This article's views do not necessarily reflect those of Contemporary Pediatrics, the editors, or the Editorial Advisory Board.
Although I’ve been writing articles for Contemporary Pediatrics since 1988, I have never received as much supportive e-mail as I have in response to my 2 maintenance of certification (MOC) articles published in the January 2015 issue. (See “MOC controversy: Issues and answers” and “MOC: A view from the trenches.”)
Much has happened since these 2 articles were published. The recent sequence of events involving MOC is not unlike a television soap opera, whose plot line is filled with all sorts of twists and turns! There is now an alternative Board providing MOC certification for physicians, and, in the near future, the American Board of Pediatrics (ABP) MOC system is likely to undergo significant revisions.
The story so far
In 2010, the American Board of Medical Specialties (ABMS) and its member boards drastically changed the model of 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. Pediatricians were listed either as “participating in MOC” on the ABP website or “not participating in MOC.” According to data provided by the ABP website, as of December 2013, approximately 34% of the pediatrician workforce has a permanent certificate; 54% of pediatricians have time-limited certificates; and about 11% of pediatricians have let their ABP certificates lapse.
The ABP maintains that MOC assures the American public that pediatricians practice the highest quality medicine. The mission statement of the ABP declares, “The American Board of Pediatrics certifies general pediatricians and pediatric subspecialists based on standards of excellence that lead to high-quality healthcare during infancy, childhood, adolescence, and the transition into adulthood."
However, MOC has been widely criticized by practicing physicians of all medical specialties, who argue that there is no evidence that MOC improves patient care. It is expensive as well as time consuming, and it takes valuable time away from patient care. The Association of American Physicians and Surgeons has filed an antitrust lawsuit against the ABMS seeking to stop the MOC program from continuing.
Many pediatricians have been critical of the ABP MOC program. Joseph Zanga, MD, past president of the American Academy of Pediatrics (AAP), founder of the American College of Pediatricians, and now chief of pediatrics at Columbus Regional Health Systems, Columbus, Georgia, has been a long-time opponent to MOC. He wrote in the Georgia AAP Chapter newsletter a few years ago that there is:
· “No Proof of Demand—except created by the ABP. . . . In practice our public votes with its feet, or via their attorneys, about our competence. No peer-reviewed study has every verified the demand in recertification’s 20-year history.”
· “No Proof of Efficacy—which surely could have been studied. The process has not demonstrated improved care of patients, nor has the reported health of children improved because of it. With approximately 40% (of approximately 90,000) of 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)." 1
Another advocate for MOC reform has been Meg Edison, MD, a Michigan-based pediatrician in general practice who is one of several founders of the website www.Rebel.MD. She has authored several compelling anti-MOC blog posts on the site. As an interesting aside, Edison’s state medical society has successfully passed a resolution that would prohibit tying medical licensing to MOC participation, joining several other state medical societies including Washington and New York that have done likewise.
The ABIM changes its MOC
The American Board of Internal Medicine (ABIM) implemented a change in its MOC program in 2014 that required physician’s participation every 2 years. This was done in an effort to encourage its members to become more diligent in participating in MOC on a regular basis. (Many physicians rush to complete requirements in the last year of their 5-year cycle.) The ABIM mandated that its members must complete at least 10 MOC continuing medical education (CME) credits every 2 years. Additionally, beginning in 2014, grandfathered ABIM physicians began to be listed as "certified, not meeting MOC requirements" on the ABIM website if they didn’t register for continuous MOC.
This change proved to be the “straw that broke the camel’s back.” Paul Teirstein, MD, chief of cardiology at the Scripps Clinic, San Diego, California, decided to begin an online petition protesting the ABIM changes. His petition asked signers to support revision of the MOC program—limiting it to a test taken every 10 years. His protest met with enthusiastic response, and of this writing has garnered more than 22,000 signatures (the ABIM has 200,000 members). A second petition asking signers to boycott MOC entirely now has more than 7000 signatures.
As a consequence of this groundswell of enthusiasm, Teirstein has collaborated with like-minded colleagues and has started an alternative board of medical specialties called the National Board of Physicians and Surgeons (NBPAS). The NBPAS is encouraging interested physicians to promote this alternative board to hospitals and insurance companies as well as to other physicians. The NBPAS requires previous board certification and participation in yearly CME. It costs only $169 every 2 years. The NBPAS website (www.NBPAS.org) includes sample letters that members can use to persuade hospitals and insurance companies to accept NBPAS certification.
Teirstein’s effort was the subject of an article published March 10, 2015, in Newsweek, titled “The ugly civil war in American medicine.” According to the article: “This new board is not just about breaking the ABIM monopoly, Teirstein says, but is also part of an effort to put the right people in charge of the profession’s future. Medicine has been ‘controlled by individuals who are not involved with the day-to-day care of patients,’ he says. ‘It is time for practicing physicians to take back the leadership.’”
The ABIM apologizes
In an unexpected move on February 3 of this year, Richard Baron, MD, president and CEO of the ABIM, sent an “apology” letter to members that began by saying simply: “We got it wrong and sincerely apologize. We are sorry.”
The letter went on to detail that the ABIM would suspend several of its Part 4 requirements and change the language reporting a diplomate’s MOC status on its website from “meeting MOC requirements” to “participating in MOC.” The letter also indicated that the ABIM will update the MOC written exam to make it more relevant to current practice and will fix MOC fees at 2014 levels until at least 2017. Lastly, the letter suggested that Part 2 (now “self-assessment”) of the MOC requirements would change by accepting most forms of certified CME.
And the ABP does not!
As you can imagine, the ABIM apology was well received by internists, and the rest of the medical community expected their specialty boards to follow suit. However, 3 days later on February 6, the ABP issued its own e-mail response to members, which stated in part: “While we are fellow members of the community of medical boards, ABIM and ABP serve different populations and have approached MOC differently. The ABP is looking closely at ABIM’s changes and the reasons behind them. . . . The ABP is making no changes to the requirements for maintaining certification at this time.”
The American Board of Family Medicine issued a similar response.
The response was not well received by the pediatric and family practice communities, and it was a topic of much discussion among primary care physicians. At the AAP Annual Leadership Forum held in March, 2 resolutions dealing with MOC reform were accepted for discussion. Additionally, the March 2015 AAP News featured a front-page article titled “Academy responds to ABIM MOC announcement.” The article indicated that the AAP would be working with the ABP to improve the current program.
In response to the ABP letter, Zanga, Edison, and several other pediatricians have developed a new website, www.peds4mocreform.org, that details objections to the ABP’s MOC system and encourages visitors to sign and distribute a new online petition to promote MOC reform. The petition promotes streamlining MOC to just yearly lifelong learning CME and maintenance of a medical license with elimination of the 10-year exam and Part 4 projects. As of this writing, the petition as garnered more than 534 online signatures.
Perhaps feeling the need to respond in more detail to the ABP membership, David G. Nichols, MD, MBA, CEO of the ABP, issued a lengthy blog post on the ABP website on February 25 suggesting that the ABP is receptive to changing the program to be more responsive to its membership.
Nichols noted that the ABP is hosting a conference in May 2015, the purpose of which is to discuss evidence-supporting revisions in the 10-year exam. Under consideration is changing the current exam to an online format in order to make it more of a learning experience. He acknowledged that the Part 4 requirements are too onerous for many. He also announced that pediatricians who go through the National Committee for Quality Assurance process to achieve patient-centered medical home certification (see “Home sweet 'medical home,'” Contemporary Pediatrics, November 2013) will be given full Part 4 completion credit. Nichols noted that the ABP is planning to simplify Part 4 Quality Improvement projects, making them more relevant to pediatric practice, and outlined several efforts now in the pipeline to make it easier to garner Part 4 credits.
The choice is yours
The end result of all these events is that pediatricians now have more choices, as well as decisions to make, regarding participation in MOC.
- If you have permanent (not time-limited) certification, you can choose to not participate in MOC, unless you are compelled to do so by your employer, hospital, or insurance companies.
- If you currently participate in MOC, you can choose certification via the NBPAS as long as your employer, hospital, and insurance companies accept the alternative certification.
- If you believe that MOC is beneficial, you can continue to participate, aware that the ABP has indicated it is interested in revising the existing program to be more responsive to the needs of its members.
Without doubt, heated discussions will continue. To be sure, we will keep you posted regarding all future events that relate to MOC.
1. Zanga J. Maintenance of Certification: Do we need another test? Georgia Pediatrician. 2010;19(1):8.
Dr Schuman, section editor for Peds v2.0, is clinical assistant professor of pediatrics, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, and editorial advisory board member of Contemporary Pediatrics. He has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.