Illustration: Paul Zwolak for OBG Management
The American Board of Medical Specialties (ABMS) has decided to trade the phrase “maintenance of certification” (MOC) for “continuing board certification,” a seemingly minor change that has an important backstory. This is the story of how the physician community flexed its collective muscle and how the American College of Obstetricians and Gynecologists (ACOG) helped broker an important détente and pathway in a highly contentious issue.
Founded in 1933 as a nonprofit organization dedicated to maintaining high uniform standards among physicians, the ABMS and many of its specialty boards have found themselves, for more than a decade, under heavy fire from physicians (especially family physicians, internists, and surgeons), their 24 subspecialties, and the state medical societies representing them.
The ObGyn experience with the American Board of Obstetrics and Gynecology (ABOG), however, is better for a number of reasons. Historically, ABOG and ACOG have worked closely together, which is an anomaly among boards as many boards have an arms-length or even an antagonistic relationship with their specialty society.
The discussion below outlines physician concerns with the ABMS and related boards and describes efforts to address and rebuild the continuing board certification process.
Direct and indirect costs
Physicians are very concerned with the costs involved in MOC. Measurable costs include testing fees, while indirect costs include time, stress, travel to test centers, and threats to livelihood for failing a high-stakes examination. Physicians want the high-stakes exam eliminated.
Relevance to practice
Physicians often feel that the MOC has little relevance to their practice, which fuels a sense of resentment toward boards that they believe are dominated by physicians who no longer practice. Subspecialists feel farther away from general practice and the base exams. Generalists feel that the exams miss the points of their daily practice.
Lack of data to show improved quality of care
Physicians want to know that the MOC is worth their time, effort, and money because it improves patient care. To date, however, empirical or clinical data on patient outcomes are absent or ambiguous; most studies lack high-level data or do not investigate the MOC requirements. Physicians want to know what the best MOC practices are, what improves care, and that practices that make no difference will be discarded. In addition, they want timely knowledge alerts when evidence changes.
Relationship to licensing, employment, privileging, credentialing, and reimbursement
Hospitals, insurers, and states increasingly—and inappropriately—use board certification as the primary (sometimes only) default measure of a physician’s fitness for patient care. Physicians without board certification often are denied hospital privileges, inclusion in insurance panels, and even medical licenses. This changes certification from a voluntary physician self-improvement exercise into a can’t-earn-a-living-without-it cudgel.
Variation
Boards vary significantly in their MOC requirements and costs. The importance of an equal standard across all boards is a clear theme among physician concerns.