Debating Maintenance of Certification for Physicians

On the fence about participating in your medical board's Maintenance of Certification (MOC) program?

Family medicine physician Russell Thomas isn't.

Russell, who practices in a three-physician medical group in rural Eagle Lake, Texas, is a huge fan of his specialty board's MOC program, the ongoing re-certification program offered by the American Board of Medical Specialties (ABMS) and its 24 member boards. The programs require physicians to participate in activities specific to their specialties, including ongoing knowledge-improvement projects, in addition to taking an exam at least once every 10 years, to demonstrate they are staying up to date in their fields.

But while Thomas says it takes upwards of 50 hours a year to focus on MOC-related activities, he believes it makes an enormous difference in his day-to-day practice.

"I see it as an absolute necessity." says Thomas. "I think all of us think we know a whole lot more than we do."

Endocrinologist and internal medicine physician Arvind Cavale, it seems, couldn't disagree more.

While the Feasterville, Pa.-based physician admits he enjoys the thrill of taking tests and took his first, post-board-certification MOC exam in 2005, he has no plans to continue the MOC program - it just takes too much time, for very little return on investment.

"What does recertification mean? It's not a license to practice medicine," says Cavale. "What is relevant in day-to-day practice is to identify what your patient is asking you."

Physicians Thomas and Cavale represent two ends of the spectrum on a divisive issue: whether MOC is worth a doctor's time. In 2013, the debate over the program's merit reached its highest pitch when the Association of American Physicians and Surgeons (AAPS) filed an anti-trust suit in a federal court in New Jersey against ABMS. Among other things, the 20-page complaint claims the defendant's program "is designed primarily to enrich [the organization] and its own executives, rather than any genuine attempt to improve quality of care for patients."

For physicians still going back and forth on the voluntary program, this ongoing debate raises important questions: Is it worth the time and money involved? What are the benefits? What are the alternatives?

Reasons for MOC

Proponents of MOC tout many perks.

For starters, physicians are proving that they are up to date on the changes and professional developments in healthcare - and this matters to patients, says Lois Margaret Nora, ABMS president and CEO. Today, 800,000 physicians are ABMS board certified, and last year, about 450,000 to 460,000 of those physicians participated in MOC programs, she says, adding that number is increasing every year.

After obtaining ABMS board certification, a process that entails "an extended period of time of training and assessment of the knowledge, skills, judgment, and professionalism of their particular medical discipline or specialty," physicians are eligible for MOC, says Nora. And the program, which is intended to reflect that physicians have achieved the highest standards in their discipline, is pretty rigorous.

"At the beginning of the 2000s, it was recognized that medicine and science changes so regularly and so ongoing that ABMS board certification became more associated with a more comprehensive program of Maintenance of Certification," says Nora. "What Maintenance of Certification  is intended to do, and we believe it does do, is, first of all, signify to the public … that we deserve their trust because physicians are doing an ongoing program of assessment and learning in their discipline."

Russell says the program helps him improve his areas of weakness through study and by informing him of quality standards that he should adhere to, such as guidelines for hand hygiene and infection control.

"For me, it's a very important way for me to identify my weaknesses in various areas of care, and do an improvement process or course to provide better patient care in that area," says Russell.

But efforts to stay up to date aren't just potentially beneficial to patients. Some hospitals choose to use ABMS board certification as one of the criteria to determine whether to add a physician who applies to the hospital for medical staff privileges, and some insurance networks also use it as a criterion, according to an ABMS spokeswoman.

Arguments against MOC

If MOC makes a difference to patients, in the nearly 10 years since he's been certified, Cavale hasn't seen evidence of it.

"In 17 years of practice, not once has a patient asked me if I am board certified or if I am involved with MOC," says Cavale, adding that being part of the program also hasn't made him more efficient or reduced his malpractice risks.

In addition to not making a difference to patients, the program costs too much in time and money, says Jane Orient, an internist and executive director of AAPS.

"If you have to spend every waking hour that you're not working cramming on material that is useless to you and you have to spend thousands of dollars buying the review materials, and thousands of dollars taking the exams … plus the expense of being away from your practice and traveling to remote locations, it amounts to many thousands of dollars and it means that you can't study the things that are most important to you, you can't spend extra time with your patients, your family life is devastated," says Orient. "It's really a huge burden with no purpose. Doctors are overworked as it is. Why do we want them to do busy work?"

Indeed, the time invested in preparing for his first MOC examination in 2005 has reaped very few benefits, say Cavale.

"In order to qualify for the board test you need to complete so many modules," he says. "And a course to complete one module could take four to six hours. These modules … have no meaning to actual patient care. With age you realize all this is bogus."

While each board exam is different - and ABMS says annual MOC participation fees cost, on average, $300 a year - ABMS confirms other expenses may include travel to test locations (and, therefore, hotel accommodations) and time spent away from patients (and the revenue generated from those patient visits). However, the board also notes that other professions like law and accounting have similar programs and associated costs.

Earlier this year, ABMS enacted new standards to encourage its member boards to continue to look for ways to reduce physicians’ cost, time, and administrative burden associated with participating in MOC as well.

Making your decision

Trying to decide whether MOC is worth your time and money? In addition to the more publicized pros and cons, physicians should also consider the following:

• Goals and beliefs. "First and foremost, they should look at, 'Does this process contribute to the ability for me to provide the best care I can for my patients?'" says Thomas. "Things change very rapidly in our business. At the end of the day, it's a minimum thing that physicians should do to ensure they're providing the best care for patients. If you're not trying to learn something all the time, you're going to get woefully behind very quickly. Maintenance of Certification is the best option we have currently." But not all physicians agree. If you believe your time is better spent focusing on your patients and learning from them, as Cavale does, then MOC might not be right for you.

• Study style. While some of you are motivated to keep up with your profession by studying and passing exams, others may prefer self study: reading journals, talking with partners, going to society meetings, and the like. "There are many assessment programs and self-study programs put forth by our various medical societies," says endocrinologist Marc Frager, who practices in a six-physician group in Boca Raton, Fla., noting that these programs cost much less than MOC. "And there's no reason to believe that Maintenance of Certification is any better than the medical-society-sponsored programs."

• Hospital privileges. If hospital privileges are important, you might want to check into what your local hospital partners are requiring. "My partners are younger and some of them have to participate in Maintenance of Certification because board privileges are required for hospital privileges at my hospital," says Frager, who, because he was board certified before 1990, doesn't have to recertify to have hospital privileges. "So If I don't participate, I still have my board certification, but they lose theirs if they don't. They have time-limited certification, so after 10 years theirs expires."