Monopoly in continuous board certification drives physicians out of medicine

Karen Schatten: ©NBPS

The largest board certification organization in the nation, the American Board of Medical Specialties (ABMS), recently announced a record-breaking number of ABMS-certified physicians in the United States — 988,737 out of 989,323 physicians, to be exact — easily cementing its monopoly status for its physician certification enterprise. Amid this highly profitable business model is a significant but little known driver that is exacerbating burnout and hastening the exit of physicians from clinical practice. ABMS Maintenance of Certification (MOC) is a proprietary continuing education product that to date has no high-quality evidence that it improves patient care. The cost and burden associated with MOC remains a significant factor driving physicians out of medicine.

MOC is undermining the foundation of the medical system — its physicians. Despite labeling MOC as voluntary, ABMS forces de facto compliance with its onerous and unproven continuing education product by successfully weaving MOC into the national credentialing landscape through its for-profit subsidiary, ABMS Solutions, LLC. Employers and government entities — hospitals, health systems, residency programs, health insurers and state boards of medicine — purchase and rely on data from ABMS Solutions for verification of physicians’ credentials. Physician data is big business, with ABMS Solutions reporting $8 million in revenue for 2022 with another $28 million held in assets. Because of ABMS Solutions’ intrinsic ties to parent company ABMS and its member boards’ physician data, ABMS Solutions reports physicians as “not certified” if they refuse to purchase MOC. Physicians are stripped of their coveted board-certified status and risk their jobs for failing to comply.

Physicians are responding as expected — by leaving medicine for good.

In close and exclusive collaborations with other arms of organized medicine, ABMS has created what amounts to a collective boycott against other certification bodies, entangling doctors in a monopoly that burdens dedicated physicians everywhere. In fact, a web of powerful organizations including the American Medical Association, the Accreditation Council for Continuing Medical Education, the Accreditation Council for Graduate Medical Education and the Federation of State Medical Boards work unchecked, and with intertwining and conflicted board relationships that have no place in science or public policy. This exclusivity also stifles employment opportunities, imposes unnecessary barriers on highly qualified physicians and, worst, reduces access to care.

Board-certified physicians are thus faced with a Hobson’s choice: continue spending significant time and money on MOC or jeopardize their job, future employment prospects and academic appointments critical for teaching the next generation of physicians. This lose-lose situation is compounded by physicians’ acknowledgement of the superfluous and for-profit nature of the MOC process. A 2023 American Society of Clinical Oncology survey of its members found that an overwhelming majority (82%) felt MOC was an unnecessary addition beyond typical continuing medical education (CME) requirements, with additional widespread agreement (74%) that MOC does not improve their clinically relevant knowledge or improve the quality of patient care.

Rupa Dainer, M.D., a former American Board of Anesthesiology board member, noted in conversation that “ABMS and its member boards know that there are no strong data supporting their MOC programs yet continue to force MOC upon physicians, the public and policymakers. This raised some very concerning ethical questions for me, and I could not in good conscience continue as part of their leadership.”

Similarly, a 2018 survey of U.S. rheumatologists found that 74.8% of respondents felt that MOC added no clinical value beyond what is already achieved by studying CME. The same survey found that the majority (73.4%) of respondents felt that the primary reason for ABMS creating MOC was either the financial well-being of board-certifying organizations or to satisfy administrative requirements in health systems. ABMS found little support even in its own survey, with just 12% of physicians finding value in MOC. These data beg the question of how and why this stranglehold of physicians and medicine persists, despite the existence of an innovative and much-demanded alternative. Dr. Dainer was not surprised by these survey results: “Dropping MOC often means leaving clinical practice and patients behind, a choice no physician should have
to make.”

With each physician lost, patient wait times increase, critically needed care is delayed and overall patient access to care worsens, even in federally designated Health Professional Shortage Areas (HPSAs). Recent data from the Health Resources and Services Administration show that more than 100 million people live in HPSAs for primary medical care. This population only sees a jarring 47.6% of health care needs met, with more than 17,000 physicians needed to serve these populations — statistics that are only worsening through unproven MOC requirements.

Physicians have been calling out MOC ever since its rollout, and it is imperative that we listen. Forward-thinking hospitals, health systems and payers are recognizing that offering competition to MOC helps recruit and retain quality physicians, leaving more time for patient care. It is past time for everyone to leave status quo burdens behind.

No single entity should be able to wield an expensive, arduous and unproven process that taxes U.S. health care, adds to physician burnout, and exacerbates the physician shortage. Requiring physicians to adhere to MOC requirements upholds a flawed and profit-driven system that drives highly qualified, board-certified physicians out of medicine.

Instead, we need to be looking at solutions that contribute to lifelong learning and keep physicians practicing medicine.

Karen Schatten is associate director of the National Board of Physicians and Surgeons.