Open Letter To The American Board of Medical Specialties On MOC

Core Competency Pizza
Core Competency Pizza

Today I had no secretarial support but soldiered on and finally mailed a letter in protest of Maintenance of Certification (MOC) to Dr. Lois Nora, MD, JD, MBA, President and CEO of the American Board of Medical Specialties (ABMS). It’s a long enough read by itself so I don’t have much preamble except to say that I’m trying to set an example for trainees on what, in my opinion, is one way to conduct civil, constructive activism in medicine.

Dr. Lois Margaret Nora, MD JD MBA

President and Chief Executive Officer

The American Board of Medical Specialties

Re: Maintenance of Certification

Dear Dr. Nora:

I’m Clinical Professor of Psychiatry at UIHC and I have just found a letter posted on line dated November 20, 2013 to you from Melissa Waters, then President of National Association Medical Staff Services (NAMSS),

The letter lists several shortcomings (with which I and probably many other physicians agree) of the American Board of Medical Specialties (ABMS) Maintenance of Certification (MOC) standards. I think the criticisms are still valid today. The NAMSS made several recommendations which I will annotate based on my status as a rank-and-file psychiatrist working every day as a consultant in our 800 bed academic medical center.

“Recommendation One: Implement More Uniform Measures among Member Boards:”

Waters thought the overall policy was vague and invited “ambiguity for physicians and medical staffs.” While she cautioned against granting member boards some independence in individualizing their implementation of the standards, she was concerned about inconsistencies which could arise, making “MOC an overly complex and arbitrary process.”

The example Waters gave was the issue of not limiting time-certificate exemptions. My understanding of this is that some older physicians are still exempt from time-limited certification. There is no “uniform timeline” for the American Board of Psychiatry and Neurology (ABPN) certification that I know of. Three years later, this still creates an air of frustration and resentment for many diplomates who must cope with the MOC, which remains a cause of “unnecessary work and confusion” for doctors.

Flexibility is also occurring in terms of how each member board interprets the standards. For example, the ABPN has recently changed the requirement for both Performance in Practice (PIP) clinical module and a PIP Feedback module. A diplomate may now choose to do either and is not required to complete both. This effectively makes the PIP clinical module optional, which was an important feature of Part IV of the MOC standards. Many psychiatrists, including me, welcomed this change. In fact, the American Psychiatric Association (APA) has recommended that Part IV be removed from the standards.

“Recommendation Two: Implement More Objective Competency Measures:”

Waters recommended that the standards “should clearly explain how competency data is compiled, assessed, and weighted for each module of MOC’s four-part competency framework: 1) Professional Standing and Professionalism; 2) Lifelong Learning and Self-Assessment; 3) Assessment of Knowledge, Skills, and Judgment; and 4) Improvement in Medical Practice.”

Although I frequently remind my medical students and residents of the 6 competency version of this framework, I’m aware of the subjective nature of the data used to evaluate the competencies. According to Waters:

“Depending so heavily on intangible data presents validity and reliability issues and may not appropriately assess a diplomate’s competency. For example, one of these six competencies, Interpersonal & Communication Skills, evaluates a diplomate’s “…skills that result in effective information exchange and partnering with patients, their families, and professional associates….” There is no objective mechanism to assess this data.”

On the other hand, I always teach my trainees that the Interpersonal & Communication Skills competency underlies and supports the rest of them. Frankly, I’m unsure of the best way to teach them other than by role-modeling, to say nothing of how to measure a trainee’s performance in this domain. Self-report and patient and peer surveys are vulnerable to error. There can be a lack of insight into one’s own flaws, yet patient and peer surveys are almost certainly cherry-picked, making their reliability suspect.

Practice improvement modules (PIPs) offered on the ABPN web site are often not relevant to my practice and substituting the Feedback module, while superficially preferable because it’s relatively easier to obtain, is flawed because I control to whom I give the feedback form.

According to Waters, these kinds of data “should not serve as major competency measures.” And if they are not used, I’m at a loss as to suggest a more objective alternative. Waters adds, “The final Standards should also address cases in which diplomates have not been tested because they are life-time certified. Because much of the certification assessment is not evidence-based, there is no objective criterion to determine these diplomates’ qualifications and competencies.”

“Recommendation Three: Accurately Define MOC’s Participation Policy:”

Waters’ statement about the so-called voluntary nature of MOC strikes a chord in me and I suspect in many other psychiatrists:

“ABMS’ MOC process is not mandatory, but it is not truly voluntary. Diplomates who do not participate in the MOC process lose their certification. This gives those who intend to continue to practice their specialties little choice but to participate. If MOC is truly voluntary, the final Standards should include a “Not Participating” category to classify non-participants. The current process only offers, “Yes,” “No,” or “Not Required.” There is no option that accurately categorizes those who choose not to participate. ABMS should better accommodate physicians’ participation decisions and provide facilities a certification end-date for those who do not choose to participate in MOC.

That MOC is technically voluntary creates many inconsistencies throughout the industry – especially for physicians and facilities. Many facilities, departments, and specialties mandate MOC, which compels participation. The resulting inconsistency is unfair to physicians and does nothing to simplify healthcare and only muddles the concept of MOC for the healthcare community, patients, and the public. NAMSS does not assert that everyone must participate, (e.g., life time certificants), but recommends that ABMS add a category that would represent the non-participatory provider, which is not punitive in nature to the healthcare community.”

While it’s probably true that the letter of the law has been followed regarding Waters’ recommendation about how the MOC non-participant is labeled, it is also true that some hospitals and third-party payers base privileging and reimbursement on participation. One example of this has happened in Michigan, prompting physicians to form the Right2Care initiative which seeks legislative assistance in preventing Blue Cross Blue Shield from basing reimbursement on MOC participation.

I believe that, while the ABMS may not be directly responsible for this behavior by hospitals and insurers, their response was probably foreseeable.

“Recommendation Four: Define and Clarify Board-Certification Status:”

Waters’ recommendation to apply a uniform procedure for identifying diplomates who are or are not meeting requirements of MOC are unlikely to materialize because of the many differences amongst the 24 different specialties. While it’s possible to define “Board Certified” it is not generally agreed that board certification reliably identifies a physician as being superior to one who is “Board Eligible.” For example, The University of Iowa Hospitals and Clinics (UIHC) does not require board certification for appointment or hospital privileging regarding physician faculty, much less participation in MOC.

One could probably argue whether regular listing as one of the top hospitals in the country by U.S. News and World Report is a solid indicator of world class care and physician excellence. But UIHC is consistently identified as such.

“Recommendation Five: Make the Recertification Examination Optional:”

According to Waters, “If MOC adequately measures “…knowledge of core content, judgment, and skills,” the 10-year examination, which claims to do the same, is unnecessary for diplomates who successfully complete continuous certification. NAMSS recommends that these diplomates be exempt from this exam.”

Changes or proposals to change the recertification examination have been made by the American Board of Anesthesiology and the American Board of Internal Medicine. The APA has also recommended changes to the ABPN recertification examination. Dr. Jeffrey Lyness, MD, psychiatry director for the ABPN, was recently quoted indicating that the anesthesiology board briefed him on its recertification exam model and he said it is “clearly allowed by the ABMS.”

I think it’s unclear yet whether more frequent tests at the same cost is better or worse overall.  What is clear is that some specialty certification boards are making changes to the standards in an effort to reduce the time and cost burdens to diplomates.

Waters’ last point about collaborating with the Federation of State Medical Boards (FSMB) to “ensure that MOC satisfies each state medical board’s maintenance of licensure criteria” alludes to the Maintenance of Licensure (MOL) initiative and which you have pointed out is “distinct and separate” from MOC. However, I and many other physicians believe that MOC would inevitably be coupled to obtaining and renewing one’s medical license. Let me say that I’ve discussed this with my state medical board’s executive director. Iowa was one of several states which initially partnered with the FSMB to implement pilot projects to determine our state’s readiness to implement MOL. The short story is that Iowa will not be doing that in the foreseeable future.

In my opinion, the state of the MOC now is not substantially different from what it was in 2013 when Waters made her recommendations.

I know you and others believe that Part IV of MOC are demonstrably helpful in improving patient care although I also notice that this is one item for which you did not provide supporting references in your blog post in 2014,

I think it’s important to reiterate that the American Psychiatric Association (APA) does not believe Part IV is essential and have recommended that it be removed from the MOC requirements. The pertinent excerpt from the APA letter to Dr. Larry Faulkner, President and CEO of ABPN on March 16, 2016:

“APA members have found Part IV to be onerous, cumbersome and not meaningful. While we very much appreciate ABPN leadership’s efforts to create alternative pathways for meeting this requirement, neither our members nor the APA Board of Trustees support the continuation of Part IV of MOC.”

In a follow up letter to ABPN diplomates on March 24, 2015, the ABPN recommended that “Based upon the feedback we have received from the AAN and the APA, the ABPN has respectfully asked the ABMS to consider modifying its 2015 MOC Standards so that Part IV is an optional component of MOC.”

Because the ABMS did not allow that, indicating that it supported all parts of the standards (which the NAMSSS clearly did not support in 2013 as noted above), Part IV remained…until just recently almost exactly a year following the decision to uphold Part IV. Now the diplomate has the option of choosing either to complete a Performance in Practice (PIP) clinical module or a Feedback Module. It’s obviously a compromise.

Dr. Faulkner went out of his way to follow the ABMS requirements. Did the ABMS change its position or did the ABPN independently modify the requirement as other boards are now doing?

In either case, the MOC is evolving just as you said it would, although maybe not exactly in the way you might have envisioned.

In view of the foregoing, I think it’s incredible for Dr. Lyness to have also been quoted in a Medscape article as saying that psychiatrists are “more satisfied” with the MOC process than other medical specialists. I did not receive a copy of the survey which allowed him to draw that conclusion.

Further, the recent changes are only a step in the right direction. I think MOC has had its chance to prove whether or not its valuable to patient care and my opinion is that it has failed to do so. I’m not the only one who holds this opinion. The APA is only cautiously supportive of what they call the initial changes in the ABPN MOC.

I think the ABMS should drop the MOC. Even as I write this, I know I’ll probably be ignored. But I’m doing this for another reason. I’m trying to role model the core competencies for my medical students and residents. The MOC controversy is a challenge to be met by all doctors acting as individuals, including those who believe in civil, constructive activism.

Systems-based practice competency implies our responsibility to be accountable for our mistakes as well as our successes in a complex health care system with many moving parts influenced by money, self-interest, and political alignments. As far as I know I’m the only faculty member at my hospital who tries to teach this to trainees.

Practice-based learning and improvement competency implies our commitment to personally designed individual programs to ensure our ability to provide safe and effective care to patients keeping pace with the latest research. This must be relevant to our practice, flexible, and not create more burdens in an already overly complicated health care system over which physicians have little to no control and which is an identified cause of burnout.

Medical knowledge and patient care competencies implies our acknowledgement of the continuously evolving knowledge base and the need to individualize the care we provide based on the particular needs of our patients in view of the inadequacy of the one-size-fits-all approach and always looking outside of our own spheres for help and new knowledge.

Professionalism competency implies our recognition of the difficulty of even arriving at an agreed upon definition of what professionalism is, much less how to measure it, but despite that challenge continuing to engage in daily self-reflective improvement for our patients, ourselves, colleagues, families, and communities.  Like art, we may not know what integrity is precisely—but we know it when we feel it as our leaders practice the art and science of medicine.

Communication and interpersonal skills competency implies our acknowledgement that this competency is foundational to all the rest and encourages the pursuit of diplomacy, respect, empathy, tolerance, justice, and civility in our relationships and this supports professionalism…and must come from the inside out and cannot be measured or imposed from without.

Since my first year of residency I’ve struggled to reconcile my practice of medicine with the principles Stephen Covey outlined in his earliest works including The 7 Habits of Highly Effective People. Covey pointed out that one is more effective if one tries to be a change agent within one’s circle of influence rather than one’s circle of concern. I have always been conflicted about that.

Some of the world’s greatest leaders are remembered precisely because they chose to work against all odds and risk even their lives over burdens and oppression that were often clearly outside their circle of influence.

Help me remove at least one of the obstacles to success facing the next generation of doctors.


Sincerely yours,



James J. Amos


Open Letter to ABPN Psychiatry Director: Hey, I’m Unhappy About The MOC

I learned yesterday of an article on Medscape titled “MOC: No Changes for Psychiatry, Neurology Anytime Soon.”

Registration is free to read the article, in which Jeffrey Lyness, MD, psychiatry director for the ABPN, professor of psychiatry and neurology, and senior associate dean for academic affairs at the University of Rochester School of Medicine and Dentistry, in New York is quoted,

“My sense is that overall, our diplomates have been more satisfied than our colleagues,” Dr Lyness toldMedscape Medical News. “It doesn’t mean everybody’s happy,” he said.

“Over time, it’s becoming clearer to people what they have to do, and also, the requirements are getting more flexible,” Dr Lyness said.

For the PIP this year, ABPN diplomates can choose either a clinical or a feedback module. In 2015, the clinical module was required, and in 2014, diplomates were expected to do both. “Now it’s one or the other,” said Dr Lyness.’

In February 2015, the American Academy of Neurology urged the ABPN to eliminate Part IV, and the ABIM has suspended the requirement entirely. The ABMS has said that Part IV is required of everybody, and yet has done nothing to the ABIM, said Dr Lyness.”

 Dr. Lyness further said in reference to the above:

“So we’ve been watching that pretty closely,” he said, but the ABPN is not taking any similar action.

“On the one hand, we do not want to jeopardize our certificates by doing something that eventually has the ABMS telling us that we’ve invalidated our certificates,” he said. “On the other hand, if the ABMS is really not going to make Part IV required, we may not want to require it either.”

For now, “we’re an ABMS member board, and we adhere to the ABMS requirements,” said Dr Lyness.

In September 2015, the American Board of Anesthesiology said it was replacing the 10-year examination with an online learning tool that quizzes physicians on a continuous basis. Shortly thereafter, the ABIM said it was considering eliminating the examination and replacing it with a similar model of continuous online testing.

Dr Lyness said that the anesthesiology board had briefed the ABPN on its model, which is “clearly allowed by the ABMS.” The psychiatry board is “in concept open to alternatives,” he said, but it is investigating how such a test would be administered, whether it would be a reliable measure, and whether a small number of questions every month or every year would be less or more burdensome.

In looking at the MOC overall, “we have to balance credibility with cost and the burden or convenience factor for our diplomates,” said Dr Lyness, adding that the ABPN was “trying to steer a reasonable ground.”

I’ve always thought that direct action is preferable to making comments on articles which hardly anyone reads. I respectfully disagree with Dr. Lyness and just mailed my opinion today to him, which I’m making public as an open letter below:


Dear Dr. Lyness:

I’m a Clinical Professor of Psychiatry at UIHC and I’d like to take exception to your remarks in the March 22, 2016 Medscape article titled “MOC: No Changes for Psychiatry, Neurology Anytime Soon.”  I think that, while it may be accurate to say that “…our diplomates have been more satisfied than our colleagues…” it’s probably also true that the ABPN does not hear what rank and file diplomates may really think about MOC because they might believe there is no point in trying to fight it anymore.

I notice that this article was published almost exactly year after a similar Medscape article was published on the same topic, “Psychiatrists: No Problem with MOC?” There were 29 comments posted which disagree with the title’s implication and there are no comments posted so far on the current article. Although this might be interpreted to imply there is less opposition, I think it means that psychiatrists are tired, and feel helpless to change the regulatory pressure which contributes to the nearly 50% physician burnout rate. My comment from last year:

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.


The NBPAS is gaining adherents from all specialties, including psychiatrists. I think of the NBPAS as one of the many indicators of how frustrated doctors are about MOC.

I introduced resolutions to the Iowa Medical Society supporting the principle of lifelong learning but opposing Maintenance of Certification (MOC) and Maintenance of Licensure (MOL) which were both adopted in the last few years. I happen to be board certified in Psychiatry and Psychosomatic Medicine and I plan to take the last recertification examination for the former in the next couple of years because I intend to retire soon after.

I think most psychiatrists are not vocal in opposition to MOC and MOL because of inertia and fatalism, not because they agree with these processes. I have participated in a conference call to the Iowa Board of Medicine opposing MOL, which ultimately decided not to implement MOL in Iowa. Part of the reason I have opposed these processes is that I believe strongly they could hurt retention and recruitment of primary care and psychiatric physicians to our state.

Board certification has become a bone of contention especially in the past five or six years. I discovered about a year ago that our hospital, a much-awarded tertiary care referral center staffed by world class clinicians and researchers doesn’t even require board certification, much less MOC participation, as a bar for faculty appointment and hospital privileging.

I have been teaching medical students and residents as a faculty member here since my graduation from residency in 1996 and I can tell you that I try to foster a devotion to developing clinical excellence, not just competence. The MOC gets in my way and I never miss an opportunity to show my trainees what I believe reflective self-improvement means for me and my patients.

In fact, the best example of how we practice continuous self-improvement is on my blog site, . There you can see many examples of practice-based learning in the form of the Clinical Problems in Consultation Psychiatry (CPCP) case conference. I’ve also started a Psychosomatic Medicine Interest Group (PMIG) which meets monthly and is also a case-based group learning approach to practice-based learning and improvement.

I can tell you that I still field questions from my colleagues about the ABPN MOC process, which is confusing, burdensome, and viewed as busy work which takes time away from patient care. While I welcome the small changes made by the ABPN including the recent relaxation of the Performance in Practice (PIP) clinical module for which a Feedback module can now be substituted, I believe the ABPN could do much more to ease the recertification burden.

The American Psychiatric Association (APA) has been clearly opposed to the current structure of the MOC and it has called for elimination of Part IV and for consideration of modifying the recertification examination structure as well. Doctors don’t learn this way anymore, especially in the age of electronic devices which allow instant access to medical literature indices.

I have shared my opinion with Dr. Larry Faulkner, MD, President and CEO of the ABPN more than once. I have even submitted a PIP clinical module for assessment and management of delirium, which was pre-approved.

Every single day I’m doing much more toward clinical self-improvement than the ABPN MOC could ever accomplish.

Like you, I’m doubtful that a small number of questions every month or every year would be less burdensome than a secure recertification exam every 10 years. However, with medical knowledge growing so quickly nowadays, I also doubt that a 10 year exam should count as a valid measure of how current a physician’s knowledge base is.

As a consulting psychiatrist for an 800 bed academic medical center, I can tell you just how much I think MOC has improved the practice of Iowa’s physicians—not one jot. I continue to see overdiagnosis of psychiatric illness and polypharmacy overprescribing which neither the MOC nor so-called “light touch intervention” by sending polite government letters to physicians telling them to stop it has done much to change [1].

We must do something different from MOC in order to improve safe and effective patient care. MOC has not been shown in high level studies to improve patient outcomes or to improve the doctor-patient relationship [2, 3]. In fact, I think it could potentially worsen outcomes in some cases by taking time away from direct patient care to participate in empty exercises which are not relevant to anyone’s practice.

Many physicians, including psychiatrists, think the ABMS and member specialty certification boards have lost their way and lost the trust of physicians, believing that it is past time for them, as Drs. Westby Fisher and Edward Schloss advise, to “…remove all requirements for time-limited board certification and resort to conventional self-selected ACGME-approved CME programs for ongoing professional education [4].”

I marvel that my medical students and residents are so enthusiastic about their futures in medicine. It grieves me to tell them the hard truth about our system, but I am duty bound to be frank with them. No one else will. Their perseverance tells me they must love the profession almost as much as I do. I could not be more proud of them.

Please help me remove the obstacles to their success and build a better path to fostering excellence.


  1. Sacarny, A., et al. (2016). “Medicare Letters To Curb Overprescribing Of Controlled Substances Had No Detectable Effect On Providers.” Health Aff (Millwood) 35(3): 471-479.
  1. 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.
  2. 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.
  3. Fisher, W. G. and E. J. Schloss (2016). “Medical specialty certification in the United States-a false idol?” J Interv Card Electrophysiol.

I urge all interested psychiatrists with a stake in this matter to mail letters to Dr. Lyness. I don’t know if a lot of letters will change his mind, but it’s worth a try.

The MOC Controversy and the Seven Deadly Sins

Jim Amos MD 7I’ve noticed it’s getting harder to keep a sense of humor about the Maintenance of Certification (MOC) lately, especially since the publication of the 3rd Newsweek opinion piece by Kurt Eichenwald on the finances of the American Board of Internal Medicine (ABIM), “Medical Mystery: Making Sense of ABIM’s Financial Report.” You probably won’t get to read the article unless you buy a subscription. I was lucky and got to read it at least once. And then there was the rebuttal by ABIM President and CEO, Dr. Richard Baron, denying that he’s hiding anything about his finances, which is implied by Eichenwald.

After reading both pieces, I thought of the seven deadly sins, with pride, anger, and greed leading the list in this drama which is becoming increasingly embarrassing to American physicians, because they’re displayed on both sides of this controversy.istock-editorial-license_7-deadly-sins-medium-1

Comburg, pulpit cover by Balthasar Esterbauer (1715) - Seven deadly sins: pride
Comburg, pulpit cover by Balthasar Esterbauer (1715) – Seven deadly sins: pride

Pride is considered the worst of the seven deadly sins. I can see it in the arrogance of board leaders who think they’re immune to criticism and, despite Baron’s apparent belief that his apology to ABIM diplomates makes him a paragon of humility–nobody believes him. On the other side, the pride of rank-and-file physicians makes many of us believe that whatever we’re currently doing for professional self-development is sufficient, or worse, that we don’t need to do anything beyond collecting CME activities.

Hey, I encounter physician incompetence every day–including my own. We need a more systematic way to stay current with medical knowledge and patient cares skills. But I still don’t believe MOC is good enough to embody the principle of lifelong learning. The recent JAMA article on professionalism and regulation included an article on Revalidation, the United Kingdom version of MOC (more accurately Maintenance of Licensure or MOL since the process is tied to physician licensure) [1]. The authors are frank about the reasons why Revalidation cannot yet be evaluated on its ability to improve patient care outcomes. And they also admit that it will probably not uncover the few doctors out there who are basically criminals.

I believe that if the medical literature could be made available to all working physicians, for example, through PubMed, most of us would use it more frequently than MOC to engage in professional development, comparing our practice to reviews and published studies–because we want to improve from the inside out.

Comburg, pulpit cover by Balthasar Esterbauer (1715) - Seven deadly sins: wrath
Comburg, pulpit cover by Balthasar Esterbauer (1715) – Seven deadly sins: wrath

Anger is another deadly sin that both the board executives and front-line, working doctors evince. Anger is evident in Eichenwald’s tone and anger is everywhere in the comments following his article. The President and CEO of the American Board of Psychiatry and Neurology (ABPN), Dr. Larry Faulkner, cautions against reacting to the MOC with anger–yet obviously he was willing to try and make the Part IV clinical module optional, probably because he recognized how angry it makes physicians because almost none of it is relevant to what most of us do day in and day out as psychiatrists and neurologists.

Comburg, pulpit cover by Balthasar Esterbauer (1715) - Seven deadly sins: gluttony
Comburg, pulpit cover by Balthasar Esterbauer (1715) – Seven deadly sins: gluttony

Gluttony in the broad sense of over-indulgence is characteristic of both board executives and front-line doctors. Why exactly do CEOs have to be paid as much money as they typically get? I’m not sure what that means. You can see how closely related greed and gluttony are. It’s harder to see how this might apply to diplomates, but think about gunner medical students, the grind of residency, and the seemingly endless work of being a doctor. And then we allow ourselves to be taken advantage of by the boards. Why couldn’t we be described as “gluttons” for punishment?

Comburg, pulpit cover by Balthasar Esterbauer (1715) - Seven deadly sins: envy
Comburg, pulpit cover by Balthasar Esterbauer (1715) – Seven deadly sins: envy

Envy is one of the sins working doctors must deal with. How can I not envy Dr. Faulkner’s $843,591 salary? Let’s see, what would board executives envy about rank-and-file physicians? Maybe they envy our daily connection with our patients, the daily drive for creativity and excellence we bring to clinical care. Dr. Baron did that, he says, for some 30 years before giving it up to make an awful lot of money. It’s too easy to say the money makes up for the loss of what most of us aspired to when we entered medical school–integrity, humanism, the reward of hard work for its own sake, the opportunity to help others heal and to teach the next generation of doctors our skill, our hard-won wisdom, and respect for the curiosity to seek new knowledge…and to respect the need for stewardship of the old ways because our patients need and want to see us as the paladins we have always sought to be for them.

Comburg, pulpit cover by Balthasar Esterbauer (1715) - Seven deadly sins: lust
Comburg, pulpit cover by Balthasar Esterbauer (1715) – Seven deadly sins: lust

Lust is not always synonymous with sex. It can be the drive for power and fame. We don’t often think of legacy in this way, but there can be a lust for legacy. It’s not hard to see how board executives might lust to leave a legacy by using MOC as a vehicle. And in our turn, the foot soldiers of medicine may lust for the legacy of being the champions of the resistance to MOC, to be remembered as the heroes who toppled the tower of greed, pride, and gluttony.

Comburg, pulpit cover by Balthasar Esterbauer (1715) - Seven deadly sins: sloth
Comburg, pulpit cover by Balthasar Esterbauer (1715) – Seven deadly sins: sloth

Sloth can be the charge of the board CEOs at the doctors who balk at participating in MOC. The message might be that we are failing to live up to the principle of lifelong learning and continuous self improvement. On the side of diplomates, the view is that the boards are failing to work hard enough to find alternatives to what are perceived to be empty time-wasting Performance in Practice (PIP) modules. Don’t we have more important ways to use our time?

So here we still are, no closer to resolving the seven deadly sins than we were years ago when the MOC debacle started, probably with good intentions but somehow becoming corrupted along the way. The boards are widely viewed as corrupt, yet despite the impression Eichenwald gives of them being criminal, even he finally says that ABIM is doing nothing illegal. But then in the next breath, he says that the Department of Justice should investigate them. And he says doctors should grow a backbone and fight the MOC with mass noncompliance–something MOC opponents have been saying for years. Interesting that Eichenwald should challenge physicians to grow a backbone, after he spent many paragraphs vilifying the identified enemy—the ABIM. I would say I have a strong enough backbone because I’m still standing under all of the pressure the boards are pressing on my shoulders.

Saying doctors don’t have backbone, whether it’s done by the press or by doctors, really sounds like more of the anger that keeps us all spinning. Backbone is not what’s lacking.

We spin this way because there doesn’t seem to be a way out of the MOC controversy. We can let our certifications expire–and then what? The belief that certification means the difference between good and bad doctors is widespread amongst the Joint Commission, the Centers for Medicaid and Medicare Services (CMS), hospital credentialing committees, private insurance companies–and many doctors. Patients? Not so much, which is ironic.

So where will all of this anger, pride, greed and the rest of it lead? I sure don’t have the answer, but I have this hope which may not be in vain, that someday we’ll all remember the 7 virtues: Humility, Charity, Kindness, Temperance, Chastity, Diligence, and Patience.

Maybe we all need to relax for a little while, take a break, appreciate how far we’ve come and not ruminate so much on how far we have to go, like the Storyshucker says.

We will not give up the search for a better way to implement continuous professional self-development. But let’s spend a little time in the garden. Play Matball.


1. Marcovitch, H. (2015). “Governance and professionalism in medicine: A uk perspective.” JAMA 313(18): 1823-1824. URL
Professionalism was assumed and governance scarcely existent, with individual physicians holding themselves to account, loosely regulated by a statutory body run by the powerful General Medical Council (GMC). The GMC was established in 1858. 

Image credits for the 7 Deadly Sins:

Lifelong Learning: Making Sure Ideas Live

I’ve been eagerly awaiting the results of Psych Practice Blogger’s survey on the American Board of Psychiatry and Neurology (ABPN) Maintenance of Certification (MOC) and they’re finally in.

That survey is now closed and I decided to close my survey on the National Board of Physicians and Surgeons (NBPAS), the alternative board which doesn’t require MOC participation or a recertification exam. The results are similar and respondents hail from across the country.

NBPAS Survey Results April 25 2015


Like Psych Practice Blogger, I wonder where we go from here. That’s pretty much been the question ever since physicians sort of woke up and realized that the MOC process doesn’t embody the principle of lifelong learning.

The other news I’ve been waiting for, although with less excitement because I think I already know it, is what the American Board of Medical Specialties (ABMS) President and CEO, Dr. Lois Nora, MD, JD, MBA announced about MOC at the American Academy of Neurology (AAN) annual meeting in Washington D.C. on April 21, 2015. As I’m sure many doctors did, I got the form letter from her about my feedback on the MOC on April 15:

Dr. Lois Nora Thank You Form LetterSo far I haven’t seen anything online about what she said or what the AAN membership thought about it, but I did see all of the YouTube video of the Presidential Plenary Address of the current President of AAN, Dr. Tim Pedley, MD, FAAN at the 2015 annual meeting. While the portion of his lecture about the MOC begins about 26 min 50 sec into the video and stops at roughly 34 min 10 sec, I suggest viewing the entire 35 minute lecture. It gives me a sense of a larger perspective on the condition of American medicine in today’s political and economic environment. It runs all of about 7 minutes. While I believe it’s important to see where MOC as an issue for front-line doctors stands in the total scheme of things, I wonder of Dr. Pedley (who I suspect has a lifetime certificate) and Dr. Nora (who was trained as a neurologist, by the way) really understand what the MOC is like for the average non-executive doctor. And I didn’t hear Dr. Pedley mention systems pressures over which we’re not allowed any control (including regulatory pressures) as an important contributor to physician burnout.

I suspect the remarks of Drs. Pedley and Nora were very similar even though I don’t have the comments of Dr. Nora for comparison. And I believe the American Psychiatric Association (APA) message about MOC (and it will again likely mirror that of Dr. Nora) will be a repetition of this one at the annual meeting in Toronto in May. This is despite the recent mention of opposition to Part IV of MOC in the April 17, 2015 issue of Psychiatric News, Vol. 50, issue 8.

“Maintenance of Certification (MOC): Trustees, acting on the recommendation of the Assembly Executive Committee, voted to support the elimination of Part 4 of the MOC requirements and to recommend to the American Board of Psychiatry and Neurology that it advocate to the American Board of Medical Specialties (ABMS) for the elimination of Part 4 of MOC (see page 16). The ABMS oversees certification and MOC for all medical specialties.”

And there’s Dr. Pedley’s article in a fragment (I don’t have the full issue because I’m not a member) of the April issue of AAN News about MOC. The full letter is here. It was originally published online in February. Then look at the remainder of that fragment of AAN News, which carries a portion of an article in the President’s Column by Dr. Pedley entitled “Ave et Vale [Hail and Farewell…translation inserted by the blogger]: One President’s Term Ends and Another’s Begins.”

There is definitely a conflict here. That’s how it seems to be–us vs them. This was also brought home to me when I saw the Wikipedia article about MOC. It’s a recent addition and there’s a warning at the head of it indicating that the “the neutrality of this article is disputed.” If you navigate to the dispute itself it’s very clear who dominates control of what is clearly a passionately adversarial debate. It’s the ABMS.

Can there be neutrality on this issue? Look at the Wikipedia articles on Bigfoot and UFOs and you might wonder why there couldn’t be. Those articles are not marked by warnings about a lack of neutrality, yet no one would dispute their controversial nature. On the other hand, what would be gained by attempting to wage this war on Wikipedia?

I see it as another one of many markers of how unhappy physicians are about MOC, so much so that you get the sense we’re flailing in any possible venue, desperate to be heard yet finding no one really listening.

Psych Practice Blogger asks where do we go from here, from the individual perspective of the rank and file doctor in America when it comes to participation–or not–in the MOC in its current form. There is a sadness inherent in our position. A couple of years ago a colleague said this struggle would never go anywhere. Now few would argue that those of us who uphold the principle of lifelong learning and oppose MOC as a vehicle for implementing it are making a substantial impact on this debate.

So let me try to answer the question, “What would you do with this?”

As an individual psychiatrist, I need to get a clear understanding of what opposition to MOC would mean in my context. I get mixed messages about what board certification means at my hospital and I suspect there are political and financial reasons for that. I will hedge my bets about joining NBPAS even though deep in my soul I agree with the leaders of that alternative certification process. My context also includes where I am in the course of my career. I’m nearing retirement and I need to be realistic about what noncompliance with MOC would mean at a time when I need to ensure that my wife and I will have a reasonably secure retirement. I can’t afford to lose hospital privileges now if my employer decides that board certification in fact is a metric which is crucial to meet in order to keep them. The answer for me will not work for everyone.

When I think about it, I’m sad too. And I think about it a lot. I’ve been at this a good while. But I keep hoping the idea that a systematic program of lifelong learning as a principle is worthwhile as long as the implementation is practical and just will be recognized and honored. We need to keep trying to work it out. And for that you need more than individual effort. I remember even when my own department leaders were reluctant to discuss the issue openly a couple of years ago. Now they’re more receptive to the idea that those who oppose MOC are not opposed to smart, productive, and honest professional development. I hope we don’t let ideas like this die.

MOC Talk Movie and Updates

So I updated the MOC Talk Video and it’s now a movie, though admittedly it’s essentially the same show aired on April Fools’ Day. However, it has a little noncopyrighted music, the powerpoint slide set is embedded (though it’s added rather than coordinated with the rest of the presentation), and one of the debaters has developed a small problem with bowel gas. You’ll need to turn up the volume to detect it and you’ll also want to see the movie full screen.

In other news, I just learned from the Iowa Medical Society (IMS) that:

SF 402:  This bill prohibits the closure of the two mental health institutes prior to June 30, 2015 until a plan is in place to address the needs of those patients and bed capacity in those areas.   In addition, it requires these facilities to continue to accept patients.  IPS is registered in support of the bill which is in the House Appropriations Committee.

Among the bills that “Died in the Funnel” meaning that they will not be considered for the remainder of the legislative session (I think). According to the IMS message, “To remain alive, a bill must have passed one chamber and a committee in the other chamber.” If I’m not mistaken the following bill will not go to the governor to be signed into law (yet?):

SF 273: interstate medical compact

And a couple of MedPage articles I left a comment on are probably worth mentioning:

The highlight from Dr. Teirstein is that, regarding whether hospitals will accept certification from the National Board of Physicians and Surgeons (NBPAS): We are presenting to committees now throughout the country. It’s probably a 4-month process. We have not gotten approvals yet. We’ve gotten a lot of support. It has to go to committee after committee, and the hospital lawyers are getting involved. It takes some time. I expect the hospitals to approve it.

I have not heard from Dr. Renee Binder of the University of California San Francisco, and president-elect of APA in a while, so it was nice to hear from her about MOC: “Its not evidence-based, and it’s very cumbersome,” and “It means well but it doesn’t mean anything.”

And so it goes…


The Great MOC Debate: April TomFOOLERY!

So this is another post on the Maintenance of Certification (MOC), this time with a YouTube video featuring a debate between board leaders. I’m supposed to be on vacation but thought of this one over coffee this morning. Happy April Fools’ Day and support lifelong learning!

In order to see the picture galleries of photos or powerpoint slides, click on one of the slides, which will open up the presentation to fill the screen. Use the arrow buttons to scroll left and right through the slides or up and down to view any annotations.


Does MOC Matter?

So it’s time for another update on the National Board of Physicians and Surgeons (NBPAS) survey. There’s still only a handful of respondents, but the opinion is still pretty clear–doctors want an alternative to the traditional boards.

NBPAS Survey So Far Mar302015

The comments are revealing and, after a while, redundant:

Survey Comments1 Mar302015

Survey Comments2 Mar302015

Respondents are from states across the U.S. and Canada.

A number of recent stunning developments make this issue important, in my opinion. So MOC does matter…in a way. The APA (ABPN-Letter (1)) and the ABPN (ABPN Letter to Diplomates) are now requesting Part IV of the MOC either be eliminated or made optional—either will make it go away because most of us would never choose to participate in the mind-numbing futility of the Performance in Practice (PIP) modules. ABMS is unwilling to give it up, yet says it’s up to ABPN to decide how to implement the MOC components (ABMS Letter To Diplomates). The ABPN suggests Part IV be optional but says it’s up to ABMS to authorize the change. The stalemate could frustrate diplomates for years to come, because even though ABMS is now for the first time asking for feedback from diplomates regarding MOC (and I encourage all physicians to do so), I doubt their sincerity about working with American doctors.

This is where alternative boards come in and the National Board of Physicians and Surgeons (NBPAS) is a newly established organization which might work, especially if ABMS doesn’t budge on the Part IV issue. It doesn’t require participation in MOC but it’s a grass roots movement which needs a lot of support from doctors and validation from third-party payers and hospitals, but had enough high-profile physicians in it at its inception to force ABIM recognition of it as a viable alternative board.

So here’s the Geezer’s Dirty Dozen on the MOC as it stands so far as I know. In order to see the picture galleries of photos or powerpoint slides, click on one of the slides, which will open up the presentation to fill the screen. Use the arrow buttons to scroll left and right through the slides or up and down to view any annotations.