Viewpoint: Author's view of MOC unrealistic

Author's view of MOC unrealistic

I believe the article "Maintenance of certification [MOC] has value for physicians and their patients," (Viewpoint, October 25 issue) is out of touch with reality.

There are other ways to participate in a "peer-developed, externally validated system," such as the Medical Knowledge Self-Assessment Program of the American College of Physicians or the Endocrine Self-Assessment Program of the Endocrine Society, which are both fractions of the cost of MOC.

Author Lois Margaret Nora, MD, JD, MBA, says the MOC process is unproven due to its "relative youth." However, voluntary recertification was started in 1974 by the American Board of Internal Medicine (ABIM). Surely some information could have been ascertained regarding the value of MOC over the past 48 years.

Voluntary recertification was the precursor to MOC. Mandatory MOC, otherwise known as time-limited certification, came about because very few diplomates participated in voluntary recertification. I'm sure Dr. Nora is aware of the increased fees and revenue that accrue to ABIM and other boards from continuous repetition of testing. Perhaps the American Board of Medical Specialties (ABMS) and member boards don't want to do a study in age-matched physicians who do and do not participate in MOC because if it showed no benefit from MOC, their tollbooth would close.

In my experience, the majority of physicians who participate in MOC and share their feelings about the program find the process to be essentially irrelevant and filled with attention to miniscule details of little clinical importance. I don't need to spend all that money to commit to quality patient care, and I demonstrate my dedication to my patients, community, and family daily without ABIM or ABMS assistance.

Can Dr. Nora answer why a secure test is needed when physicians have immediate access to clinical support on smartphones or computers? Does the secure test exist only as a source of revenue to the member boards?

Why is certification now time-limited? Is it to coerce diplomates into incessantly studying for tests and paying outlandish fees for member boards? Isn't it a cruel joke to call MOC "voluntary" with time-limited certification?

When can the ABMS demonstrate it is actually benefitting patients and physicians? When is the ABMS going to listen to the large and rapidly growing number of diplomates who think the MOC process is too expensive, intrusive, and onerous? When are the member boards going to lower the outrageous salaries of their leaders who are paid from the MOC tollbooth? These salaries are a clear insult to diplomates paying the exorbitant MOC fees. When are the member boards going to address the complaints of the participants in its programs?

When is the ABMS going to act on Dr. Nora's words? Actions speak louder than words, Dr. Nora.

MARC S. FRAGER, MD
Boca Raton, Florida

Testing doesn't make better docs

I disagree with Dr. Nora's opinion on maintenance of certification (MOC).

I am a family physician in practice for 12 years. I have worked in community health and private practice. I am medical director of an internal medicine clinic and involved in administrative duties. I see and talk to my patients and cover preventive health at office visits. I have built a full practice in less than 2 years of patient referrals, based on what I do.

I am a very good physician and must say that testing does not make a better physician. I work with doctors who test in the top 5% of their class and pass multiple boards yet lack the human skill set to offer good, compassionate patient care.

I learn more from up-to date and active continuing medical education courses than American Board of Family Medicine modules.

In addition, I have never been proficient at testing because I think of the entire differential diagnosis and find there is never enough information in a single test question. Think of the last time you were in medical rounds and a case was presented. Was there only one answer, or did you discuss the case further?

I would rather see oral boards every 5 years, with increased annual requirements for learning than the system currently in place.

MOC is a broken system that needs to go away.

ALEX DE MORAES, MD
Bellevue, Washington

Conduct a survey to gauge needs

I fully support the need for physicians to maintain their certification. However, Dr. Nora's viewpoint sadly fails to address the issues. In fact, she sounds more like a self-serving politician trying to validate the reasons for why the American Board of Medical Specialties (ABMS) needs to operate on a bloated budget.

Rather than use vague and unsubstantiated feedback like "many physicians speak of the relevance" of maintenance of certification and "some older doctors" speak of the importance of holding themselves to the same standard to which junior colleagues are held, I challenge Dr. Nora to be more specific and scientific by allowing a third party to tabulate the results of a survey that poses the following questions:

• As a physician, do you believe that ABMS has done what it can to keep the cost of recertification affordable?

• As a physician, do you believe that ABMS can achieve the same results through an online recertification process that would be less costly and time-consuming than its current approach?

• Do you believe that the management team of ABMS adequately represents the needs of full-time, actively practicing physicians?

STEPHEN H. CARSON, MD
San Diego, California

Unproven system not worth cost

I have chosen not to pursue maintenance of certification (MOC) because of the cost and absolute bizarreness of the process. I also, quite honestly, could not make heads or tails of the process as directed on the official Web site. It felt like a scavenger hunt where I had to do A before I would be told what the next thing B was that I'd be doing.

Is giving my patients a survey to ask if I washed my hands as I should and then tallying up the results going to make me a better pediatrician? I can't see how. Yet that was one of the MOC quality improvement projects recommended to me from the Web site. Sorry, but if I haven't learned how and when to wash my hands after 10 years in practice, then do you honestly think a silly survey is going to do anything? Additionally, my families want me to take care of their kids, not give them surveys and even more paperwork.

Sorry, but no deal. I refuse to pay a lot more money than it used to cost to maintain board certification to support an unproven system of recertification for which the only guaranteed purpose is to line the pockets of the executive doctors at the American Board of Medical Specialties and the American Board of Pediatrics. I'm too busy just trying to stay on top of patients, billing, and way too many onerous insurance requirements to play the MOC game.

CHRIS HICKIE, MD, PHD
Tucson, Arizona

Programs hold no value for most

Nothing gives the American Board of Medical Specialties (ABMS) the right to assert that its maintenance of certification (MOC) programs are the answer to patients' concerns for competency.

Since the 1960s, we have complied with the American Medical Association's continuing medical education Physician's Recognition Award program, which has grown to a $2.5 billion industry that documents the physician commitment to lifelong learning.

Hospital boards, peer review, the U.S. Drug Enforcement Administration, state law enforcement, the Centers for Medicare and Medicaid Services, insurance providers, state peer review organizations, families, patients, colleagues, and malpractice carriers all contribute to the proof that competency is confirmed in practice and has been for decades.

In ever-increasing measures, most physicians see no additional value in the ABMS MOC program. As overachievers, most have attained board certification, but 25% of all U.S. physicians have never been certified, and they provide competent care.

At some point, this farce of certification becomes transparent, especially under the recertification lifelong payment schedule of the ABMS. The posting of MOC status is little more than a corporate attempt to intimidate physicians into the purchase of this very expensive "product," even when in possession of the traditional lifelong certification. The problem is not grandfathering those with lifelong certification, it is the blatant extortion of younger colleagues into lifelong purchasing schemes.

The future of education is free Internet access to valuable materials, not expensive testing in vacation resorts (to encourage volunteer examiners and tax rebates).

Regulatory capture is the passing of laws to force the purchase of private corporations' products and is nothing new. The Federation of State Medical Boards' (FSMB) maintenance of licensure program is nothing short of attempted regulatory capture, very expensive, and prescribes not only testing every 5 years but also experimentation on patients without obtaining consent just to meet the ABMS/FSMB program requirements.

Patients want a physician who has compassion, time to listen, experience, and time to focus. They do not want overworked, distracted academicians who are preoccupied with the next test on entry-level basics or chart reviews for a corporate private interest group.

PAUL KEMPEN, MD, PHD
Broadview Heights, Ohio

Costs add up

When maintenance of certification (MOC) advocates calculate the cost of MOC, they do not take into account the cost of travel and lodging for self-assessment modules and, more importantly, the loss of income for offices that must close when the physician is away. Two thousand dollars is just the tip of the iceberg.

Also, I would like to see the evidence that this leads to better physician care. I am a five-time certifier (and never again).

ROBERT L. D'AGOSTINO, MD, ABFM
Canton, Massachusetts

Phoning in care a dangerous idea

I am an internist who has been part of a small-group private practice for over 16 years. I have heard constant reference to the medical home model to improve compensation to primary care physicians (PCPs). I carefully read the article "PCP status, compensation poised to improve" (October 25 issue) in which Robert Berenson, MD, makes mention of this several times.

The largest issue I have with his representation is care delivered over the telephone, care in my mind that carries extraordinary liability with absolutely no standards. Even if this care is compensated monetarily, have there been any clinical studies that prove it is safe, effective, and reduces healthcare costs?

As an internist who does not operate a concierge practice, I am adamantly opposed to diagnosing and treating conditions over the phone, with very few exceptions. I doubt anyone would be able to successfully defend treatment rendered over the phone if there was an adverse outcome. I also believe that without a comprehensive assessment, including a hands-on physical exam, and with the complexity of modern medicine and aging population, no one can evaluate adequately over the phone.

Has someone set up a protocol for treatment over the phone that has been scientifically studied, peer-reviewed, and accepted as a new standard? If a protocol has been set up, has it been adequately vetted by the medicolegal community? I don't see PCPs willing to accept this high-risk treatment strategy without adequate, evidence-based medicine to back it up.

If this is what administrative medicine sees as the future role for PCPs, then I would plan to change my job and discourage any medical students from pursuing a career in primary care. I do love my career choice, but I cannot be reduced to becoming a pencil pusher and telephone triage operator.

MATTHEW A. SHEHAN, MD
Omaha, Nebraska

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