Revised maintenance of certification rules are drawing howls of protest from doctors who are angry about "extortive" costs and other burdens.
Rarely does one hear raging, frantic invective from doctors at the level some are now spewing about new maintenance of certification (MOC) programs required for physicians who seek board certification.
The new MOC rules, customized by 24 specialty boards, require doctors to continuously learn rather than to cram for and take an exam every 10 years. Some of these boards, like the American Board of Internal Medicine (ABIM), require MOC point accruals for two-year or five year cycles.
Another sore spot for physicians: For the first time, the public can see which doctors meet or don't meet the requirements. The new rules are, as Illinois internist Westby Fisher, MD, said in an interview, "infuriating."
I'm not seeing the justification for all this angst. In just the last week, I've heard or read doctors' screeds on the MOC requirements. They've been described as "exorbitantly expensive," "extortive," and so on.
One Pittsburgh anesthesiologist, Paul Kempen, MD, likens components of MOC practice improvement module requirements to the fascism of "Nazi Germany," and to the "Tuskegee syphilis experiments."
Really?
In one of his many blog postings about MOC Fisher implies that the boards setting the MOC rules are controlled by "cockroaches."
Fisher, who maintains certifications in internal medicine, cardiology and cardiac electrophysiology, believes the requirements were "created in the dark" by "unaccountable corporations" and their directors, who are earning huge profits off of the fees. He believes they "scurry" under a claim that federal rules allow them to do this because the MOCs are quality initiatives, which he argues they are not.
"My problem with this whole thing is that they're tying it to my ability to earn a living," Fisher told me. "And the minute they do that they're stepping on my personal liberties, impacting my family and my livelihood."
Still, I fail to see the updated MOC requirements as the catastrophe many physicians would have us believe it is.
Indeed, the American Board of Internal Medicine, whose rules cover 200,000 physicians, says much of what Fisher and others have written contains "blatant errors."
"There is a great deal of misinformation out there. But trying to clarify with some of these bloggers is like poking the hornets nest," says Lorie Slass, the ABIM's senior vice president for communications.
Let's go through some of the physicians' concerns. Responses are mine, in combination with information provided by the ABIM.
1. The cost is too high. The ABIM's MOC protocols, which are more or less representative of other specialty board rules, cost about $200 per board certification annually, plus about $1,400 for a practice module to take the exam every 10 years. Maintaining three specialty certifications might cost $500 a year.
Wait, $200 is expensive? For a physician? That's one nice dinner for two. In fact, doctors can attend any medical conference in a year and get all the MOC points they need for the first five years. While some unhappy doctors claim they have to buy the costly practice improvement modules, that's untrue. The $200 fee includes it.
2. MOC requires doctors to undertake practice improvement projects requiring them to survey patients, which some doctors say violates HIPAA and fails to provide human research protections required by law.
Untrue. The patient survey consists of 48 questions that resemble those on the Centers for Medicare & Medicaid Services CAHPS (Consumer Assessment of Healthcare Providers and Systems) surveys.
The survey is an option in some, but not all, practice improvement modules offered. It does not violate HIPAA and is not human subject research. For modules with surveys, no more than 50 patients need to be surveyed and doctors themselves pick the patients.
3. The certification exam questions are irrelevant to physician practice, and many deal with obscure conditions.
Slass replies: "We don't ask about obscure and rare information." Rather, questions are chosen by doctors who are "actively involved in patient care and think carefully about what might be experienced in practice. It's what a competent physician in that specialty would be expected to know."
My take: Even if some questions are obscure, what's wrong with that? Besides, diagnostic and treatment knowledge changes rapidly, and these will help doctors stay on their toes.
4. Practice improvement modules require doctors to perform unnecessary, extensive chart reviews to examine their own quality, which detracts from time seeing patients.
Chart review can enable doctors to see a population picture of their care practice patterns. A doctor whose focus is solely on the needs of individual patients (one patient with diabetes at a time) may miss opportunities to treat entire patient populations more efficiently and effectively (all patients in a practice with diabetes).
5. State licensing boards and hospitals are inappropriately adopting MOC requirements as conditions of licensure or staff privilege. In an April legal complaint, the conservative Association of American Physicians and Surgeons said that means MOC is a restraint of trade.
I know that many in the healthcare industry are not convinced that the old certification rules guarantee that all doctors are sufficiently up to speed on the conditions they receive payment to manage and cure.
From the time a doctor is trained and receives license to practice from the state to the time in 10 years he or she takes the exam, and the 10 years after that, there is an enormous gap unfilled by an occasional continuing medical education course. Nor is there enough disciplinary oversight from a licensing board if a doctor's practice comes under licensing review.
The new system undoubtedly will fall far short of filling the gap. But it's at least a strong start, and as ABIM officials have reassured me, it's sure to be tweaked and improved along the way.
6. MOC is too hard on older doctors and will force them to retire early, worsening the physician shortage.
Doctors who passed their first board certification exam prior to 1990 don't have to take the 10 year exam until 2023. If they do not pass by then, they will still be listed as certified, but will also be shown as "not meeting requirements."
Richard Baron, president of the ABIM, says older doctors will not get a pass on meeting cyclical requirements. "If someone is seeing a lot of patients a day, why wouldn't that be applicable?"
That's the question I have too. A board's certification should mean that doctors know today's standards of practice, not those in play decade or more ago.