Physician Dissatisfaction With MOC Goes Mainstream, Inspires Activism
One year ago, the changes made to the Maintenance of Certification (MOC) program run by the American Board of Internal Medicine (ABIM) were only beginning to irk interventionalists. But the saga of nailing down the most effective way to recertify physicians has now gone mainstream, with doctors from every specialty having an opinion, and has given rise to a potential alternative to MOC.
To recap, the ABIM announced in January 2014 that, in congruence with new recommendations put in place by the American Board of Medical Specialties (ABMS)—the umbrella group for all 24 specialty boards—all diplomates would need to register for MOC, earn points every 2 years by completing MOC activities, and take a recertification exam every 10 years. Failure to do so, physicians were told, would result in their names being listed on the ABIM online database as “not meeting MOC requirements.”
The new system would cost physicians hundreds of dollars more than they were already paying, and many complained that the online interface was not user-friendly.
After a petition—which now has almost 23,000 signatures—was started by Paul S. Teirstein, MD, of the Scripps Clinic (La Jolla, CA), in an effort to eliminate MOC, debates raged and websites popped up to address whether MOC is the optimal way to maintain and measure physician competency.
A Surprising Apology
Although the ABIM initially maintained its stance, on February 3 of this year the organization released a statement announcing immediate changes to its MOC program. These included suspension of the requirements for practice assessment, patient voice, and patient safety for at least 2 years as well as removal of the punitive labeling system for physicians who chose not to take part. Such doctors would now be referred to as “not participating in MOC.” Most notably, they apologized.
“We launched programs that weren’t ready, and we didn’t deliver an MOC program that physicians found meaningful. We want to change that,” ABIM President and CEO Richard J. Baron, MD, said in the statement. “We got it wrong and sincerely apologize. We are sorry.”
But these steps were not enough for some MOC critics. “ABIM has made some changes that are helpful and positive, but it’s far from sufficient,” Dr. Teirstein told TCTMD in a telephone interview. “We’re still left with the repeat testing and modules that… are onerous, a waste of time, and expensive. They took away about 10% of the bad stuff.”
Dr. Teirstein, who has become the unofficial leader of the physician recertification reform movement, helped found the National Board of Physicians and Surgeons (NBPAS) in January of this year as an alternative for continued board certification for all physicians and specialists. Application for NBPAS certification costs $84.50 per year ($169 for 2 years), and certification is based on CME compliance, medical licensure, and hospital privileges in some cases. Importantly, applicants must have previously been certified within at least 1 of the ABMS specialties, which means that the NBPAS does not perform initial certification for new graduates.
As president, Dr. Teirstein says he has about 3 extra hours of work per day, but he—like all of the other 16 NBPAS board members—is unpaid.
“My initial complaint with MOC was that it was wasting my time,” he said. “Now I’m spending a lot more time on this project, but this isn’t a waste of time, so I don't mind doing it.”
NBPAS board member J. Marc Pipas, MD, a medical oncologist at Dartmouth-Hitchcock Medical Center (Lebanon, NH), said, “There’s a widespread acknowledgement that the American Board process has become very problematic for many people, and it’s become very expensive. The National Board is a very reasonable and appropriate alternative to the sort of oligarchy that the ABIM has had. They are a self-appointed group, self-policed, and we feel that on a lot of levels, they have not done the job that they were charged to do.”
He added in a telephone interview with TCTMD that “the ABIM has lost its way by setting the bar so high in terms of requirements that they’ve become irrelevant in terms of clinical appeal.”
‘Hold Hands and Jump in the Water’
Dr. Teirstein reported that more than 1,000 diplomates have signed up for the NBPAS, but he is unsure how many of them will either renounce their ABIM certification or suspend their MOC activities.
Much of this may depend on how many institutions will eventually accept NBPAS certification as an alternative to the long-trusted ABIM certificate. “It’s going to be another couple of months before we get any recognition,” he said, noting that he is currently having conversations with several hospitals and tasking his board members with doing the same. “It’s something new and something different. They don’t want to be the first.”
Dr. Pipas said that he has spoken with the senior leadership at his institution about recognizing NBPAS certificates. “What we’re seeing across the country is hospitals looking at one another to see how they’re going to handle this.… Our hope is that what we can do is get a group of hospitals to sort of hold hands and jump in the water at the same time,” he said.
But NBPAS board member Paul G. Mathew, MD, a neurologist at Brigham and Women’s Hospital (Boston, MA), said he plans on waiting to approach his institution until more of his colleagues have also signed up for NBPAS membership, emphasizing that “there is no harm” in holding 2 certificates.
“Many physicians would normally wait until their ABMS certification expires, and I’ve been advising them not to. The more members that NBPAS has, the more leverage it will have,” he told TCTMD in a telephone interview. “I liken signing up for NBPAS so prematurely to supporting a political action committee…. It’s almost like casting a vote and really showing a sign of solidarity among physicians that the current system is unacceptable.”
Both Drs. Pipas and Mathew spoke about how generic examinations in the past have tested them on skills not necessary for their daily practice, and neither plans on renewing their certifications in the future.
The only way Dr. Mathew said he and most physicians would go back to doing things ABMS’s way would be if they “drop the MOC program and return to lifetime certificates.”
Exams should be part of an overall learning continuum, Dr. Pipas added. “But if you have a process that becomes so consuming of people’s time that it starts to tear into other responsibilities [to] their patients, careers, and even with their families, then you have to ask yourself, is this really helping anyone at all?”
Is There a Civil War Brewing?
With 2 controversial articles in March and April of this year, Newsweek exposed some alleged holes in ABIM’s finances and simultaneously brought the issue to the public. Dr. Teirstein said the articles appear factual according to his experience, but he thought the connotation of an “ugly civil war” brewing in American medicine is incorrect.
“Civil war implies a substantial size of the opposing sides, and in this case the ABIM is a pretty small group,” he said. “It’s really just a handful of doctors that the rest of the doctors are against. It’s a lopsided civil war.”
But Newsweek speaking to a “lay audience helps us get the word out to doctors, because a lot of doctors read the lay press, so I’m very happy with that,” Dr. Teirstein continued. “I also think it’s a relevant question for the public to debate and think about. Most of the patients… think it’s a great thing, because they see the doctors being pulled in many directions and not having enough time to speak to them.”
Eric R. Bates, MD, of the University of Michigan Health System (Ann Arbor, MI), told TCTMD in a telephone interview that it will be important for the ABIM to work on their “tarnished” reputation and brand going forward, both for the sake of patients and physicians.
Additionally, Charles E. Chambers, MD, president of the Society for Cardiovascular Angiography and Interventions (SCAI), said, “Credibility is very important here and that’s what ABIM has to address.”
He reported to TCTMD in a telephone interview that the ABIM acknowledged its mistakes in a recent meeting with other societies. “At this point, what has come out reflects that they weren’t transparent,” he said. “Here forward, we have to demand transparency.”
Dr. Bates added, “It may just be that they got too old and the business plan got a little sclerotic, and they kept adding on things without getting enough feedback from their customers about how the process should have changed over the years. Maybe this is really good and maybe they’ll get it right and we’ll have a new system, or maybe they can’t get it right and somebody else will figure out how to compete with them.”
ABIM Speaks Up
In response to the Newsweek columns, the ABIM released a statement on April 8 that contains a link to the organization’s most recent financial report. “[T]he opinion column inaccurately suggests that ABIM’s decision to offer a new program with new payment options in 2014 was driven by financial considerations and also mischaracterizes ABIM’s financial position,” the group said. “ABIM has always maintained a sufficient cash balance to meet the future commitments made to more than 90,000 diplomates who have paid ‘up front’ and enrolled in its program for 10 years, and ABIM’s accounting accurately reflects these future obligations.”
In an email with TCTMD, Dr. Baron described the ABIM as “fully transparent in our financial dealings and fully stand behind the accuracy of the financial statements posted on our website.”
Over the past year, he explained, “we listened to feedback from physicians, and took immediate steps to let them know we got it wrong. We essentially hit the ‘reset’ button. During the past few months, we’ve opened dialogue with practicing physicians to make sure we get it right going forward.”
Dr. Baron said the ABIM’s apology letter “signaled the start of an important, ongoing conversation we need to have with the physician community. We know we need to listen to feedback and recalibrate. We are determined to get it right this time, knowing it will take a while to give all physicians the opportunity to weigh in.”
Reflecting on the current environment of American medicine, Elizabeth W. Loder, MD, of Brigham and Women’s Hospital, writes in a blog published online March 19, 2015, in the BMJ: “Physicians have learned they have real clout and that organized effort can overturn something many saw as inevitable…. Look for this to be the first of many doctor-led revolts.”
Contrary to how it might seem, physician activism is nothing new, especially among interventional cardiologists, Dr. Chambers said. “Interventional cardiologists have notoriously been very passionate people,” he noted, adding that Dr. Teirstein “has made it clear that if you have a point, that you get out there and have your voice heard.”
Importantly, Dr. Bates added, many physicians have over the past 10 years earned MBAs and tried to get involved in other ways. “The more physicians we can get into regulatory and administrative positions, the better, more clinically meaningful information will be available for how to take care of patients,” he said.
“This project has inspired a lot of us,” Dr. Teirstein said. “We have an obligation, a responsibility to stand up for our profession, and we can’t just keep our heads down and address the urgent problems that come to us every single day from all over. What we have to do is take a minute and think about the bigger picture and how to make things better.”
- Dr. Baron reports serving as the president and CEO of the ABIM.
- Dr. Bates reports serving on the ABIM’s interventional cardiology exam writing committee and working with SCAI and the American College of Cardiology in various capacities.
- Dr. Teirstein reports serving as the president of the NBPAS.
- Drs. Pipas and Mathew report serving on the board of the NBPAS.
- Dr. Chambers reports serving as the president of SCAI.
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