Friday, December 28, 2012

Maintenance of Certification and Quality: There Are Two Sides

I had written a previous post on this subject earlier, but with two articles out this week in premier journals (the New England Journal of Medicine  and JAMA), I am seeing some interesting chatter on Twitter from well-respected physicians describing the downsides of Maintenance of Certification, or MOC.  Here are two previously written blogs (#1  and #2) outlining these “downsides”.  It is clear to me how these physicians feel about the MOC process.
There could be many ways to discuss the issue of MOC in this blog.  I will try to focus on simplicity: “for” and “against”, along with literature that highlights each of these arguments.
Arguments challenging the current process of MOC
1.       It takes physician’s time away from direct patient care.
2.       It is a “bureaucratic scam”, due to the fact that it is very costly, with the beneficiaries of monies being the leadership of the Boards comprising the ABMS (American Board of Medical Specialties).  [Interesting that this article is not referenced in PubMed, but can be found through standard non-medical search engines.]
4.       It has not been shown to benefit patients or patient care.

Arguments in favor of the MOC process
1.       If not the current ABMS MOC process, then there exists the possibility that other regulatory agencies (such as OSHA) could dictate how physicians should practice (see quote in article by Dr. Robert Wachter). 
2.       There exists a correlation between higher scores on MOC examinations and quality of care. (Article 1 and Article 2).
3.       Physicians who spend the majority of their time in practice, not just “academic types”, validate the content of MOC examinations.
4.       The farther out a physician is from training, the lower is the quality of care provided.  While this seems to be a pretty harsh statement against the “there is no substitute for experience”-argument, the current literature does support this position.

I am sure that there are many other arguments for and against MOC.  This blog is not intended to be a mathematical "weight comparison" of articles on the topic.  My own opinion on this is simple: physicians need to engage in lifelong learning (Article #1 here and Article #2 here), under the “Practice-Based Learning and Improvement” competency.  Whatever the ideal process should be for this, I cannot say with certainty, but I would much rather have those within my own specialty, who also understand educational methodologies, regulate ongoing physician certification, rather than others that are removed from the day-to-day challenges of the current practice of medicine.  The current leaders in my specialties, who dictate the regulations as they currently stand, are the ABIM and the ABP.  This was summarized in my Annals of Internal Medicine letter to the editor earlier in 2012. 
So what do you think about the process of MOC as a way for the ABMS to hold physicians to a standard acceptable to the public?  Is it working well?  If not, what could be improved?

In full disclosure, I am not employed by the ABIM or any of the ABMS boards.  I personally know one member of the ABIM, from his days as a former program director.   I have not written examination questions for the ABIM or the ABP.  I get no royalties from the ABIM, the ABP or the ABMS, and have no stock in these companies or any of their subsidiaries. 


  1. Just a quick comment to answer your question on why the Journal of American Physicians and Surgeons article isn't in Pubmed. The journal itself is not indexed for MEDLINE. It seems there's some controversy regarding the quality and political motivation of the journal, so it's unlikely that it'll ever be indexed in MEDLINE (and therefore available in PubMed) because of rigorous standards (the title has been submitted for review at the National Library of Medicine twice and was not accepted).

    As a sidenote, thanks for your thoughtful blog posts on issues of medical education! I recently moved from being a hospital librarian to the realm of academic medicine, and find your words invaluable!

    Amy Donahue, MLIS, AHIP

  2. Thank you, Amy, for your helpful info on AAPS.