Slow Medicine: MOC in the Middle

The American Board of Internal Medicine (ABIM) has received a fair amount of criticism from US internists and subspecialists because of its imposition of antiquated and irrelevant requirements for Maintenance of Certification (MOC).

Those requirements have become increasingly demanding and have brought a large community of internists together to question the ABIM’s demands and oversight in this process. This issue received national attention in a most eloquent opinion piece by Paul Teirstein, MD, published in The New England Journal of Medicine earlier this year.

Richard Baron, MD, president and CEO of ABIM, authored an unprecedented apology to diplomats of the board, in a February statement. He acknowledged that ABIM needs to make changes to the MOC program, and that it would listen to internists about what they need to make MOC more modern and relevant to their everyday practice.

The drama continued in March when Newsweek published a scathing criticism of the ABIM-not only the process of MOC and its relevance to practicing physicians, but also of its dubious-perhaps unscrupulous-financials.

Physicians not only spend time (precious time!) doing all the MOC tasks, but also pay inordinate amounts of money to prepare for and take MOC exams. All of this takes time and effort away from their practices and their patients. This might be easier to stomach if that money was being used responsibly or for the “greater good,” but the Newsweek article suggested it is likely supporting lavish salaries and travel expenses for ABIM executives.

So where does that leave us? Well, I’m one of the unlucky academic internists who first became a diplomat of the ABIM in 2005, and my certification expires on December 31-right in the middle this controversy.

The ABIM has been largely silent about how newly announced MOC changes will impact physicians in my cohort. In fact, they have said nothing other than a statement that MOC will change, but they have been completely vague in regard to the details.

I am caught in the crossfire-desperately wanting to be a conscientious objector, given that the ABIM has lost the clarity in its role, its integrity has been compromised, and its value in my life as a practicing internist is deeply in question-yet unsure of the true implications to my professional career if I object.

The reality is that my employer expects me to be a board-certified internist, as stipulated in my contract. My qualification to be a provider with insurance companies could hang in the balance, as well, if I let my certification lapse.

At the very least, the ABIM could speak to the special implications of their MOC revision to my cohort of internists. If they have declared revisions to MOC and an overhaul of the examination and the requirements, with a planned announcement of next steps in early 2016, why hold the current cohort of physicians with expiring certification hostage to the “old” system even though they have already publicly admitted its flaws?

I implore the ABIM to at least provide a “grace period” for all MOC requirements to myself and other physicians in my cohort, until they actually figure out their next steps, rather than continuing to enforce this double standard on us.

I hold a leadership position in an internal medicine residency program, I am a career medical educator, and I care for a large panel of patients who depend on me. While it seems clear that the dynasty of the ABIM may be coming to a close, and its role is largely outdated, completely compromised, and largely irrelevant in its current state, the uncertainty of what is next is difficult to sit with.

That’s why this career medical educator sat at a computer cubicle for the better part of 8 hours last week and took her MOC exam. I had a heavy heart as I did so, feeling that in some way I compromised my principles by being in that seat. My competence as a physician was not tested in this exam. Rather, the test seemed largely irrelevant, with a fair amount of esoterica that has nothing to do with my everyday care of adult patients. It was incredibly disappointing.

In my real job, I read the medical literature every day. I address uncertainty multiple times a day. I look up what I don’t know in real-time. I speak to my internist and subspecialist colleagues when something comes up that I cannot, or should not, handle. I think deeply about the controversies in medicine, with the long-held belief that understanding the controversy means truly understanding medicine. I have expertise in screening and prevention. I teach residents to identify uncertainty, to read, to question why, and to carefully and compassionately care for patients. These seem like the relevant tests of my competence. I’m not sure I need the ABIM’s seal of approval.

The ABIM has certainly lapsed from its self-defined mission of “accountability to both the profession of medicine and to the public.” It will take significant work to gain back the trust of its diplomats, if at all.

I applaud the grassroots efforts of Teirstein and others with their formation of the National Board of Physicians and Surgeons (NBPS) as an alternative to the ABIM. They formed the NBPS with a commitment to “providing certification that ensures physician compliance with national standards and promotes lifelong learning.”

I would hope for this group to define itself more explicitly as they work to attain credibility with physicians, hospitals, and payers. I hope for them to be more than just a reactionary alternative to the ABIM, but a group that will carefully and thoughtfully shepherd our profession through this process and more clearly define relevant “national standards” for practicing physicians.

Rachel Stark, MD, MPH, is a physician at Cambridge Health Alliance in Somerville, Mass, and teaches medicine at Harvard Medical School. She wrote this post as a Slow Medicine guest columnist.

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This article was first published on MedPage Today and reprinted with permission. Free registration is required.