The Controversy Over Maintenance of Certification

The movement opposing the American Board of Medical Specialties (ABMS) Maintenance of Certification (MOC) program is gaining momentum. Physicians who oppose mandatory MOC requirements by hospitals and insurers have been influential in proposing legislation in 17 states so far to ban the requirements.

“Some state medical societies have asked their state governments to legislate what MOC can and can’t be used for,” said Brian Nussenbaum, MD, executive director of the American Board of Otolaryngology (ABOto) and a member of ENTtoday’s editorial advisory board. The ABOto, which started requiring MOC in 2002, is one of 24 member boards that comprise the ABMS. To date, bills restricting the use of MOC for privileging, reimbursement and/or licensure have been introduced in 26 states and passed in seven (Georgia, Maryland, Missouri, North Carolina, Oklahoma, Tennessee, and Texas).

The legislation opposing mandatory MOC has been driven by some diplomates who say that certification processes are not relevant to their practices, are too time consuming and costly, and don’t accurately reflect what’s necessary to maintain the public trust in continuing certification. In addition, high-stakes exams that need to be taken at least every 10 years cause a great deal of anxiety.

Physicians in the anti-MOC movement support initial board certification but say that MOC has evolved into a money-making scheme that forces them to pay testing fees that are too costly and are required too often.

Among groups that oppose MOC are the National Board of Physicians and Surgeons, the Association of American Physicians and Surgeons, Practicing Physicians of America, and the Association of Independent Doctors. Individual physicians are also contacting their state medical societies and legislators to ban mandatory MOC requirements by hospitals and insurers.

The ABMS, which sets the standards for physician certification, says MOC is necessary for quality of care and patient safety. Dr. Nussenbaum also stands behind the rationale for MOC—he said that initially becoming a board-certified physician immediately after completing residency and an ABOto diplomate is not enough to ensure that the physician will continue to maintain that competency throughout his or her entire career. “Our philosophy is that initial certification is not equal to lifelong certification,” he added. “Certification, rather, is a lifelong process that starts with initial certification and is ongoing throughout an individual’s career.”

Additionally, according to ABMS, there is evidence that board certification and MOC are associated with higher standards, better quality care, and improved patient outcomes. Certified physicians are also significantly less likely to be disciplined by state medical boards. There is also evidence that physicians participating in MOC provide care at a lower cost, mostly by ordering fewer tests and demonstrating more efficient patient management.

David W. Eisele, MD, Andelot professor of laryngology and otology and professor in and director of the department of otolaryngology–head and neck surgery at Johns Hopkins School of Medicine in Baltimore and chair of the ABOto MOC Committee, added that MOC is an entirely voluntary process, despite its value. “It isn’t a requirement to practice medicine,” he said. “In fact, even hospitals that require medical staffs to participate in MOC have mechanisms in place that allow non-board-certified physicians to have privileges.”

Furthermore, Dr. Nussenbaum said, “Having a governmental body legislate MOC … threatens professional self-regulation for physicians.”

The Importance of MOC

MOC allows physicians to demonstrate that they have maintained their knowledge base, learned new essential information, maintained their professional standing, and continue to improve in medical practice, said Dr. Nussenbaum, who emphasizes that ABOto is primarily responsible to the public. “For physicians, MOC reinforces their responsibility to be professional in their development and practice improvement,” Dr. Eisele said. “It can also give them confidence in their ongoing learning.”

Jo Shapiro, MD, an otolaryngology surgeon, director of the Center for Professionalism and Peer Support at Brigham and Women’s Hospital, and associate professor of otolaryngology at Harvard Medical School, both in Boston, said MOC is important because every physician should keep up to date with professional knowledge and skill sets. “MOC is one of the most important forms of professional self-regulation for physicians,” she said. “Most professions, such as teachers, Realtors, and pilots, require ongoing education.”

No physician is required to have board certification. Currently, some hospitals require physicians to participate in MOC and some don’t. In addition, some health insurers use it as a requirement to participate in their plans. “It should be the hiring institution’s prerogative to decide what qualifications they want physicians they are hiring to have,” said Dr. Shapiro, who is also the Society of University Otolaryngologists representative to the American College of Surgeons Board of Governors. “The proposed legislation would take away this prerogative.”

Specialty societies, as well as individual diplomates, should stand up for MOC because it is a core foundation to our profession. To allow state regulators, instead of hospitals, to decide proper qualifications for physicians would erode our professional self-regulation. MOC should be supported, not undermined, as a way to maintain public trust in physicians. —Jo Shapiro, MD

Prior to 2002, certificates for otolaryngology were issued for a lifetime. Physicians who received certificates before 2002 were grandfathered in and are exempt from needing MOC. “Even though I don’t have to participate in MOC, as I’m grandfathered in, I choose to do so because it is important to do so,” Dr. Shapiro said.

To prevent the anti-MOC movement from progressing, Dr. Shapiro encourages physicians to testify in support of MOC to state legislatures—which she has done—or to colleagues. “Specialty societies, as well as individual diplomates, should stand up for MOC because it is a core foundation to our profession,” she said. “To allow state regulators, instead of hospitals, to decide proper qualifications for physicians would erode our professional self-regulation. MOC should be supported, not undermined, as a way to maintain public trust in physicians.”

Instead of having the government involved, Dr. Nussenbaum believes the controversy should be resolved within the house of medicine, by having specialty boards work with specialty societies and diplomates to continue to improve their processes and introduce new program innovations. “This is already happening within ABOto,” he said.

Controversy within Otolaryngology

Dr. Nussenbaum said there have been fewer critics of MOC within otolaryngology, and he thinks this is because the ABOto has been at the forefront of addressing any concerns. “When ABOto started its MOC program, its philosophy was to be practice focused, not to be costly, and not [to] be time consuming,” Dr. Nussenbaum said. “We have eight different practice focus areas in our MOC program in order to maintain relevance to the diplomates,” he said. “If a physician only practices pediatric otolaryngology, for example, he or she will not have to answer questions about head and neck cancer.”

“Annual dues are a flat $310 no matter what activities the diplomate has due that year; ABOto does not charge for every individual MOC activity,” Dr. Nussenbaum said. Diplomates can take the knowledge assessment test as early as the eighth year of their 10-year cycle. “The failure rate in otolaryngology is very low. In the rare instance that someone fails, the diplomate still has one or two more chances to pass it before their 10th year.”

The American Academy of Otolaryngology–Head and Neck Surgery (AAO–HNS) supports many of the principles behind MOC and recently signed a joint statement with the ABOto that promotes lifelong learning that is monitored by continuous assessment (see below). “Both groups feel that time spent on learning should fit within the normal flow of the physician’s practice at a reasonable expense,” said James C. Denneny III, MD, executive vice president and CEO of the AAO-HNS Foundation. “Both groups also feel that physician self-regulation is essential to the medical profession, and continuous certification is essential to both physicians and patients.”

ABOto’s Evolution

Each of the boards that comprise the ABMS has a unique concept of MOC; each one measures different parameters and employs different strategies for assessment, Dr. Denneny said. But certain boards have not been responsive to the legitimate concerns of their diplomates.

One of the biggest complaints from opponents is having to take a closed-book, secure, multiple-choice exam at a testing center—although the pass rate among ABOto diplomates is very high. To address this, the ABOto is launching a pilot alternative online program to MOC called CertLink. This longitudinal assessment will require diplomates to answer approximately 15 questions online per quarter; they will receive immediate feedback, along with a commentary of the answer choices and relevant references. “They will learn from answering questions on their computer at their convenience without having to take the secure exam. “In other words, it will be more of an assessment for learning process rather than an assessment of learning,” Dr. Nussenbaum said.

CertLink’s soft launch will occur in July 2018 and will be available for diplomates with 10-year certificates that expire in 2019 and afterward. Initial practice-focus areas will include head and neck, facial plastics, and general otolaryngology. Other areas will be offered as soon as it is feasible.

“A continuous type of learning and evaluation is the most effective,” Dr. Denneny said. “It gives instant feedback to each physician, allowing them to improve where necessary.”

Dr. Eisele foresees physicians preferring CertLink over the 10-year exam as it becomes easier to use. “We got a lot of positive feedback from diplomates, as it’s expected to be more convenient, flexible, and clinically relevant,” he said.

Currently, ABOto doesn’t have an active part IV MOC because it has been working to develop a program that is both valuable and meaningful to its diplomates. “We are on a path to having an active part IV MOC in collaboration with the AAO-HHS and the ACGME,” Dr. Nussenbaum said.

Editor’s note: Dr. Nussenbaum will begin an “Office Hours with the Executive Director” program at the ABOto in mid-January 2018. He welcomes talking to anyone who has questions, suggestions, or feedback. Contact 713/850-0399 to arrange a time.

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Karen Appold is a freelance medical writer based in Pennsylvania.