Reform or Remove Maintenance of Certification? A New Survey

OK, so it’s been 11 days since I posted the poll for Performance in Practice (PIP) Activity for Maintenance of Certification (MOC). The link to the original post is here. The result so far is below:

PIP activity for MOC poll result

There were absolutely no responses other than my “Yes” vote. This is exactly what happened in February 2013 the first time I ran the poll. I know the response rates to surveys and polls are pretty low…but none at all?

That strikes me as unusual. Repeated lack of response to a proposal to improve the PIP component of the MOC could mean at least a couple of things. One interpretation is that hardly anyone knows what MOC and PIP are. Another interpretation is that people are refusing to vote because they don’t want to support MOC in any way, shape, or form.

The first interpretation is pretty hard to accept. If people are reading my blog, they should know everything they need to know to vote. The second interpretation is plausible.  But then why not simply vote against?

Here’s what many would consider a brief, essential summary of what this is about:


Maintenance of Certification (MOC) was designed by the American Board of Medical Specialties (ABMS) in the year 2000 for the 24 specialty boards including the American Board of Psychiatry and Neurology (ABPN) to address a perceived need presumably by the public for greater accountability from physicians for continuous quality improvement, competence in medical practice, and protection of the public.  There are 4 MOC components including proof of professional standing which means:

  • Holding an unrestricted medical license in your state;
  • Participating and recording Self-Assessment and CME;
  • Taking the recertification exam every 10 years;
  • Participating in the Performance in Practice (PIP) module which are practice improvement activities involving chart review of your patients as compared to the medical literature, as well as patient and peer feedback reviews.

Theoretically, comparing your practice to standards set by the medical literature in the form of controlled trials, and practice guidelines should lead clinicians to reflect on their current assessment and management methods and modify them to be in concordance with the standards. The assumption is that this will result in safer and more effective medical care for patients, leading to improved outcomes.

While it’s clear that the clinical skills and knowledge base of physicians erode over time, there are no clinical trials which definitively establish that MOC in its current form addresses that challenge in a way which improves patient care outcomes.

MOC is controversial. Many physicians object to MOC and a lawsuit was filed in Federal court against the ABMS in April 2013 by the Association of American Physicians and Surgeons (AAPS) on the grounds that MOC restrains trade and causes a reduction in access by patients to their physicians. Several states have adopted resolutions to oppose MOC and Maintenance of Licensure (MOL), the MOL being essentially a move by the Federation of State Medical Boards (FSMB) to tie medical licensure to participation in MOC.

That said, MOC is embedded in the Patient Protection and Affordable Care Act (PPACA or Obamacare), which is also controversial but ties physician reimbursement to MOC via the Centers for Medicare and Medicaid (CMS) with the creation of the PQRI financial incentives to physicians who participate in Maintenance of Certification (MOC). In connection with that, beginning in 2014, “physicians who do not submit measures to PQRI will have their Medicare payments reduced.” This is taken directly from a condensed version of the ACA, It’s near the top of page 23 in Sec. 3002 of “Subtitle A–Transforming the Health Care Delivery System” in the pdf document.

In part, this probably explains the energetic efforts by many physicians to get Obamacare repealed. Given the low likelihood of that happening, some physicians propose a kind of continuous improvement approach to MOC itself.

Dropping the PIP requirement for patient and peer feedback, which is vulnerable to cherry-picking and cronyism, is one suggestion. Another is to add PIP clinical improvement activities which are more relevant to physician practices.

Starting January 2014, the PIP clinical practice improvement activities have to be approved by the ABPN. Currently, selection of PIP activities is limited and may or may not be relevant to a practitioner’s patient population.

A PIP activity that would be relevant to the practice of most psychiatrists who subspecialize in Psychosomatic Medicine is lacking. My proposal is to introduce the idea that a PIP for the assessment, management, and the prevention of delirium in hospitalized patients makes a great deal of sense for physicians from many specialties.

According to the American Delirium Society (ADS), key facts about delirium make this proposal sensible:

  • More than 7 million hospitalized Americans suffer delirium annually.
  • Among hospitalized patients who survived their delirium episode, the rates of delirium at discharge are 45%, 1 month 33%, 3 months 26%, and 6 months 21%.

My lecture to medical students should be enough to persuade a reasonable person that focusing energy on educating doctors about a deadly but potentially preventable neurocognitive syndrome is vitally important and ought to be a part of MOC.

However, there are many who would probably disagree on strategic grounds and say that we as physicians should continue to fight tooth and nail against MOC. While I’m opposed to both MOC and MOL as fit vehicles for lifelong learning, I believe that, given the current legal, reimbursement, and regulatory context, it’s probably more practical to spend effort on opposing MOL because it’s duplicative and unnecessary. Essentially, MOL is MOC and if you’re participating in MOC, there’s no reason to add MOL and tie it to physician licensure. There is no legal mandate for MOL. Most of the states which were supposedly collaborating with the FSMB on the so-called MOL implementation pilot projects have adopted resolutions opposing MOC and MOL through their state medical societies. In my opinion, it’s possible to defeat MOL. On the other hand, viewing MOC as a program which can and should be reformed is more feasible than struggling to have it expunged.

I believe in the principle of lifelong learning. However, MOC is not the way and it should be reformed. MOL should go away because we don’t need it on top of MOC.

Based on the above, I’ve created a new survey to which I hope readers will respond. All six questions are mandatory. I’m going to anticipate that the type of web browser you use may affect access to and performance of the survey, e.g., you might want to try it in Firefox instead of Internet Explorer.

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