Maintenance of Certification Has to Go
We have to demand evidence for accrediting doctors
We are two practicing physicians who strongly support a petition gaining traction on Change.org to eliminate the American Board of Internal Medicine’s Maintenance of Certification (MOC) requirement. From our perspective, MOC is a financial product made to enrich a professional organization that has no credible data that it ensures better physicians.
In order to practice medicine in 2023, a physician has to constantly be learning– keeping up with the latest drug and device approvals, reading clinical trials, incorporating new prognostic scores, and even learning entirely new or emergent diseases, such as COVID-19. Trying to practice medicine based solely on what you learn in medical school, residency or fellowship is a doomed strategy.
Already, there are a variety of checks and balances that ensure doctors keep learning. First, is of course, the strong intrinsic desire of doctors to practice the best available medicine. Doctors want to do what is best for their patients and many of us read far more than what is needed to maintain our licenses. Second, is the decision, made nearly 3 decades ago, to make board certification lapse every 10 years, requiring renewal. Third, is the use of continuing medical education (CME), employed by many state medical associations to ensure annual or biannual education.
Fourth, and most controversially, is the ABIM’s MOC program. MOC is the latest burden to the busy physician, and can be satisfied with a large payment to the ABIM organization, and open book test questions. In fact, data from the ABIM reveals that 51% of the organization’s income comes from the MOC fees. That ABIM income is used to pay the lofty salaries of ABIM executives, including the over 1 million dollar salary of ABIM’s president Richard Barron.
Collectively, there is nearly no credible evidence, which, if any, of these activities, improve the quality of medical care. All of these strategies were deployed largely to give the public the assurance that physician’s care about self-policing, but we have never subjected any of them to the most robust validation. That might have been fine in the 1990s, but is untenable today.
Doctors are now in a crisis of professional burnout, and rates of moving to non-clinical jobs such as the pharmaceutical industry is now as high as 1 in 17 for some specialties, as our recent research shows. As such, we have a duty that every single task we demand of doctors has been shown with solid, prospective studies to improve medical care.
MOC is unlikely to pass this standard. It is at least the 4th hurdle physicians have to jump through. It can be satisfied by answering questions with open access to any medical reference and Google. It is hard to believe that testing doctors– people who have studied for decades– with an open book exam makes them any better. Instead, it seems far more likely its real motivation is to boost the revenue of a greedy organization.
Some contend that doctors who are compliant with MOC activities get better scores or provide better care than those who are not compliant. In fact the ABIM promotes a paper on their website that claims that docs who initially certify for MOC have better outcomes than those who do not.
This is the classic error of confusing correlation with causation. Doctors who are non-compliant (or slowly compliant) may be inferior to those who are rapidly compliant, but this does not mean that MOC provides value, but rather that any test of obedience selects for better physicians. By this logic, one could quiz doctors on baseball statistics, and surely those who memorize the stats will be the better doctors– but that doesn’t mean learning bartering averages makes you better at navigating renal failure or a new cancer diagnosis. Additionally, this research also suffers from the flaw that patients are not randomized to providers and important unmeasured confounders may exist.
In another study, promoted by ABIM, the authors interviewed 39 internists who were completing MOC. They conclude “Most physicians interviewed expended substantial effort studying for their MOC exam, and recalled numerous examples of how knowledge gained through this process seemed to improve quality and/or efficiency of care”
What they miss is that interviewing 39 people is the lowest form of evidence imaginable. It has no control arm– what would they have done if not for MOC. It doesn’t show this knowledge improves patient outcomes, and worst of all is subject to selection bias– who agrees to be interviewed by ABIM?
Ironically, the proponents of MOC need a remedial education in evidence appraisal. They seem not to understand basic principles of science. Instead of conducting flawed research, we would be happy to give them a course on how to improve their work, for the low price of $5000, billed annually to a credit card.
MOC is the straw that broke the camel’s back, but every burden warrants reconsideration. Does a 10 year recertification improve medical care? Does checking a box every 2 years when you renew your license saying you did CME make you a better doctor? Ultimately, the knowledge given and tested in these activities is a sliver of the knowledge a doctor needs, and often skewed towards embracing controversial for-profit drugs that came to market with disputed evidence. For instance, for some activities the right answer is Entresto in heart failure with reduced ejection fraction, or Olaparib in pancreatic cancer, two drugs, with disputed evidence base. Often questions are written by doctors with conflicts of interest with the drug companies. As such, at times, keeping up with medicine feels like being further indoctrinated to prescribe drugs that warrant serious reflection and consideration.
Physician burnout is omnipresent and MOC is a burden doctors face. MOC earns the sponsor massive amounts of money. What is entirely uncertain is whether MOC– or other cudgels to motivate physician learning– actually work and actually make us better doctors. This is not acceptable for a profession based in science and evidence. We urge others to sign the petition that MOC has to go, and call for a broader reconsideration of the burdens placed on practicing doctors.
Vinay Prasad is Professor and a practicing hematologist oncologist at UCSF, tweets at @vprasadmdmph, and writes for the substacks Vinay Prasad’s Observations and Thoughts, Sensible Medicine, and the Drug Development Letter. He hosts a popular Youtube Channel, and several popular podcasts.
Aaron Goodman is Associate Professor and a practicing hematologist oncologist at UCSD, he tweets at @aarongoodman33, and writes the substack Papa Heme’s Educational Portal