Cardiologists’ Anger Flares Anew Over ABIM Maintenance of Certification

Cardiologists once again are expressing their frustrations and anger toward the maintenance of certification (MOC) process overseen by the American Board of Internal Medicine (ABIM), saying it wastes their time and money but offers little in the way of meaningful benefits.

This is nothing new. Physicians have been complaining about the requirements needed to maintain their certification status for years, a sentiment that sparked the creation of an alternative certifying body—the National Board of Physicians and Surgeons (NBPAS)—back in 2015.

Now, though, there’s fresh pushback. The end of a COVID-19 pandemic-related pause on completing MOC requirements, which expired at the end of 2022, appears to be a factor. While most physicians will go through the ABIM process, pay the fees, and then return to their busy clinical schedules, some—on a background of mounting rates of burnout and job dissatisfaction—have reached a breaking point. They say that the MOC process, despite changes the ABIM has made to their requirements in recent years, is an onerous and unnecessary addition to continuing medical education (CME) requirements they already must meet at the state and hospital levels.

Cardiologists who recently spoke to TCTMD about the MOC program were adamant that they want to keep up to date on the latest advances in medicine, but used words like monopoly, rent-seeking, extortion, and ransom to describe what they see as an unfair wielding of power by the ABIM over their certification status: if physicians don’t pay their fees, they don’t get listed as certified by the ABIM.

“To be very clear, I am a devoted believer in the value of continuing education,” said Dhruv Kazi, MD (Beth Israel Deaconess Medical Center, Boston, MA), whose group assessed the costs of the MOC program in 2015. “This idea that since we attended med school and completed a residency and fellowship, we don’t need to train again, that’s absurd. What I’m arguing is: is an involved MOC program with high fees and a bunch of busy work the most cost-efficient, high-value way of maintaining that education?”

The Process and the Pushback

The ABIM is the largest of 24 member boards of the American Board of Medical Specialties (ABMS), encompassing about one-quarter of US physicians, including cardiologists. Physicians are required to complete a certain number of MOC credits each year to maintain their ABIM certification status. The program has evolved over the years, with multiple options for fulfilling the requirements. The annual fee for the first certificate is $220, plus $120 for each additional certificate, with many physicians holding certificates in multiple subspecialties. In addition to the annual fee, physicians taking the 10-year MOC exam option pay $700 at that time.

There are additional financial costs in terms of paying for the activities that earn the MOC credits, which could be completed through a collaborative pathway like that offered by the American College of Cardiology (ACC), as well as review courses to get up to speed on what’s needed for the exams. However, another common complaint with the program is a lack of practice relevance in terms of what’s required of physicians to fulfill the MOC criteria, with little flexibility in terms of what types of CME can be used.

In addition to the monetary investment in the process, doctors spend a lot of time completing the requirements, too. “The real cost of the program is the fact that we’re making physicians who could have been using that time for alternative activities, including providing patient care, engage in these fairly time-intensive activities,” Kazi said. “And when we assessed the 2015 program, we said 90% of the cost of the program was the time that physicians spent on engaging these activities, some of which have questionable benefit.”

Other complaints abound. Some point to the ABIM’s sharing of physician data, particularly in light of a recent data breach affecting about 800 organizations, including the ABIM.

Others are aggrieved about the “grandfathering” of physicians who were already board-certified when time-limited, ongoing certification was introduced in 1990—replacing lifetime certification with a requirement for recertification on a 10-year cycle—calling this discriminatory toward younger physicians.

The overarching problem, for many, is that even though the ABIM’s MOC process is technically voluntary, it’s become a de facto requirement for practicing medicine in the United States. That’s because most hospitals and health insurers require it, so physicians who don’t maintain their certifications risk losing their jobs or not being able to find new ones.

There could be legal issues as well, noted Allison Dupont, MD (Northside Hospital Cardiovascular Institute, Gainesville, GA), citing incidents in which physicians have been sued and the lack of ABIM certification was used a reason to find them at fault. “It's almost like holding your certification at ransom, is how I view it,” she said. “Because we're certified, yet they're able to tell people that we're not certified because we're not giving these fees to them.”

Money for Nothing?

Westby Fisher, MD (NorthShore University HealthSystem, Evanston, IL), who describes himself as a “national thorn in [ABIM’s] side,” is a board member of the nonprofit Practicing Physicians of America, which has supported lawsuits against the ABIM and other ABMS boards. He portrayed ABIM as a greedy organization focused on extracting more and more money from physicians through the MOC fees.

“Physicians are rightfully very incensed because this group doesn't do anything. The maintenance of certification has never been shown to improve the quality or safety of patient care,” he said. The MOC program represents “virtual extortion of physicians by these continuous fees, and doctors understand that this is just a moneymaking operation for these guys.”

The program is “really kind of a pay-to-play thing, and unfortunately affects our right to work because if we lose our certification, we lose hospital credentials, we lose our ability to bill insurance companies, we lose our credibility when we're sued in court because we no longer are board-certified,” Fisher said. “They're just making money and they certainly are not benefiting patients in any way because they make their doctors leave the practice. We have a lot of doctors who have left medicine because of this problem.”

Edward J. Schloss, MD (The Christ Hospital, Cincinnati, OH), likened the situation to “taxation without representation,” saying the ABIM is a private organization and doesn’t answer to physicians. “We are absolutely taxed by time and money. We have no representation,” he said. “And no one's ever shown in a manner that passes any scrutiny that any of this has any value to anyone other than the profiteers of the ABIM.”

Completing the MOC requirements “would be all fine and dandy if it was not an onerous process and it was something that we all bought into,” Schloss said. “But there's a very strong sentiment within the cardiology community, and I think it extends well outside of cardiology as well, that these boards do not offer us value and they are most certainly a large source of time and money loss on our part.”

What the MOC program requires for certification, according to Paul Teirstein, MD (Scripps Clinic, La Jolla, CA), founder and president of the NBPAS, is largely “make-work”—answering multiple choice questions with little relevance to one’s practice and completing time-consuming practice-improvement projects that don’t improve the quality of care delivered. “The overriding motivation just increasingly appears to be a financial gain on the part of the American Board of Medical Specialties,” Teirstein told TCTMD. “They charge money for this every year, and it's like a toll booth for the doctors.”

Does MOC Improve Care?

Increasingly, cardiologists are asking whether these financial investments deliver any concrete benefits to practice. “There's no proof that these allow patients to receive better care, and there’s no proof that it advances a physician's knowledge any more than the CME” that is already required by states for licensure, said Dupont. Hospitals, too, have their own CME requirements, and all of this adds up to a lot of time spent keeping up to date, she said.

“So for me to do all of those CMEs and oftentimes pay for all of those CMEs outside of the ABIM, and then come back and have to pay the ABIM to say, ‘Look, I did my CMEs,’ really is disgusting,” Dupont said. “It’s extortion.”

The point should not be simply to say that one is certified, Kazi argued: “That’s not the endgame. The endgame is to improve quality of care and efficiency of care and to generate value for our patients, and that’s the piece that is missing here. It’s unclear to me that the MOC has ever been shown to achieve that goal.”

Though the ABIM lists numerous papers purported to show the positive benefits of involvement in the MOC certification process, cardiologists speaking with TCTMD remained unconvinced that it adds anything substantive on top of completing CME.

“Purely as an outcomes researcher, I can tell you that many of those studies are horribly confounded,” Kazi said. “The empiric evidence that MOC improves outcomes is sparse. And the statistical approaches used in some of those studies would have difficulty getting through peer review at this point.”

The ABIM’s program has been around for decades, he added. “What are we getting for it, and is there a more efficient way for physicians to regulate themselves? The MOC program is a substantial investment, and the onus should be on the ABIM to prove to physicians that this process is necessary and that we’re helping patients, which, in the end, is what we all care about.”

Teirstein said the evidence put forth by ABIM is often done by the organization itself: “They manufacture their own evidence. They write their own papers. Highly paid researchers do the research, and they claim it shows benefit. But if you analyze the research, it doesn't show benefit at all. Meanwhile, there are other studies that have shown no benefit.”

ABIM Defends Value of Certification

Richard Baron, MD, president and CEO of ABIM, pushed back on claims that there’s no evidence supporting the clinical benefits of participating in the MOC process. “There's a ton of evidence that people engaging in this program in important clinical ways do better than people who are not engaging in this program,” he told TCTMD. He cited a study in JAMA Network Open showing that at a time when practice was already moving away from routine prescription of opioids, physicians who performed better on an ABIM exam were less likely to prescribe the drugs for back pain compared with physicians who had worse test scores.

This is “a real example of active change in practice when the standard of care changed, manifested by people who were engaged in the program that demonstrated you’re staying current,” Baron said.

Baron further defended the “real value” of physicians being able to say that they have maintained their certification through the ABIM—and the costs of providing it.

“The market values board certification because there's meaning and standards and substance behind the program,” he said. “The market values that, and what the fees are designed to do is cover the costs of having a program that shows that you're certified, that you have met a set of standards that are meaningful standards.”

There are multiple ways that physicians can go about getting certified, he added, pointing to the ACC’s Collaborative Maintenance Pathway as an example. “The common thread is you have a substantive set of standards and you demonstrated that you stay current,” Baron observed.

Responding to those who have said they’re being stripped of their certified status for not making the payments, Baron insisted that nobody loses certification simply for not paying their fees, and that the fees are used appropriately. “The program has requirements. And processing that people have met those requirements involves taking in data from a bunch of sources. It involves offering assessments to people to take them. It involves having things like a customer service operation to respond to questions that people have. It requires generating the assessments that are valid and legitimate, bringing experts together and creating all of that,” he said. “All of that is happening all of the time. That's the program, and being reported as certified says you're meeting the requirements of that program.”

Baron said that when he started at ABIM about 10 years ago, he and others recognized that improvements to the MOC program were needed in the face of anger coming from the cardiology community and beyond, and worked to change it.

“We've evolved dramatically,” he said. “There was not a longitudinal knowledge assessment program before. There is now. There was not a collaborative program with the American College of Cardiology. There is now. So there are a variety of ways that the program has changed.”

Baron acknowledged that the ABIM could do a better job at communicating the value of maintaining certification, adding that the organization made a big mistake by not better explaining the purpose of switching from lifetime to time-limited certification, which was to ensure that physicians were keeping abreast of changes in medicine. “We did a terrible job explaining it,” he said. “And not only that, we undercut our own story by making the political decision that people would still have lifetime certification if they got it originally. We said, ‘Well, we told you it wasn't time-limited, so you'll have it forever.’ That undercut the story that the program was about staying current in the field.”

As the world continues to emerge from the COVID-19 pandemic, he defended the need for ABIM certification. “I don't think it's that hard for people to understand that knowledge changes quickly, that self-assessment is not a trustworthy or reliable way to demonstrate that you've stayed current, and that having a program that does that in a way that is publicly recognizable and publicly identifiable adds value to all of us as a profession,” Baron said. “And at a time that we're all trying to distinguish doctors from all kinds of other people who pretend to be doctors on the internet or elsewhere, having a substantive credential that's reliable, I think, [is] more important than it's ever been.”

An ABIM representative also responded to Schloss’s contention that ABIM does not represent physicians, pointing out that eight of nine members of its cardiovascular board are practicing clinicians, including one nurse, and that the organization publicly advertises all governance openings.

As for criticisms about the time it takes to fulfill the MOC requirements, the representative indicated that the process has become less time-consuming since the 2015 analysis by Kazi’s group. She pointed to the longitudinal knowledge assessment (LKA) introduced last year, which takes up about 4 hours per year for participants: “Because the LKA is intended to test ‘walking around knowledge,’ there is no expectation that a physician would spend significant time or any money outside of taking it. It is intentionally designed as a lower-stakes, formative assessment.”

Staying Up to Speed

All of the cardiologists who spoke with TCTMD stressed the importance of continuing education throughout a career of practicing medicine.

“I'm all about lifelong learning,” Schloss said. “Most doctors will rightfully tell you they are all about lifelong learning, but lifelong learning that is prescribed by a third party that doesn't represent us, doesn't have representation from us, and includes quite a bit of things that aren't relevant to each individual physician—that's not the kind of lifelong learning that's appropriate or necessary for us.”

He and others pointed to the NBPAS process, which closely matches the CME requirements for licensure across states, as a better, less costly, and less onerous way to maintain certification—after initial board certification from the ABMS or American Osteopathic Association (AOA)—than that offered by the ABIM.

“That's why I'm encouraging people to go to their hospital systems and ask them to recognize the NBPAS rather than requiring ABIM certification,” Dupont said.

NBPAS Associate Director Karen Schatten, MLS, touted the benefits of competition and said the advantages of their certification pathway include the requirement for CME credits to be within a physician’s specialty and the alignment with other existing physician requirements for state licensure, making the process less time-consuming than the ABIM program. And it costs, on average, 72% less.

NBPAS certification is currently recognized by at least 191 hospitals, although there are probably many more that have accepted but not notified the organization, according to Executive Director Katie Collins. Many of the large insurers and major national accrediting bodies for hospitals and payers—including the Joint Commission and the National Committee for Quality Assurance—have started accepting the certification as well.

Yet the NBPAS is still trying to make headway against ABIM certification, which is required by most hospitals and health insurers. Since its creation, NBPAS has certified about 11,000 physicians, including 8,000 active and 3,000 who are either retired or haven’t renewed. In comparison, data from the ABMS showed that there were 262,379 board-certified diplomates in internal medicine alone.

Another issue making it difficult for NBPAS is the fact that any physicians teaching in residency programs are required by the Accreditation Council for Graduate Medical Education (ACGME) to hold certification from one of the ABMS or AOA boards. Schatten said discussions with the ACGME are underway to try to overcome this obstacle.

For Fisher, what’s needed for physicians to keep up to date on evolving medical knowledge is “self-selected, accredited continuing medical education for state licensure. That's all we need. We don't need maintenance of certification. That was totally created because the ABIM was burning through cash for all their salaries.”

Schloss said “it’s debatable whether any form of certifying body is necessary, but if people want to have certification that distinguishes them, then a voluntary organization like NBPAS would be quite reasonable and I would certainly support it.

“And then beyond that,” he continued, “we have all the other mechanisms that are in place, like state regulatory boards and accountability to our patients and the legal system and hospital oversight. All of those things provide a lot of value and there there's some degree of accountability and representation in those systems that does not exist in the ABIM.”

Eyeing a Path Forward

Whether this latest round of dissatisfaction will spark any meaningful changes in the coming years remains unclear, although it continues to be on the ACC’s radar.

In an emailed statement, Edward Fry, MD (St. Vincent Medical Group, Indianapolis, IN), immediate past president of ACC, said the organization “understands the very real clinician concerns about cost, burden of time, and relevance to practice, while also acknowledging that achieving and maintaining clinical competence are fundamental to meeting the professional and ethical responsibilities to patients and the public.”

Over the past few years, “the ACC has intensely focused time and resources on developing better, less expensive, and more meaningful tools to promote competence beyond maintaining certification that currently solely relies on passing timed tests,” Fry said. “We are actively developing innovative approaches to change this paradigm to help clinicians grow and maintain competencies throughout their lifelong learning journey while reducing unnecessary burdens and delivering on the Quadruple Aim.”

Some say that to make a big change, physicians need to unionize, but that would be difficult, Dupont said. “The other option, which I think is probably more likely to occur and more realistic, is that we need to educate our hospital systems. Everybody needs to be aware of this problem, and unfortunately not everybody's on social media to know that it's even a problem,” she said, adding that professional societies like the ACC, the Society for Cardiovascular Angiography and Interventions, the Heart Rhythm Society, and others outside of cardiology need to help with that.

Schloss underscored how challenging it can be to change policies at the hospital level or to heap yet another task on the plates of busy physicians. “It's like a lot of organizations: once certain policies get put into place, they become ossified, and trying to change them is extraordinarily difficult,” he said, adding, too, that “doctors are not particularly known for their ability to organize as a group. . . . We're quite busy with our jobs and we're driven by the passion of taking care of patients, and over the years we've certainly gotten used to doing a lot of things that we don't particularly like to do just to keep working.”

That needs to change, said Kazi, urging physicians to become “more vocal.”

“I think it’s important for patients and society to understand how onerous this program is for physicians, both in terms of time and money, and how sparse the empiric evidence is suggesting that MOC improves outcomes,” he said. “I also believe it’s important for physicians to understand that we’ve done this to ourselves . . . and any alternative will require our active participation to design a continuing education system that is efficient and cost-effective, and more importantly, helps our patients.”