A Letter to the State Senator from a physician who holds a time-unlimited certificate

"I am writing with regard to the requirement for physician Maintenance of Certification (MOC) which is included as a frequent component of healthcare legislation.  Language chosen for this mandate has resulted in significant anger and dismay in the community of medical providers.

As a doctor near the end of my medical career this issue has no great importance to my personal practice though it may accelerate my retirement. My interest largely stems from the fact that my son is just approaching the completion of his residency and from the concerns expressed to me by younger physicians, a number of whom I have trained.

Traditionally, certification has been the end point in various paths of medical training.  Tests are administered to demonstrate that the trainee has acquired an acceptable level of knowledge and is entitled to practice in a medical specialty or subspecialty. Recently, the poorly documented concern that knowledge may fade over time with an increase in adverse outcomes has resulted in requirements for recertification. In the past this has been at ten year intervals. This has been unpopular but accepted. With the passage of the Affordable Care Act a requirement for nearly continuous evaluation has been created. This process is termed “Maintenance of Certification”. The legislative language used creates a strict definition that produces a near monopoly for the organizations that perform initial certification.  Subsequent legislation has continued to refer to the importance of maintenance of certification (H.R. 1470).

This requirement has been greeted as unfair and arbitrary. Particular concern has arisen because the organization that certifies many medical subspecialties, The American Board of Internal Medicine, has come under scrutiny for its efficacy, methods and motives. These concerns are reviewed in two Newsweek articles authored by Kurt Eichenwald (http://www.newsweek.com/2015/03/27/ugly-civil-war-american-medicine-312662.html and http://www.newsweek.com/certified-medical-controversy-320495). In brief, the argument is made that the certifying organization lobbied to manipulate legislative requirements to promote the growth of a profitable industry that they will largely control. The process that they have created is expensive, extraordinarily time consuming and often requires extensive efforts in areas that have no relationship to a physician’s actual practice. Most importantly, the process has no demonstrated value in terms of improving outcomes. The burden of this process is considered so onerous that many physicians in private conversations express the possibility of leaving practice rather than submitting.

I think, when considering this issue, that it is worthwhile to try to shift terms. Certification is the process of determining that a practitioner has received adequate training to be considered a specialist or subspecialist. What society is actually concerned about is whether these practitioners continue to perform in a competent manner. Other countries, which have better outcomes than the United States, have consistently accepted participation in well designed, ongoing educational programs as sufficient to infer meaningful efforts in the maintenance of competence. Almost all subspecialty groups have such ongoing educational programs designed to promote knowledge in areas that are relevant to the pattern of a physician’s practice.  Participation in these or similar activities in addition to tracking outcomes in an individual physician’s practice with processes such as the Physician Quality Reporting System (PQRS) seem to be a more than reasonable requirements for demonstration of ongoing physician competence.

I strongly urge you to make efforts to remove language from legislation that refers to “Maintenance of Certification”. This term promotes a bias among payers with regard to using methods proposed by organizations such as the American Board of Internal Medicine (ABIM) as the best and possibly only approach to assuring continued physician competence. Efforts directed toward demonstration of competence should be minimally burdensome and certainly flexible enough to strengthen the knowledge and skills that a physician requires in their unique practice.

I would be happy to discuss this with you further if you would find it useful.  I would also be happy to refer you to physicians who have spent considerably more time and effort than I analyzing and addressing this issue.

Thank you for your consideration."