The Geezer is “Not Meeting MOC Requirements”

I enjoyed reading Dr. George Dawson’s recent blog post on Maintenance of Certification (MOC) in which he supports the principle of lifelong learning while questioning the American Board of Medical Specialties (ABMS) attempt at modeling the principle, known as MOC. I applaud his decision to participate in the alternative certification board, the National Board of Physicians and Surgeons (NBPAS).

I have supported the position of Dr. Paul Teirstein, MD, one of the leading physicians spearheading NBPAS, and I’ve recommended that the University of Iowa Hospitals and Clinics (UIHC) consider accepting NBPAS as an alternative to the ABMS MOC. Three Iowa hospitals already do so.

I’ve also completed two surveys recently, requesting feedback about MOC, one of them written by the ABMS and the other from Dr. Westby Fisher. I suggest any physicians interested in providing feedback about MOC complete both. This is not the first time I’ve provided feedback to the ABMS about MOC.

As most of my readers and trainees know, I’ve been in phased retirement and expect to be fully retired by 2020. Because of that, I’ve decided not to seek continued certification through either NBPAS or ABMS. I chose not to pay the fee required by the American Board of Psychiatry and Neurology (ABPN) to sit for the recertification examination. Consequently, that has resulted in my being identified as “Certified” although “Not Meeting MOC Requirements.” This is data about me as a physician which is readily available to the public and other organizations. I think it’s unfortunate that it tends to convey the impression some physicians are less qualified than others based on their certification status alone.

I’m aware that declining to sit for what would have been the last MOC recertification examination in my career might not be viewed as much of a protest, especially in an academic medical center which so far has not required MOC participation or, for that matter, board recertification, as a condition for clinical privileges.

All I can say in reply is maybe that should prompt some to question the importance of MOC if highly ranked university medical centers seat credentialing committees which continue not to insist on MOC participation by the talented and highly qualified researchers and clinician educators they continue to recruit and retain.

I’m also aware that many physicians are not in a position to decline participation in MOC. Some organizations and health insurers demand it, prompting several physicians and state legislators to collaborate toward adopting or consider adopting laws to discourage it.

To be fair, MOC is often not the only criterion that organizations use to ensure patients are getting the best health care available. And there are many who work diligently to improve the MOC process and believe it works (Pato, Brooks, Tieder, Stoff). Enhancing the motivation for physicians to participate in MOC is complicated and needs to consider different practice environments, physician burnout, and financial incentive programs which have typically attracted few physicians overall (Glover).

It’s difficult to find much information on PubMed about MOC, whether you search using the Most Recent or the Best Match filter. In both, I found a paper by two doctors which appeals to my sense of humor as well as to my sense of fair play. The first author is a Singapore physician, for whom the dollar cost of recertification was over $10,000. His nerves took a beating as well as his bank account. Speaking of banking, here is the authors’ final observation:

Physicians should be able to choose a programme that best fits their scope of practice. However, it is likely that, besides the efforts put in by physicians themselves as a commitment to professionalism, the economic price will be borne by patients in the name of public assurance of medical competence and safety. If the burden becomes too onerous, one can always become a banker.— Teo, B. W. and S. Subramanian (2015). “Maintenance of certification: the price of medical professionalism is $10,108.05, two weeks leave and five white hairs.” Singapore Med J 56(4): 181-183.

“It is far better to light the candle than to curse the darkness”—attributed to William L. Watkinson in a 1907 sermon according to Quote Investigator.


Pato, M. T., et al. (2013). “Journal club for faculty or residents: A model for lifelong learning and maintenance of certification.” International Review of Psychiatry 25(3): 276-283.

Brooks, E. M., et al. (2017). “What Family Physicians Really Think of Maintenance of Certification Part II Activities.” J Contin Educ Health Prof 37(4): 223-229.

Tieder, J. S., et al. (2017). “A Survey of Perceived Effectiveness of Part 4 Maintenance of Certification.” Hosp Pediatr 7(11): 642-648.

Stoff, B. K., et al. (2018). “Maintenance of Certification: A grandfatherly ethical analysis.” Journal of the American Academy of Dermatology 78(3): 627-630.

Glover, M., et al. (2017). “Participation and payments in the PQRS Maintenance of Certification Program: Implications for future merit based payment programs.” Healthcare.

Teo, B. W. and S. Subramanian (2015). “Maintenance of certification: the price of medical professionalism is $10,108.05, two weeks leave and five white hairs.” Singapore Med J 56(4): 181-183.



Here’s my first post for the new year and it’s about perspective. I got the idea while griping about the cold weather we’ve had for the past few days. I had to enlist the aid of two of our Consultation-Liaison Psychiatry mascots to keep an eye on the office thermostat.

The thermostat controls the temperature in two offices. I say “controls” with tongue-in-cheek. Note the thermostat setting. Note also that it doesn’t feel like 75 degrees in our offices–take my word for it.

It’s pretty cold outside, but just for perspective, I asked Winston, our main mascot, to find an old article on a pretty tough winter in Iowa, back in 1935 (Knauth, Otto W. “The Winter of 1935-36.” The Annals of Iowa 35 (1960), 288-293. Available at: There were conflicting messages about the copyright status of the article (from no known copyright restrictions to copyright violators will  be shot on sight), which Winston found just by googling.

You know it’s cold when Knauth says “the coal crisis continued with reports of isolated persons burning corn and even furniture to keep warm. At Vinton, police patrolman Jack Bingaman, wearied of repeated thefts of coal, warned that henceforth he would “let the doctor find out” who the thieves were.” A brand new diesel streamliner had to be towed from Clinton to Chicago by a steam locomotive. There were hundreds of cases of frostbite. Animals were frozen standing up. It killed over 20 people by early February.

It doesn’t seem so cold now.

Compare the perspective on health care a surgeon gained by getting so sick herself that she needed to be in the intensive care unit. As a physician trained the way most of us are, she thought the patient care and communication skills doctors learned in training was sufficient. As a patient, she got a different view of the situation, and became a leader in trying to change the culture of medicine. Another perspective-taking exercise is developing a culture of access to all in the academic community, including those with mental disabilities. The question is not “can we?” modify how we educate physicians and faculty–but “will we?”

Empathy in the sense of walking a mile in another person’s shoes is important.

Especially if the walk is likely to result in a bad case of frostbite. Happy New Year!

Happy Holidays from the Retiring Geezer

I noticed a JAMA Network title today, “Is It Time to Retire?” I say title because I couldn’t access the piece itself, probably because I’m not registered with JAMA Network. However, the title fits with my current situation because I’m in phased retirement. I found a podcast based on the article, which was published in the April 18, 2017 issue of JAMA. It was about how difficult it is for physicians to make the decision to retire and the role of sometimes unrecognized decline in cognitive and technical skills with advancing age. I was mildly annoyed with the implied reference to Maintenance of Certification (MOC) credit. One of the persons interviewed was a representative from the American Board of Psychiatry and Neurology (ABPN). She dropped a line about the American Board of Anesthesiology MOCA Minute.

By the way, a colleague asked me what I thought about the new ABPN alternative to the high stakes 10 year recertification examination. The MOC pilot  allows diplomates to complete repeated self-assessment activities based upon specific literature references selected by a committee of peer diplomates. I asked what the ABPN would charge for it. It would be the same. It is still all about the money. I told her that I’m retiring and that I do not plan to participate in MOC anymore. I have one more recertification exam and I’m close enough to full retirement that I don’t think it’s worth the money or the time to sit for a test full of items not relevant to my practice.

Here’s an irony; go to the ABPN website and try to find the one MOC module that would be appropriate for Consultation-Liaison (C-L) Psychiatry. You’ll probably be frustrated so just look here to find the delirium learning activity. It was an attempt by Dr. Emily Morse and I to finally make the ABPN MOC mean something practical for general hospital psychiatrists–and it just happens to be relevant to the practice of internal medicine and surgery as well.

Then I read Dr. Meg Edison’s post, “My MOC Failure.” My first feeling was fear, then disgust that I should have to feel afraid of certifying board organizations which have no accountability to dedicated, hard-working physicians for promoting an unproven method for fulfilling the practice-based learning and improvement competency.

I also noticed Dr. Westby Fisher’s recent post,  saying that MOC is officially “dead.” However, it’ll probably just evolve into something less obviously sinister but just as expensive and will still waste physicians’ time.  This reminds me of a quote attributed to Dogen: “A flower falls even though we love it; and a weed grows, even though we do not love it.”

But this is turning into my usual rant against MOC. Hey, it’s Christmas and let’s return to the original topic of retirement. Everyone asks me “What are you going to do?” as though retirement is about not doing anything. It’s a fair question, to which I don’t have an answer yet. I used to do bird-watching.

As I usually do, I searched the medical literature. It turns out there is not a lot written about physician retirement. You almost have to google the question, which is often a crap shoot in terms of actually finding any useful information. The bottom line seems to be it is just damn hard to quit being a doctor. We spend the greater part of our youth and young adulthood scrambling to get into medical school, find out about the corrosive effect on empathy and other abuses of the hidden curriculum but soldier on because of the accumulated student loan debt, ignore the one or  two lecture format classes about the importance of saving for retirement in a career that is shorter by about a decade on average than other professions, drive ourselves through the brutal call schedules of residency, choose between private practice or academic careers where the drum beat of competition and the increasing complexity of regulatory, payor, and political pressures keep us postponing whatever else non-medical could be happening in our lives until the best theme song for us would be “Cats in the Cradle.”

Sadly, a few doctors do quit in the ultimate way, by suicide. My work is not my life. I am opposed to anything giving the message that your work is your life to any trainee, colleague, and friend.

What is the answer to the question “Is It Time to Retire?” I catch myself getting garrulous, repeating the same cobwebbed anecdotes about what a C-L psychiatrist does when I’m doing formal and informal teaching. That turns up as feedback from trainees–“too anecdotal” I mean. My content knowledge about things I never see is low–although my experience and communication skills about the many moving parts of our health care system has steadily grown over the years. Since I’m basically the only C-L psychiatrist here, I catch myself wondering about the meaning of institutional memory and how that might apply to a person who is as vulnerable as the mountain is to erosion.

There are clues letting me know that it’s high time to go. I just renewed for the umpteenth and probably the penultimate time my Basic CPR competency. My teacher was very kind and so was my partner as I struggled with getting an adequate seal of the respirator mask on the dummy’s face. I confess, I’m better at giving rescue breaths without the masks. But the masks are mandatory equipment now. I asked for more opportunities to practice during the class and could just barely get it. Imagine how hard that is on a physician’s ego. I was very pleased to learn the new emphasis on teamwork in giving CPR, which is a welcome change. I can do another task other than rescue breathing with the mask. I don’t have to be the leader–something most doctors feel entitled to because that has been the expectation. And I didn’t know that we’re now getting electronic cards from the American Heart Association. I’ve been used to the paper pocket card. It took me a little while to figure that one out.

I’m moving slowly away from memberships in professional organizations, department meetings, taking on new projects. It’s a long goodbye. Most of the memories are good and I’m grateful. I’m just a little stuck on what I’ll be moving toward.

My wife, Sena, says that I’ll do more of the cooking. I’m collecting recipes–and staying out of the kitchen for now, which I know is not the way to learn. Corn flakes are my specialty.

I’ll be on duty at the hospital over the holiday weekend. That means I’ll get a break from wondering about the recipe for a good life after retirement. Happy holidays!

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Odds And Ends Today

Odds and ends today. There is a new message from Bev about the Mindfulness programs at Iowa and it begins with a nice quote:

It only takes a reminder to breathe,

a moment to be still, and just like that,

something in me settles, softens,

makes space for imperfection.

The harsh voice of judgment

drops to a whisper

and I remember again that

life isn’t a relay race;

that we will all cross the finish line;

that waking up to life is what

we were born for.

As many times as I forget,

catch myself charging forward

without even knowing

where I’m going,

that many times I can

make the choice

to stop, to breathe and be,

and walk

slowly into the mystery.

-Danna Faulds

The UIHC Mindfulness programs including but not limited to Mindfulness Based Stress Reduction (MBSR) have been in the news recently. An article on the Big Ten Network by John Tolley about a month ago, entitled “An Iowa Group Promotes ‘Mindful’ Management of College Stress: BTN LIVEBIG,” aims to bring mindfulness to college students to help them deal with the stresses of university academic life. The Mindfulness program coordinator, Kerri Erness-Potter, M.A. is the faculty advisor for Mindful@Iowa and as an adjunct faculty member in the College of Education teaches a course on the subject. One of her main messages is that “Our bodies are constantly telling us things, but most people are just pushing through the day, and unless something is throbbing or screaming at them–they ignore it. Mindfulness is about being in the present.”

Mindfulness Mid-Week Meditation is held over the noon hour at the UI Stead Family Children’s Hospital Meditation Room on Level 12 and it’s organized by the UIHC Chaplains. Mindfulness meditation has been offered by the MBSR staff on the fourth Wednesday every month. It’s open to the public.

Lately, people have been trying to return a camp stool to me (my little chair), thinking that I had lost it. I have not. This has become a bit of an adventure with Safety and Security officers trying to hunt me down to return a camp stool that doesn’t belong to me. They sort of leaned on one of our psychiatry staff nurses to reveal my whereabouts. Even under the hot lights, she refused–and then thought this sacrifice deserved a special donuts reward. I was only too happy to oblige.

I’ve had the camp stool for about a year and a half now and rarely forget it on the wards. Patients and families get a big kick out of it–a doctor who carries his own chair. It was a gift from a colleague in Palliative Care, Dr. Timothy Thomsen, who along with others, is now trying to persuade me to co-author an editorial or letter to the editor to some journal about our camp stool fraternity. The lost stool belonged to another member of the Palliative Care service. Tim describes the idea behind the chair so much better than I ever could, I’ll just quote him:

“…the impact of the stool upon families and patients is profound and it seems to convey a caring and humanism which is absent when we stand or sit some distance away.  “I care about you and want to get close to you so you know that I do.”  It speaks to your willingness to be vulnerable.”–Dr. Timothy Thomsen.

I’ve also just heard that at the medical student mid-clerkship meeting, there is a consensus that the psychiatry department should issue stools to every medical student. This message was copied to the acting department chair. No pressure.

Patients still sometimes mistake my camp stool for nunchucks (“I’ll be good, Doc!”). Happened again today (“Darn tootin’ you’ll be good!”).

We’ve been pretty busy on Consultation-Liaison Psychiatry service lately. By the way, the American Board of Psychiatry and Neurology (ABPN) sent a notice the other day about the name change thing for the specialty:

“Based on requests from practitioners in the field, the name of the ABPN subspecialty of Psychosomatic Medicine will change to Consultation-Liaison Psychiatry, effective January 1, 2018.

ABPN believes that this name change better describes the discipline’s key focus of treating behavioral conditions in patients with medical and surgical problems.”

And will the ABPN soon drop the Maintenance of Certification (MOC) requirements as well? Wait and see if you want. It won’t happen before I retire I’m sure. It would sure make a nice retirement gift, much better than a gold watch.

As I was saying, we’ve been pretty busy.  I put about 2-3 miles and 20-30 floors every day on the step counter installed on my smartphone. It’s been hard on our mascot, Winston:

Not to worry–ran him down to the gift shop today and he’s just fine.

News Flash: Retiree Fooling Around With Painted Ladies

As many of you know, I’m adjusting to phased retirement. It’s reminding me of Stephen Covey’s The 7 Habits of Highly Effective People Signature Program I took about nine years ago. It was a time when I was negotiating a major change in life. It was focused on work.  I now have a new perspective on Covey’s Time Matrix:

I got a message from a colleague asking me what I thought about the decision by the American Board of Psychiatry and Neurology (ABPN) recently to make changes in their Maintenance of Certification (MOC) program. The biggest change is a proposal to offer an alternative to the recertification examination, similar to the proposal by The American Board of Pediatrics.

The ABPN alternative will offer a choice to complete repeated self-assessment activities based on specific literature references selected by a committee of peer diplomates.

I suspect the ABPN will charge just as much for it as the recertification examination. I’m not impressed and do not plan to participate, which my personal Time Matrix indicates.

I’m not as focused on work right now. As a psychiatric consultant, I spend a lot of time in Quadrant I; that is, in activities that are both urgent and important.

What I’m faced with now is learning how to be more comfortable spending time in Quadrant II.

My wife, Sena, says I’llbe doing more of the cooking. I hope she likes pot pies or beans and fried sway-back nematodes. They’re an acquired taste.

I’m not a gardener, but I like what Sena does in the garden. I get curious about what I see out there, such as what kind of butterflies are swarming around our Hyssop.

I just learned that Hyssop is one of those plants with some medicinal properties. It also smells like licorice. At least that’s what Sena says. Around this time of year, I tend to sneeze at anything that even looks like it might be ragweed, no matter what color it is. So I’m not about to take a snort of anything that might pollinate.

Anyhow, I’m not a naturalist by any stretch. But I think the butterflies after the Hyssop are probably Painted Ladies, not Cloaks. See what you think.

Maintenance of Certification: Point-Counterpoint

By now, many doctors have seen the JAMA viewpoint article in support of Maintenance of Certification (MOC) but you might have missed the rejoinder on MedPage Today. See my tweet below:

I read the JAMA viewpoint by Dr. Welcher and colleagues and I was trying to think of a response. Then I discovered the MedPage article “State Legislatures Wade Into MOC Debate” by Cheryl Clark. Supporters and opponents of MOC have, of course, been talking past each other for the last decade.

This reminds me of a point I tried to make about negotiating in Consultation-Liaison Psychiatry and in politics a few days ago based on a paper recently published in Psychosomatics (Siegel, A. M. and H. R. Bleier (2017). “The Role of Negotiation in Consultation-Liaison Psychiatry.” Psychosomatics 58(2): 187-190). This was linked to case report which highlighted the use of negotiating tools promoted by authors Fisher, Ury, and Patton in their book “Getting to Yes: Negotiating Agreement Without Giving In.” The companion book often cited along with it is “Difficult Conversations: How to Discuss What Matters Most,” by Stone, Patton, and Heen. Surprisingly, both books are available on line in their entirety. Isn’t there a copyright law against that?

I suppose this approach could be applied to the MOC debate. While I’m not the best person to be a cheerleader for it, given that I’ve been a regular critic of everything about MOC, it still makes sense to try to listen to the other side and be aware of one’s own confirmation bias. What makes me more aware of this is the constant bombardment of readers and viewers of the rampant political divisiveness by journalists who are themselves politically biased.

Now add to that a very interesting special article in the Spring 2017 issue of The Journal of Neuropsychiatry and Clinical Neurosciences:

Mario F. Mendez (2017). “A Neurology of the Conservative-Liberal Dimension of Political Ideology.” J Neuropsychiatry Clin Neurosci 29(2): 86-94.
Differences in political ideology are a major source of human disagreement and conflict. There is increasing evidence that neurobiological mechanisms mediate individual differences in political ideology through effects on a conservative-liberal axis. This review summarizes personality, evolutionary and genetic, cognitive, neuroimaging, and neurological studies of conservatism-liberalism and discusses how they might affect political ideology. What emerges from this highly variable literature is evidence for a normal right-sided “conservative-complex” involving structures sensitive to negativity bias, threat, disgust, and avoidance. This conservative-complex may be damaged with brain disease, sometimes leading to a pathological “liberal shift” or a reduced tendency to conservatism in political ideology. Although not deterministic, these findings recommend further research on politics and the brain.

Needless to say, the authors acknowledge the many limitations of generalizing from the limited literature on the topic. But it’s fascinating, nevertheless, to think we may be hardwired to be hard-nosed. If our political views are lateralized in the brain, maybe that’s what gives us “political-handedness” that makes us more likely to say “Talk to the hand!” to those who disagree with us.

It’s isn’t far-fetched to compare the MOC controversy with liberal vs conservative battles. Recall the origin of the model legislation against MOC? We owe that to what some would call the right-leaning Association of American Physicians and Surgeons (AAPS). Incidentally, current Secretary of Health and Human Services R-Tom Price is a member of the AAPS–and was criticized by some journalists for that.

What if opponents and supporters of MOC actually sat down and talked to each other instead of past each other? I’ve always supported the principle of lifelong learning. I just don’t think MOC embodies the principle well enough. And let me point out that there are conflicts of interest in at least one of the authors of the JAMA MOC supporter article:

“Dr Hawkins reports being the co-editor of a textbook on the evaluation of clinical competence for which he receives royalties from Elsevier; being a salaried employee of the American Board of Medical Specialties from February 2009 until December 2012.”

Does that completely invalidate their position? Many would say so based on the millions of dollars the MOC machine makes for board members. See how easy it is for me to fall into the anti-MOC tirade? I’ve been doing it for years.

On the other hand, I agree that patients deserve to know their physicians are keeping up with medical knowledge and skills. I don’t understand where the evidence is which supports private insurers requiring participation for reimbursement. I applaud boards for at least trying to make the MOC processes less burdensome. However, even the AMA has adopted a policy that sounds very similar to those being approved by many state medical societies:

“Any changes to the MOC process should not result in significantly increased cost or burden to physician participants (such as systems that mandate continuous documentation or require annual milestones).

The MOC program should not be a mandated requirement for state licensure, credentialing, reimbursement, insurance panel participation, medical staff membership, or employment.”

How do we get to yes?

Separate the people from the problem–You don’t have to be a conservative or a liberal to love or hate MOC. The issue is how do doctors, young and old, engage genuinely in lifelong learning and reflective personal practice assessment?

Focus on interests, not positions–Would focusing on our mutual interests include how to make sure we’re paying attention to developing all the attitudes, knowledge, and skills that help doctors help patients heal and thrive?

Generate options for mutual gain–Would it make sense to validate other methods as alternatives to MOC for staying competent and achieving excellence as physicians, being role models for medical students and residents, and acting as empathic, humanistic clinicians?

Agree on using objective criteria–What would be acceptable to patients, doctors, and regulatory boards to use as objective markers for successful application of medical core competencies as identified in the medical literature?

Sound good? Down with MOC! Oops, sorry, that was a slip. Let’s all calm down and contemplate what happens in the natural world where politics doesn’t matter and survival does.

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Open Letter to Iowa Lawmakers Supporting Legislation Opposing MOC

The Iowa Medical Society (IMS) will soon be voting on a new resolution to oppose Maintenance of Certification (MOC) and preserve the principle of lifelong learning. It will entail pursuing the help of Iowa lawmakers in the pursuit of legislation toward clarifying what MOC should not be used for. I support it and acknowledge my bias as well as respect the opinions of colleagues who do not share my views on MOC. Below is my letter to my congressmen. You are free to disagree with it and should you wish to express dissenting comments, I will share them.

Dear Sirs:

I support the Iowa Medical Society (IMS) policy resolution proposal urging state legislators to introduce a bill opposing the American Board of Medical Specialties (ABMS) Maintenance of Certification (MOC). ABMS created MOC and made it a requirement for certification under their trademark and which member specialty certification boards are required to support) MOC. The IMS proposal reads as follows:

“IMS shall pursue legislation to prohibit the imposition of a requirement that a physician secure Maintenance of Certification (MOC) as a condition of licensure, hospital privileges and reimbursement from third party payers.”

The IMS will vote on the resolution at their annual meeting April 28, 2017. A similar law was passed in Oklahoma in April 2016. This legislation is being considered by 10 other states. Moreover, 20 state medical societies have adopted resolutions opposing MOC.

I submitted the original IMS proposal for supporting continued lifelong learning and opposing Maintenance of Licensure (MOL) in 2013, which was adopted into IMS Policy as 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.”—IMS Policy Compendium.

I also submitted PRS 14-02 opposing Maintenance of Certification to the IMS Policy Forum in 2014, which was also adopted, PF-275.020:

“IMS opposes mandatory Maintenance of Certification (MOC) for licensure, hospital privileges, and reimbursement from third party payers. IMS supports continuing medical education and the principle of lifelong learning by physicians.”—IMS Policy Compendium.

Not everyone agrees with the IMS Policy resolution suggestion above and think pursuing legislation is the wrong way to go. Some believe that it’s the responsibility of physicians to decide on what the standards should be for medical specialty certification and that patients have a right to know whether their doctors are keeping their skills and knowledge up to date. It’s also been suggested that if physicians have problems with the structure and processes of MOC, they should simply work with the ABMS.  A paper has been cited which was written by the President and CEO of The American Board of Pediatrics in support of this position—(Nichols, D. G. (2017). “Maintenance of Certification and the Challenge of Professionalism.” Pediatrics).

I hardly think it’s an unbiased opinion, but I respect it and acknowledge my bias as well. I concede the point that physicians should set the standards and patients should know we are doing that, but I think we’re capable of doing that for ourselves.

In my opinion, rank and file physicians are turning to legislation because they don’t think the ABMS and member specialty certification boards are trustworthy. The American Board of Internal Medicine (ABIM) has been the subject of controversy for quite some time in this regard (see Dr.Wesdotblogspotdotcom). Further, according to Charles Cutler, M.D., M.A.C.P., in the winter 2016-17 issue of Philadelphia Medicine, Philadelphia County Medical Society, in an issue entitled “Is The ABIM Too Broken to Fix?” article “A Message to the ABIM: Reign in Spending and Stop Turning Staff into Millionaires,” reforms should in fact include doing just what the title says and much more (Cutler, C., MD, MACP, A message to the ABIM: Reign in Spending and Stop Turning Staff into Millionaires, in Philadelphia Medicine: The Official Magazine of the Philadelphia County Medical Society Philadelphia Medicine 2016, Hoffmann Publishing Group, Inc.).

I realize that some specialty certification boards are making special efforts to improve the MOC process and The American Board of Pediatrics is one of them. However, MOC is controversial. Based on a recent survey of physicians, MOC is not an effective or practical way to support lifelong learning for doctors (Cook, D. A., et al. (2016). “Physician Attitudes About Maintenance of Certification.” Mayo Clinic Proceedings 91(10): 1336-1345.):



To determine physicians’ perceptions of current maintenance of certification (MOC) activities and to explore how perceptions vary across specialties, practice characteristics, and physician characteristics, including burnout.

Patients and Methods

We conducted an Internet and paper survey among a national cross-specialty random sample of licensed US physicians from September 23, 2015, through April 18, 2016. The questionnaire included 13 MOC items, 2 burnout items, and demographic variables.


Of 4583 potential respondents, we received 988 responses (response rate 21.6%) closely reflecting the distribution of US physician specialties. Twenty-four percent of physicians (200 of 842) agreed that MOC activities are relevant to their patients, and 15% (122 of 824) felt they are worth the time and effort. Although 27% (223 of 834) perceived adequate support for MOC activities, only 12% (101 of 832) perceived that they are well-integrated in their daily routine and 81% (673 of 835) believed they are a burden. Nine percent (76 of 834) believed that patients care about their MOC status. Forty percent or fewer agreed that various MOC activities contribute to their professional development. Attitudes varied statistically significantly (P<.001) across specialties, but reflected low perceived relevance and value in nearly all specialties. Thirty-eight percent of respondents met criteria for being burned out. We found no association of attitudes toward MOC with burnout, certification status, practice size, rural or urban practice location, compensation model, or time since completion of training.


Dissatisfaction with current MOC programs is pervasive and not localized to specific sectors or specialties. Unresolved negative perceptions will impede optimal physician engagement in MOC.”

Even the American Medical Association (AMA) has a policy which reads:

“Any changes to the MOC process should not result in significantly increased cost or burden to physician participants (such as systems that mandate continuous documentation or require annual milestones).

The MOC program should not be a mandated requirement for state licensure, credentialing, reimbursement, insurance panel participation, medical staff membership, or employment.”

There is no compelling research evidence showing that MOC participation improves patient outcomes:

(Hayes, J., et al. (2014). “Association between physician time-unlimited vs time-limited internal medicine board certification and ambulatory patient care quality.” JAMA 312(22): 2358-2363– Among internists providing primary care at 4 VA medical centers, there were no significant differences between those with time-limited ABIM certification and those with time-unlimited ABIM certification on 10 primary care performance measures. 

(Gray, B. M., et al. (2014). “Association between imposition of a Maintenance of Certification requirement and ambulatory care-sensitive hospitalizations and health care costs.” JAMA 312(22): 2348-2357. — Imposition of the MOC requirement was not associated with a difference in the increase in ACSHs but was associated with a small reduction in the growth differences of costs for a cohort of Medicare beneficiaries.

The growing opposition to MOC is so deep and broad that an alternative board has been created to provide another choice for physicians who need or want board certification. This is the National Board of Physicians and Surgeons (NBPAS), which doesn’t require participation in MOC nor recertification examinations. NBPAS leadership are also making it a priority to address a particularly misguided misapplication of MOC by some private insurance payers, who are making MOC participation a condition of reimbursement. Legislators, the public, and physicians should be aware of the potential for conflict of interest issues possibly inherent in this business practice.

Dr. Paul Mathews, MD, who is a unpaid volunteer leader within NBPAS, has written about the complex relationships involved in the relationship of 3rd party insurance and physicians when it comes to imposing MOC as a restriction on reimbursement:

(NBPAS), which is a newly established alternative to the ABMS which doesn’t require MOC participation:


As a volunteer board member of NBPAS (no compensation or honorarium as opposed to the salaries of ABMS board members, which can range from $300,000 to greater than $800,000), I have often wondered why private payers require MOC when Medicare does not require board certification or MOC. The answer is quite disturbing. Private payers actually participate in certification, which is issued by the National Committee of Quality Assurance (NCQA). Margaret E. O’Kane is the founder and president of the NCQA, and she is also a member of the ABMS Board of Directors. The NCQA requires private payers to require physicians to participate in MOC in order to be NCQA certified. Thus, anyone contracting with a private payer will require MOC. In the conflicted case of Ms. O’Kane, she profits from the NCQA requiring private payers to require physicians to participate in MOC, and then she profits again from her ABMS position when said physicians must pay to comply with MOC requirements” – (Mathew, P., MD (2016). MOC and Physician Burnout: Treating the Cause, Not the Symptoms. Practical Neurology).

In my opinion, physicians should have the right to simply forgo MOC or alternative certifications and pursue the continuing education which is relevant to their practice. There ought to be a genuine choice to participate in MOC or some other vehicle for fulfilling the principle of lifelong learning. Those who want MOC should be able to continue participating in it. Those who don’t should be allowed to continue using the method they’re most comfortable with for maintaining their knowledge and clinical skills, including CME and other creative methods for staying current with the medical literature. They should not be afraid they’ll not be allowed to practice medicine or not be reimbursed for their hard won knowledge. MOC is widely perceived to be at best an annoying imposition on physicians’ time. At worst, it can interfere with patient care because of the time burden which is viewed as time wasted by many physicians.

While there are some doctors who oppose the IMS policy change and the legislative efforts that it portends, there are many who support it. There are several reasons for it and some of them frustrate and sadden doctors. I agree that the IMS should represent all doctors. I think it’s too bad that this MOC controversy divides us.

Nonetheless, I support the IMS policy change suggestion as noted above and urge legislators to strongly consider supporting legislation opposing MOC.