Maintenance of Certification (MOC) – Do We Need Another Test?
Joseph Zanga, MD, FCP, FAAP
INTRODUCTION: The American College of Pediatricians supports the highest standards of medical practice among its members and within the field of pediatrics. The College therefore supports ongoing medical education for physicians to incorporate applicable new research in the care of patients. The College questions, however, whether the costly and intrusive process of the Maintenance of Certification (MOC) program assists in education or practice.
“The public is demanding proof of physicians’ continuing competence; the government is demanding the same.”
“Documenting this will lead to the improvement in the quality of care and the health of children.”
In about 1986, with approximately those words, Robert Brownlee, MD, then President of the American Board of Pediatrics (ABP), introduced the concept of recertification to the American Academy of Pediatrics (AAP) Chapter Presidents’ Forum (now known as the Annual Leadership Forum). The assembled pediatricians asked for proof of those statements. No proof was ever forthcoming, but recertification began nevertheless. In response, the Chapter leaders recommended to the AAP that only initial membership in the Academy be dependent on Board Certification. They proposed that once approved as a Fellow of the AAP, continued Fellowship would not be dependent on recertification. “Once a Fellow, always a Fellow” was accepted by the AAP Board and ultimately by the membership.
Today we are faced with the latest ABP product, Maintenance of Certification (MOC). Pediatrician support is grudging at best, especially from those who were educated and tested before Recertification, and promised unqualified lifetime certification. Although many objections have been raised to the MOC process, this statement will focus on two of the most salient.
No Proof of “Demand” – except that created by the ABP. The one quoted proof is a study whose question begs an answer in support of testing. In practice, our public votes with its feet, or via their attorneys, about our competence. No peer reviewed study has ever verified a demand for MOC in recertification’s 20 year history.
No Proof of Efficacy – which surely could have been studied. The process of recertification has not demonstrated improved care of patients, nor has the reported health of children improved because of it. With approximately 40% (of about 90,000) ABP certified physicians in the Lifetime Certified category, a well-designed study could have, prospectively or retrospectively, given the ABP data upon which to proceed (or not). We also have never been provided the data on how many pediatricians are practicing without certification, how many may have chosen not to recertify, or how many have failed the process. This information needs to researched and reported as well.
(There are over 850,000 licensed physicians in active practice in the US today. Approximately 260,000 are not Board Certified. Of the almost 634,000 who are, only a bit more than half are participating in the MOC process, established by ABMS policy in 2000. That number is less for the Lifetime Certifieds. For the ABIM only 1% of lifetime certifieds have chosen to recertify, and it’s 8% in dermatology, 12% in nuclear medicine, 5% in plastic surgery, 1% in urology.)
At a time when evidence based medicine is the proposed gold standard of care, it is astonishing that the studies described above have not been conducted. There are other more practical objections to physician participation in the MOC. For example, it requires time away from the office, patient care and perhaps even from time already allotted to CME, with no demonstrable, peer reviewed, benefit. Then, consider the cost. A $1000 fee over 5 or so years for a individual is not devastating, but think of it in the aggregate. If all 36,000 lifetime certificate holders entered the process, $36 million would go to the recertification organization. Neither the American Board of Medical Specialties (ABMS) nor the ABP have yet even tried to explain the fees charged to pediatricians or others for recertification.
(If there is any doubt that the greatest motivation for MOC is primarily to increase the multi-million dollar reserves of the Boards and the unjustified compensation/perks afforded to their senior staff, take note of another of the Boards which now has a program to recertify without exam for $1000 or with exam at their testing center in Florida for $1800. Clearly, this Board just wants you to send large amounts of money, regardless of whether or not you take a test or otherwise prove your competence.)
It appears however that pediatricians might ignore the ABP only at our own peril. According to a February, 2005 report, the Federation of State Medical Boards, encouraged by the ABMS, which includes the ABP, began recommending MOC as a condition in the re-licensure process (recently a voluntary MOC/Licensure process was approved in Massachusetts and a similar proposal defeated in Ohio). A Lifetime Certificate holder (or any unsuccessful/non-participating pediatrician), now listed by the ABP as “not meeting the requirements of the MOC” might not qualify to continue his/her medical license. If the ABP cannot “demonstrate to the public or government” that the MOC identifies some who are less than competent, shouldn’t they and everyone else conclude that the process could readily be construed as self-serving?
The medical profession is one of the most over-regulated professions in the nation. Physicians cannot accept a pad of paper or a pen from a pharmaceutical representative for fear of being accused of contaminating patient care. Physicians are scrutinized by employers of all sorts, by hospital credentialing committees, by medical insurers and medical liability insurers, and by licensing authorities. (Will these all require MOC?) Physicians read journals, attend CME, teach students from medical and allied professions, educate our patients and their families, and yet still more is now being demanded/required of physicians without proof that it will benefit us or our patients. The American College of Pediatricians asks that this re-certification process be independently examined for need and efficacy. If there is need, then this time the program design should be based on evidence, with an included evaluation schema. MOC should prove its need and worth before it demands our participation.