of the quality improvement program of the of the Paediatric Association: 1. Site visits by peers (visitatie), 2. Continuous medical and professional education, 3. Clinical (evidence based) guidelines and the development of performance indicators, 4. Complication registration and patient safety. It is important to note that the Dutch government decided to financially support the development of evidence based guidelines. Instead of CME with no proven benefit, we should expand the use of teaching modules similar to those of the American Board of Internal Medicine (ABIM) (Dale, 2007) which has developed the concept of practice improvement modules or “PIMS.” “The PIMS are based upon chart reviews and patient surveys to determine quality, a structured evaluation of one’s own performance, and then action to create improvements and report on what has been learned or accomplished.” It is important to note however, the ABIM understands that it still has critical areas to explore: “What does it take to be an internist?” “What is required to be a really good internist?” and “Who would I want to be my internist?” The same questions apply to pediatrics. The American Board of Family Medicine has focused on teaching modules (SAM’s) that were well received by physicians, half of whom anticipated a change in their practice as a result. (Hagen, et al 2006) The SAM is an educational tool and not a formalized knowledge test. Nor does the SAM process assess outcomes. I am not alone in my doubts about recertification (Abbasi, 2008; Campbell, 2007) I believe we should be moving away from repetitive process evaluation (knowledge testing) to outcomes assessment. We should be focusing on education tailored to encourage best practices as they come to be defined. Perhaps as auditors and insurers look to outcomes as proof of good care, we may do away with recertification and in its place put an active, supportive educational process for practitioners. Rather than trying to sell a program of unproven value to the AAP, the clinician, insurance companies and state agencies, you should step back and prove that it will give the results you promise. To quote anonymous: IT IS BETTER TO REMAIN IN THE DARK RATHER THAN LIGHT THE WRONG CANDLE. (SIGN IN AN EXPLOSIVES FACTORY) REFERENCES Abbasi K. The three Rs: relicensing, recertification and revalidation J R Soc Med, 1 August 2008; 101: 387. Campbell EG, Regan S, Gruen RL, Ferris TG, Rao SR, Cleary PD, and Blumenthal D. Professionalism in Medicine: Results of a National Survey of Physicians. Ann Intern Med. 2007;147:795-802. Choudhry NK, MD; Fletcher RH, and Soumerai SB, 2005, Systematic Review: The Relationship between Clinical Experience and Quality of Health Care. Ann Intern Med. 2005;142:260-273. College certification and recertification [editorial]. CMAJ 2004;171(4):301. Dale DC. Recertification in Internal Medicine – The American Experience. Ann Acad Med Singapore 2007;36:894-7 de Brantes F, Wickland PS, Williams JP, The Value of Ambulatory Care Measures: A Review of Clinical and Financial Impact from an Employer/Payer Perspective Am J Manag Care. 2008;14(6):360-368. Draycott T, Sibanda T, Owen L, Akande V, Winter C, Reading S, Whitelaw A. 2006. Does training in obstetric emergencies improve neonatal outcome? BJOG: Feb;113(2):177-82. Freed GL; Uren RL; Hudson EJ; Lakhani I, Wheeler JRC , and Stockman III JA. Policies and Practices Related to the Role of Board Certification and Recertification of Pediatricians in Hospital Privileging JAMA 2006; 295(8):905-912 (doi:10.1001/jama.295.8.905) Freed GL; Singer D; Lakhani I, Wheeler JRC , and Stockman III JA. Use of Board Certification and Recertification of Pediatricians in Health Plan Credentialing Policies. JAMA. 2006; 295:913-918 www.jama.com Gray, Vandergrift, Johnston,et al JAMA. 2014;312(22):2348-2357. doi:10.1001/jama.2014.12716 Hagen MD, Ivins DJ, Puffer JC, Rinaldo J, Roussel GH, Sumner W, and Xu J, Maintenance of Certification for Family Physicians (MC-FP) Self Assessment Modules (SAMs): The First Year. J Am Board Fam Med 2006;19:398 – 403. Hayes, Jackson, McNutt,et al. 2014. (JAMA. 2014;312(22):2358-2363. doi:10.1001/jama.2014.13992) Kilbride HW, Wirtschafter DD, Powers RJ and Sheehan MB. Implementation of Evidence-Based Potentially Better Practices to Decrease Nosocomial Infections. 2003;111;e519-e533 Pediatrics DOI: 10.1542/peds.111.4.SE1.519 Patel D, Piotrowski ZH, Nelson MR, and Sabich R (2001) Effect of a statewide neonatal resuscitation training program on Apgar scores among high-risk neonates in Illinois.. Pediatrics Apr;107(4):648-55.) Schulpen TWJ and Lombarts KMJ. Quality improvement of paediatric care in the Netherlands Arch. Dis. Child. 2007;92;633-636 doi:10.1136/adc.2006.104091.
    • Dr. Dr V
      Excellent analysis and gave a more fully understanding of what I always felt. Very expensive and little effective education. Dr Villalta
    • Anonymous
      I am Board Certified originally in the early Ninties and twice more since. I took and passed my MOC exam in the fall of 2013. But I allowed my first 5year cycle to lapse as of the end of 2014. Why? Because at my age I have been around the block a couple of times, including certification, recertification, and now MOC. And I am sick and tired of being extorted to participate in this farce racketeering scheme by the ABMS. Not another dime will they extort with their "voluntary" MOC program. It is as "voluntary" as when an armed thug holds a cocked and loaded pistol to your temple and asks for your wallet. The Emperors of the ABMS are riddled with conflict of interest scandals, Presidents who often either were not themselves Recertified or, like Dr, Nora, only took MOC to earn their princely take home salaries. The ex-President of the ABP, James Stockman, took home over $1,300,000 in annual compensation in his last years in office. The fact that insurance companies, hospitals and the Federal government have become unwitting enforcers of an extortion scheme the Mafia would envy bespeaks the pathetic condition of our profession and its medical societies today. The ABMS should be prosecuted in criminal and civil courts with the aim to clawback the outrageous salaries of their Presidents and to obtain triple civil monetary damages to physicians extorted in this racketeering scheme.
    • Dr. Hartzler
      what anonymous said!
    • Anonymous
      MAFIOSI
    • Anonymous
      I am Board Certified originally in the early Ninties and twice more since. I took and passed my MOC exam in the fall of 2013. But I allowed my first 5year cycle to lapse as of the end of 2014. Why? Because at my age I have been around the block a couple of times, including certification, recertification, and now MOC. And I am sick and tired of being extorted to participate in this farce racketeering scheme by the ABMS. Not another dime will they extort with their "voluntary" MOC program. It is as "voluntary" as when an armed thug holds a cocked and loaded pistol to your temple and asks for your wallet. The Emperors of the ABMS are riddled with conflict of interest scandals, Presidents who often either were not themselves Recertified or, like Dr, Nora, only took MOC to earn their princely take home salaries. The ex-President of the ABP, James Stockman, took home over $1,300,000 in annual compensation in his last years in office. The fact that insurance companies, hospitals and the Federal government have become unwitting enforcers of an extortion scheme the Mafia would envy bespeaks the pathetic condition of our profession and its medical societies today. The ABMS should be prosecuted in criminal and civil courts with the aim to clawback the outrageous salaries of their Presidents and to obtain triple civil monetary damages to physicians extorted in this racketeering scheme.
    • Anonymous
      I am Board Certified originally in the early Ninties and twice more since. I took and passed my MOC exam in the fall of 2013. But I allowed my first 5year cycle to lapse as of the end of 2014. Why? Because at my age I have been around the block a couple of times, including certification, recertification, and now MOC. And I am sick and tired of being extorted to participate in this farce racketeering scheme by the ABMS. Not another dime will they extort with their "voluntary" MOC program. It is as "voluntary" as when an armed thug holds a cocked and loaded pistol to your temple and asks for your wallet. The Emperors of the ABMS are riddled with conflict of interest scandals, Presidents who often either were not themselves Recertified or, like Dr, Nora, only took MOC to earn their princely take home salaries. The ex-President of the ABP, James Stockman, took home over $1,300,000 in annual compensation in his last years in office. The fact that insurance companies, hospitals and the Federal government have become unwitting enforcers of an extortion scheme the Mafia would envy bespeaks the pathetic condition of our profession and its medical societies today. The ABMS should be prosecuted in criminal and civil courts with the aim to clawback the outrageous salaries of their Presidents and to obtain triple civil monetary damages to physicians extorted in this racketeering scheme.
    • Anonymous
      I am Board Certified originally in the early Ninties and twice more since. I took and passed my MOC exam in the fall of 2013. But I allowed my first 5year cycle to lapse as of the end of 2014. Why? Because at my age I have been around the block a couple of times, including certification, recertification, and now MOC. And I am sick and tired of being extorted to participate in this farce racketeering scheme by the ABMS. Not another dime will they extort with their "voluntary" MOC program. It is as "voluntary" as when an armed thug holds a cocked and loaded pistol to your temple and asks for your wallet. The Emperors of the ABMS are riddled with conflict of interest scandals, Presidents who often either were not themselves Recertified or, like Dr, Nora, only took MOC to earn their princely take home salaries. The ex-President of the ABP, James Stockman, took home over $1,300,000 in annual compensation in his last years in office. The fact that insurance companies, hospitals and the Federal government have become unwitting enforcers of an extortion scheme the Mafia would envy bespeaks the pathetic condition of our profession and its medical societies today. The ABMS should be prosecuted in criminal and civil courts with the aim to clawback the outrageous salaries of their Presidents and to obtain triple civil monetary damages to physicians extorted in this racketeering scheme.
    • Dr. Vic Strasburger
      I agree completely with your criticisms of MOC, Dr. Schuman, and thank you for citing my Clinical Pediatrics commentary. Here's the problem in a nutshell and why I became involved in this -- this is a media issue! We now have the technology to keep pediatricians current and up-to-date ONLINE!!!! The systems can be made secure so that people won't cheat (does anyone really think pediatricians cheat? -- how offensive!). We already vote for the President of the AAP online. The current system is simply not designed to EDUCATE pediatricians. The recertification exam tests arcane facts, not common conditions. On my Adolescent Medicine recertification exam, there were as many questions about Androgen Insensitivity Syndrome (occurs 1/100,000) as on acne (85% of all teens)! An online system could be $25-50/year, take an hour or two to complete with a small quiz at the end, and would actually update and inform pediatricians. Why not do it? Vic Strasburger, M.D. Distinguished Professor Emeritus Univ. of New Mexico School of Medicine
    • Dr. nudelman
      This is a Great idea. However, it doesnt include a structure to provide a cash cow to parasitic administrators. Therefore, the powers that be will not support it.
    • Dr. Vic Strasburger
      Yes, that's precisely one of the problems -- this has become a major money-making operation that has spiraled out of control. When the American Board of Pediatrics has $40 million in reserves and the ABP President makes $700,000 or so a year, it's a tough gig to give up! The ABP also invests incredible amounts of money into psychometric testing (e.g., how many people are going to answer Question X wrong?) -- which would be completely unnecessary if an online curriculum simply educated pediatricians.
    • MARIONEMASS
      Well said, Dr Schuman. I applaud you for including a history of the certification process, as it is instructive to see how things were handled in the past. Not all of the changes are productive evolution. Part 4 is an absolute waste of my time and money. As a teen lifeguard, I found kids that splashed me to be distracting me from the health of the swimmers I guarded. Part 4 is akin to splashing the lifeguard... distracting us all from the real work that will help our patients. I took the every 10 year test this year, and while I found most of it reasonable, why are we asked to retain minutia? For example, I fail to see how it helps my patients for their physician to know that Trisomy 18 is associated with rocker bottom feet and clenched hands. Were I to see a child with these anomalies, I would comfort and counsel the parents, send off the chromosome analysis and go off to my resources. The test should be open book, which is how we all should practice. I do not find it onerous to perform 50 credits per year of CME, in fact I enjoy it. But I am now wondering where all my money to pay for these activities is going??? Recently an expose regarding the ABIM(American board of Internal Medicine) was able to trace their MOC money back to a $2.3 condo. Perhaps someone should follow our money to insure that it is going to a just place. Furthermore, regarding price of CME in general.....I have always regarded it as an honor to teach students, residents, and nurses. I have volunteered for such positions, because I view it as my duty. So why am I spending hundreds of dollars for the courses I attend??? None of the lunches were that good! I look forward to productive discussion, and real reform with the goal solely to be for the good of our patients. Marion Mass, M.D.
    • Dr. nudelman
      MOC has shown itself to be nothing but mindless busy work designed to justify an administrative structure that does nothing but earn non-clinical Pediatricians 6 figure incomes that are totally parasitic. The so-called "research" we did was a joke. It was value-less "data that a first year medical student could easily dismiss as useless. The process itself is an exercise in demeaning, insulting hoops that we are forced to jump through. There is NO proof that this in any way improves pt care. There are new licensing Boards being developed by physicians who actually Respect their fellow Physicians that will require only that we take our Boards and document quality annual CME. As soon as it is available, the ABP can kiss my Gluteus Good-Bye.

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