MOC in rheumatology is 'no guarantee of anything': Debate over certification rages on
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Although maintenance of certification has long been held as proof that physicians are staying current with changes in their field, the tide may be turning, as an increasing number of physicians do not view its requirements as relevant to their specialty.
In 2015, the American Board of Internal Medicine issued an unprecedented mea culpa for substandard changes to the maintenance of certification (MOC) program, which culminated with the American College of Rheumatology promising to explore a move to certification using the American Board of Allergy & Immunology.
While the move to ABAI has not happened, satisfaction with ABIM certification and, in fact, the whole MOC process has continued to erode in the rheumatology community.
For some experts, including Paul Kempen, MD, PhD, president of the Association of American Physicians and Surgeons, moving from ABIM to ABAI is beside the point. “The government wants some private company to tell everybody: You are a competent physician,” he said. “But if you read the ABIM literature, the document states certification is no guarantee of anything. There is no guarantee about the quality or type of physician you are.”
Kempen was clear about what he believes organizations like ABIM and ABAI are offering. “They are for-profit corporations that call themselves nonprofit organizations,” he said, noting that they take hundreds of millions of dollars in fees each year.
David Daikh, MD, PhD, professor of medicine at Oregon Health and Science University, was slightly more measured in his commentary. “Of course, MOC has been a volatile issue,” he said in an interview, noting that he understands the concerns voiced by Kempen and others. “However, I do think that some sort of maintenance of certification is important, and a reasonable process and goal.”
The rapidly changing nature of science and medicine demands ongoing education, according to Daikh. “It should be incumbent upon us to stay up-to-date,” he said. “This is part and parcel of caring for patients, and the vast majority of physicians uphold that trust.”
Even a skeptic like Kempen acknowledged that some sort of continuing education for clinicians can be useful. But whether that takes the form of a shift from ABIM to ABAI, a change in CME accreditation or something else entirely remains to be seen. A statement on the ACR website notes that they “do not know the details of the evolution or what actual timelines for change would be.”
Healio Rheumatology reached out to both ABIM and ABAI for comment, but ABIM declined and ABAI has not responded. Without input from either of these organizations, at present, there remain more questions than answers on the future of MOC in the specialty.
Setting the Stage
When ABIM made changes in 2014 that forced clinicians to update certification yearly, rather than every 10 years, the criticism was loud enough that the organization was forced to respond.
“We clearly got it wrong,” Richard J. Baron, MD, ABIM president and CEO admitted in a Feb. 3, 2015, press release. “We launched programs that weren’t ready and we didn’t deliver a [MOC] program that physicians found meaningful. We want to change that.”
Despite that admission, the system has not changed. The effect on physicians can be felt financially and professionally. “They are selling a subscription, and you have to have it,” Kempen said. “You will likely need it to get insurance coverage, and you likely will not be able to get a job in a hospital if you do not have it.”
Hospital administrators and other such employers may argue that having certified physicians on staff offers confidence to patients, but Kempen says this thinking is flawed. “The public has no idea what board certification is,” he said.
New rheumatologists may feel the need to become certified at the outset of their career, locking them into yearly MOC for life. “If you let your certification lapse, they may not let you recertify,” Kempen said. “It is a nonprofit organization acting like the mafia, which is a bit of a problem.”
Kempen acknowledged that when the idea of recertification was first proposed in the late 1970s, ABIM “had a good product” that fostered some degree of faith that doctors met certain standards of practice. “Now, for many doctors, the only reason they have certification is because they are afraid not to have it.”
The situation came to a head in 2018, when ACR leadership surveyed members regarding a potential move from ABIM to ABAI. The results showed that while most respondents were either satisfied with or neutral about initial certification under the ABIM system, there is more dissatisfaction with the demands of MOC.
Daikh suggested that much of the content of ABAI certification aligns closely with rheumatology practice. However, most respondents to the ACR survey did not expect any major differences between ABIM and ABAI initial certification programs in rheumatology. That said, a small majority of respondents would prefer ABAI to ABIM initial certification.
“The process of certification is in many ways a legal standard to demonstrate that we maintain at least a minimum standard of competence,” Daikh said. “I still believe it is important and valuable to convey that we have been certified.”
The broader rheumatology community may not agree. In a 2019 paper published in Arthritis Care & Research, Sawalha and Coit evaluated data from 515 rheumatologists surveyed about the effect, value and purpose of MOC programs in rheumatology. Results showed that 74.8% of respondents found “no significant value of MOC,” apart from what they may learn from CME programs.
Moreover, 63.5% of rheumatologists believe there is no improvement in patient care from MOC, while 43.4% said that the most significant effects of MOC programs included improving the financial status of board certifying organizations. In addition, 30% of respondents believe that the point of MOC is to satisfy administrative requirements in health systems.
All of this underscored Kempen’s views on the system.
“The process certainly has some contentious areas,” Daikh added.
The Way Forward
One positive result of the study from Sawalha and Coit was that 65.6% of the rheumatologists surveyed believe that MOC allows them to stay current with advances in medical knowledge. However, this came at the cost of time away from patients (74.6%) and family (74%). Overall, a majority of respondents suggested that ongoing MOC requirements could lead to burnout, early retirement and reduced workforce in rheumatology.
“The challenge is now to figure out what the process of MOC should look like,” Daikh said.
Both Daikh and Kempen noted that forcing practicing rheumatologists to sit in examinations year after year, at best, takes doctors away from patients and, at worst, is belittling to their knowledge and professionalism.
“Many in rheumatology have advocated that the process of maintaining certification should be based on the things we already do to maintain clinical acumen,” Daikh said, noting that doctors regularly read peer-reviewed literature, engage in CME activities and join online groups discussing patient care. “A separate and additional process that is expensive and forces clinicians to take time away from their practice is really onerous.”
Kempen agreed that some version of the CME system may be sufficient, but he is unconvinced that even this is necessary.
An issue with a CME-based approach is that there is “a range of quality” in CME programs, according to Daikh. “Some programs are great. But many are not very rigorous or organized by people who do not necessarily have an eye toward both educating and validating competence.”
Daikh suggested that in an ideal world, organizations like ABIM and ABAI would be able to tailor programs to individual specialties and establish clear CME courses and standards for clinicians to follow. “More and more rheumatologists are specializing in certain areas,” he said. “It would make sense for them to engage in ongoing educational activities in those areas, rather than going back and reviewing the entire body of rheumatology, as they do now. It is an undue burden on physicians.”
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