Doctors and MOC: Paying Under Duress?

A friend sent me the following link to a thought-provoking blog post about psychiatry written by a psychiatrist:

I think the most disturbing comment from this pricelessly funny but disturbing essay was from someone who was identified as “almost did a psych residency.”

Thank you, Alone. You saved me many years of wading through shit. I stumbled onto your blog right as I began to apply for residency. I ditched psychiatry (but not the blog, obviously) and never looked back!

I notice the petition to change the American Board of Internal Medicine (ABIM) just increased the signature goal to 15,000 after the previous goal of 10,000 was achieved easily. Unfortunately, ABIM openly disagreed with thousands of signatories, which served only to fuel the justifiable discontent and close the door to reasoned discussion about the flaws of the Maintenance of Certification (MOC) program and what would be a better way to pursue the principle of lifelong learning in the service of our patients.

Here is one of my many concerns: the commenter is probably the tip of the iceberg of a growing recognition amongst medical students and probably college undergraduates that there is something seriously misguided in the ferocious zeal with which regulators oppress doctors.

As I’ve tried to point out to the leadership in the Iowa Medical Society and the Iowa Board of Medicine, this does not bode well for recruiting new physicians to our underserved state.

This is exactly why I’ve promoted supporting lifelong learning, in part by opposing Maintenance of Licensure (MOL) in Iowa. I urge all physicians to encourage leaders in their state medical societies and medical boards to likewise adopt resolutions to oppose MOL.

Another way we can help each other is to create petitions to present to our state medical boards in order to emphasize our dedication to lifelong learning and to preserve our ability to continue to provide high-quality medical and psychiatric care. You can find my petition and I welcome your signatures. I would be more than happy to support other such petitions.

I believe this kind of direct action by physicians stands the best chance of success in resisting the growth of wasteful, expensive processes like MOL, which have no high-level evidence base showing they improve patient outcomes. In fact, one recently published study seemed to cast doubt on the efficacy of MOC programs in this regard: Galliher, J. M., B. K. Manning, et al. 2014. “Do Professional Development Programs for Maintenance of Certification MOC Affect Quality of Patient Care?” The Journal of the American Board of Family Medicine 271: 19-25. See link

Some physicians say that doctors should strike, refuse to engage in MOC processes, and simply not comply with this highly controversial regulatory encumbrance. While I see the point, I’m reminded of the special predicament in which physicians find themselves, which makes mass noncompliance virtually impossible to implement on a broad scale.

Doctors who protest the growing bureaucratic morass engulfing the medical profession by publicly supporting noncompliance often find themselves sharply criticized by those who continue to view us as crybabies. This reaction was evident in the many negative comments following Dr. Daniel F. Craviotto’s article in the Washington Post recently. The public perception of physicians still tends to cast us as wealthy and greedy—ironic to say the least if one views the tax forms of regulatory bodies at link

I publicly oppose MOC and MOL and I remain compliant with it. Why? Because despite the claim by the perpetrators of these processes that they are “voluntary,” MOC is clearly now embedded in credentialing and insurance reimbursement. Many physicians would lose their livelihoods if they didn’t participate in MOC. If MOL is implemented in your state, then your medical license will essentially be tied to participation in MOC or an equally burdensome process.

And then there is our integrity and conscience—the qualities which led us to learn and practice medicine in the first place. The Oath of Hippocrates sealed our dedication to our patients’ health and well-being.

It reminds me of what I read decades ago in a tenant/landlord educational pamphlet when I was an undergraduate. Back then, if you were a student living in an apartment complex to which the landlord was not dutiful about upkeep and repairs yet demanded rent from you (and you had nowhere else to move), your only option was to write on the back of the check, “Paid under duress.”

I view physicians as being under duress with nowhere else to go and required to pay the landlord boards their unfair tax in the form of exam and MOC module expenses, which are frequently not relevant to our practices.

Not every member of the public joins the boards in piling on more burdens for physicians. But how can we engage them? One way is to ask them to complete a survey sponsored by Independent Physicians for Patient Independence.

Surely we could ask patients what they think of MOC, especially since regulators claim that patients are demanding it. I suspect that many of them are unaware of what board certification is and that they choose their physician based on other factors, such as convenience of access.

We all need to creatively explore other options in addition to paying under duress.



  1. Ben Lopez says:

    I agree with the comments above. This is another corruption of the process of life long learning (which itself is essential). My plan is to continue pursuing the life long learning, but not the MOC / MOL tracks. It will probably mean cutting ties with the insurance-medical-industry complex, and a financial loss, and I’m willing to take the ‘hit’. Not necessarily a ‘poor’ choice.

    Perhaps if a significant number of physicians follow this path, a better dialogue may ensue.

    To paraphrase:

    “If you take the King’s penny, you’ll do the King’s work”

    Liked by 2 people

    • Say it, Ben. The quote sounds a lot like “If you dance to the music, don’t you know you got to pay to the piper.” Done by who else but the Chairmen of the Board?


  2. Chelsea Chesen, MD says:

    Ditto, doctor. I am a psychiatrist also compliant with MOC “under duress.” The number of hoops through which one [doctor] must jump year after year in order to simply avoid public shaming (ie. a fall from grace synonymous with one’s board certification status timing out or worse) seems to be increasing at an alarming rate. The very idea that my successful participation in MOC somehow equals my competency to third-party payors (who then honor my competency by questioning every clinical decision I make, forcing me to fill out reams of wasteful forms begging for them to provide that which is the standard of care only to be denied in the name of prior authorizations), is absurd. And the concept that patients demand that their doctors comply with MOC is ludicrous, given that most patients know nothing about board certification or even licensure in the first place. And that patient satisfaction and critique has such a prominent place in the MOC line-up further proves how out-of-control we physicians have become with regard to regulating ourselves. Providing documentation that one’s patient feedback has been responded to with quality assurance upgrades in one’s practice is now required before one is deemed qualified to even sit for one’s recertification exam. When does the madness stop? One late night while studying for my MOC exam recently, I asked myself WHY, when there is already a huge shortage of psychiatrists and when I am already ten times busier than I care to be, am I willing to bow to the ABPN and pay (with time, stress, and money) for their continued endorsement, which is essentially unrecognizable by and worthless to my patients? Oh right…because if I don’t, the insurance companies, whose panels I’ve joined in order to try to keep care affordable to most of my patients, have determined that they require it. And because I don’t want to end up on that list of “crybabies” you mentioned. If we all stand up together and say that we’re “mad as hell and we’re not gonna take it anymore…” the insurance companies will keep us on panel without the MOC nonsense–because we provide medically necessary care to their covered lives…and they need us. Because make no mistake–hear me roar–we are needed! There is job security for us all. For the well-intentioned hard-working physician (especially psychiatrist) out there–autonomy is within reach because we do something valuable and necessary. We will always be needed. MOC or not.

    Liked by 1 person

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