Sinko de MOC Mojo On Cinco de Mayo

Happy Cinco de Mayo out there and welcome to today’s post which is about one of the more recent MedPage Today articles about Maintenance of Certification (MOC).

So far, there are just a few comments at the end of that article, one of which is mine in which I highlight that the MOC debate goes way beyond the American Board of Internal Medicine (ABIM) image problems and major missteps:

The MOC controversy is spreading across medical specialties. Last week, a radiologist in private practice who sits on my state medical society’s board of directors asked for my advice on how to make the case for opposing MOC to the American College of Radiology at its upcoming national House of Delegates meeting in Washington, D.C. He supports the principle of lifelong learning while opposing MOC as a poor working model of the principle and a disruptive element in our health care system, serving mainly to intimidate doctors, giving the impression that greed is the main driver for imposing this non-evidence-based process on American physicians.

Outgoing president of the American Academy of Neurology, Dr. Tim Pedley, devoted about 7 minutes of his presidential plenary lecture to the MOC controversy (especially Part IV) at the AAN annual meeting in Washington, D.C. last month, highlighting the burdens for neurologists, also mentioning the American Psychiatric Association opposition to Part IV of the American Board of Psychiatry and Neurology MOC program.

The ABPN President and CEO has publicly recommended to the ABMS to make Part IV optional, which would significantly reduce the busywork aspect of MOC largely because few frontline doctors would choose to participate in it. ABMS is not listening.

That’s the problem. There’s no oversight authority above the ABMS which would prevent the imposition of burdensome regulatory policies driven by short-sighted physician executives most of whom are not in clinical practice, as pointed out by Dr. Charles Cutler at the MOC  debate on December 2, 2014 hosted by the Philadelphia County Medical Society.

No wonder doctors hope the National Board of Physicians and Surgeons will be vetted. It’s another expression of grass roots constructive activism against the Goliath ABMS, which has lost its legitimacy as a leader.

There’s a 300 word limit on comments which made it impossible to flesh out the argument I try to make with links to pertinent events that you can find on the web. I’ve posted Dr. Pedley’s YouTube video in another post  (along with a link to the December MOC debate in Philadelphia). I think it’s worth mentioning again because he’s a prominent physician leader and gives well-balanced remarks on the MOC issue as it relates to neurologists. The remarks are also broadly applicable to the MOC controversy for thousands of other subspecialty physicians, including psychiatrists, not just because the relevant board is the American Board of Psychiatry and Neurology (ABPN).

What some readers might not catch about the David and Goliath allusion actually comes from a previous post  as well as another connecting the failure of the American Board of Medical Specialties (ABMS) to project an image of itself as a responsible leader to rank and file doctors in America to the book “David and Goliath” by Malcolm Gladwell [1]. It’s tough to talk about the limits of power of the boards because, at the moment, their power seems almost limitless.

According to Gladwell, the principle of legitimacy is connected to the perception of a powerful leader or group (say a government or medical certification board) and it rests on 3 basic premises:

  1. Whenever we’re asked to obey an authority, we like to feel like we have a voice in the matter. We want to be heard. Other than the apology by ABIM President and CEO “Rich Baron” (and I thank whoever came up with that spin on his real name) hardly any doctors feel heard right now.
  2. The law that the authority is proposing should be more or less predictable. Many current diplomates live in fear that the continually evolving rules of MOC will leave them without a valid certificate, which they need to make a living.
  3. The authority has to play fair and can’t treat one group differently from another. Read “grandfathering” here.

While diplomates study for recertification exams peppered with questions irrelevant to their practices, the boards are flunking a crucial test of their credibility. They need to get in touch with the people because they’re acting like Big Brother, guaranteed to elicit hostility and reactive opposition from the proletariat. If this sounds political, you’re getting the point exactly because this debacle is driven by politics–not by science.


1. Gladwell, M. (2013). Rosemary Lawlor: “I wasn’t born that way. This was forced upon me.”. David and Goliath: Underdogs, Misfits, and the Art of Battling Giants. New York, Little, Brown and Company: 197-231.

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