The MOC Civil War: Put the Horse Back in the Barn–Or Get a New Horse?

So here’s some news, including an article in Newsweek about the growing opposition to Maintenance of Certification (MOC), which for tens of thousands of physicians across the United States does not embody the principle of lifelong learning. The controversial MOC has been the subject of countless articles in trade journals and blogs for years; it’s gratifying to see that the issue has finally hit mainstream press. The title of the Newsweek story is “The Ugly Civil War in American Medicine.” Civil war is ugly and all the more lamentable when we could end it if the boards would relinquish their death grip on the Performance in Practice (PIP) and Self-Assessment (SA) modules of the MOC.

The other piece of news is the meeting on March 6, 2015 hosted by the Pennsylvania Medical Society (PAMED) which was attended by leaders in the American Board of Medical Specialties (ABMS) and the American Board of Internal Medicine (ABIM) as well as leaders from many state medical societies.

The YouTube video above shows one side of the debate between leaders of the ABMS and the ABIM.  Dr. Paul Teirstein, who recently started the National Board of Physicians and Surgeons (NBPAS) recently, which is an alternative certification board, suggests that rank and file doctors can “put the horse back in the barn,” meaning we can drive the burdensome and wasteful MOC out and bring Continuing Medical Education (CME) back as the primary means of maintaining certification. The video was recorded at the Association of Professors on Medicine (APM) winter meeting in Laguna, CA on February 26, 2015.

I think Dr. Teirstein makes his point with a sense of humor, which I like. The debate looks a little one-sided because you don’t hear the other side’s arguments. That’s because they have not yet given permission to publicize them as the anti-MOC side did. You have to wonder why.

Or maybe you don’t wonder because Dr. Teirstein’s presentation is so compelling.

This is the third major debate about MOC since 2013, and the victories, not surprisingly, are overwhelmingly given to those who oppose MOC.

I’ve been trying to reform MOC for years now and I’m sending messages to leadership at the American Board of Psychiatry and Neurology (ABPN), as well as leadership at my hospital which I’ve copied below.

“I have a suggestion for adding an alternate specialty certification board to the American Board of Psychiatry and Neuology (ABPN) for credentialing. I understand this has to be reviewed by Joint Commission and NCQA.

I would like to ask you to consider an alternative board which doesn’t require participation in the Maintenance of Certification (MOC). I’ve attached a sort of primer on MOC, published in The Carlat Psychiatry Report (TCPR), TCPR May 2013 .

I’ve corresponded with Harvard neurologist Dr. Paul Mathew about his efforts to persuade the American Board of Psychiatry and Neurology (ABPN) to cancel the Performance in Practice (PIP) and Self-Assessment (SA) modules which are considered very burdensome, see link for his petition http://www.endmoc.com/#.VOVJZX_UPF4.twitter

Dr. Mathew mentions the alternative board, the National Board of Physicians and Surgeons (NBPS), website https://nbpas.org/ . I’ve attached a ppt slide presentation about it. Dr. Paul Tierstein is a cardiologist in California who started an anti-MOC petition that has collected well over 22,000 signatures.

I’ve gotten two proposals to oppose mandatory MOC (see link to IMS journal article on PRS 14-02 http://www.iowamedical.org/iowamedicine/105-1-Iowa-Medicine-Winter/FLASH/index.html?page=14 ) as well as Maintenance of Licensure (MOL) in Iowa adopted through the Iowa Medical Society:

H-275.019: Licensure and Discipline, Maintenance of Licensure IMS supports the continued lifelong learning by physicians and the improvement to quality of practice; opposes the institution of Maintenance of Licensure for those physicians who are board certified and/or maintaining relevant CME and peer-reviewed quality of practice and/or participating in Maintenance of Certification; and opposes further Maintenance of Licensure implementation for all other physicians without sufficient supportive data demonstrating that the Maintenance of Licensure program supports patient outcomes and improves quality of care. H-2013 as entered in the IMS Policy Compendium 2014.

Because I think it’s unlikely that the ABPN will modify the MOC, I’m requesting the UIHC credentialing office to pass this message on to the appropriate committees to consider accepting the NBPAS as an alternative certification body. It’s weakness is that it’s a young grass roots movement which is still working on getting validation from third party payers and hospital credentialing committees. Its strengths are its support from a growing number of high-profile physicians across the country and the lack of high-level research evidence supporting the MOC as it stands.

I teach medical students and residents every day about the importance of the principle of lifelong learning and the need for the next generation of doctors to cultivate a systematic way of integrating it into their professional lives. Many physicians like me don’t believe MOC as it’s designed by the ABPN embodies the principle.”

So probably the “appropriate committees” who are in the position to decide on this would be the NCQA and the Joint Commission.

It’s a long shot but worth a shot. Can we or do we want to put the horse back in the barn–or do we want a new horse?

So what would a new horse look like? I think it should be an activity that doctors believe is relevant to their practices. I also think it should be at least at low cost, preferably free, fast, and available on line.

It could be something like our Clinical Problems in Consultation Psychiatry (CPCP). A splendid example would be the CPCP done by medical students just yesterday on antidepressants and short bowel syndrome. All of the residents and medical students I talk to about the MOC do not look forward to having to cope with it. I tell them that even a geezer like me has to comply with it for now–and I may have to until the day I retire, which may not be that far off. So why do I beat the drum so hard? I want my trainees, the next generation of doctors, to know I stood up for them.

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Comments

  1. I guess some people believe the ABPN MOC is acceptable and psychiatrists have no issues with it. Think again. See the Medscape article entitled “Psychiatrists: No Problem with MOC?” in which past APA President Carol Bernstein suggests exactly that in the tweet below (registration is free to read the article):

    Now see the deidentified comments so far (mine is obvious, of course):

    “I am a past president of my state psychiatric society and remain active. One of our perennial woes has been the question of how to increase our membership. Well here is our answer. If the APA and state societies promised to fight against the ridiculously confusing and unnecessary MOC requirements of the ABPN, you would have every psychiatrist in the country writing a big fat check.”

    “Well, I disagree with Dr. Bernstein so thoroughly I doubt that the comment section has enough space in it for what I have to say. I have not renewed my APA membership this year because I don’t think the $981 fee and the lack of representation of my interests is worth the trouble.
    I have personally authored resolutions to support the principle of lifelong learning and oppose both MOC and its cousin Maintenance of Licensure (MOL) and they have both been approved by the Iowa Medical Society.
    I’m also inquiring into our credentialing department to see if our university would accept adding the alternative board recently started by Dr. Paul Tierstein, the Nation Board of Physicians and Surgeons, because it doesn’t require participation in the MOC.
    I teach medical students and residents every day about the importance of the principle of lifelong learning and the need for the next generation of doctors to cultivate a systematic way of integrating it into their professional lives. MOC is not the way.
    All of the residents and medical students I talk to about the MOC fear it.So why do I beat the drum so hard? I want my trainees, the next generation of doctors, to know I stood up for them.
    You’re welcome to view more of my thoughts about the inanity of MOC and MOL on my blog site at
    https://thepracticalpsychosomaticist.com/

    “A lot of “hysteria”? What an arrogant, dismissive remark. Dr Bernstein, whatever her titles may be, is obviously not close enought to the psychiatric community to feel its pulse, but perhaps it is so much the better for her. A bit too close and an errant fist may run into her nose.”

    “If it is true that psychiatrists have not loudly complained about the MOC program, that does not mean that they accept it. I certainly don’t. I am grandfathered in the general boards but subject to MOC for my speciality board. In my first experience with MOC, I have found it burdernsome, expensive and the time and effort that the SA credit and PIP activities require actually distract me from meaningful self-study, my work, and make me angry. I spent hours first trying to figure out what I needed to do, got conflicting information from the APBN and then many more fulfilling requirements. I can frankly say that none of this activity improved my knowledge or skills, or would affect quality more than the usual CE activities. If I did not need to maintain certification (or feel that I do) as a forensic expert, I would drop the certification. The APBN needs to continue to walk this way back and stop the power and money grab.”

    “MOC is an overly burdensome money grab by ABMS and their co-conspirator parent the ABMS. There is no scientific basis to support their ever evolving requirements.”

    “Most psychiatrists don’t take insurances so they could at least economically afford to do all this nonsense ( just an old primary doctor comment).”

    “The big picture is that we need to figure out a good way to let people know we’re staying up to date in our field. But when you get down to the details, having to count your CME credits and review your charts and do a patient satisfaction survey can make people frightened.”
    I thought the big picture was to contribute to a better educated and therefore more effective doctor….not a mere display to the public that “we are staying up to date”
    The flaws in the logic here are substantial and time precludes me from providing additional comments (I am busy trying to get my colleagues/patients to respond to my requests for Feedback Forms and researching which companies have secured ABPN approval for CME). Maybe Certification with the National Board of Physicians and Surgeons is not such a bad idea.”

    “If you ask any physician, ‘Do you really care about quality of care for your patients and staying up to date in your field?,’ I think they would all say, ‘Yes.’ We want to be good doctors. We want to take good care of our patients. But the question is, who’s going to monitor that?”
    Isn’t that really up to the patient population to determine? Further, if a body is given the responsibility of “monitoring” how or what it takes to be a good physician, who is “monitoring” that body? If the governing body offers dictats that must be followed by it’s constituents it should, in the very least, provide sound reasoning fore such mandates…The potential conflict of interest here is substantial.”

    “Well, here’s one psychiatrist saying it’s burdensome and not needed.”

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