MOC Program Continues to Stir Controversy, Elicit Debate

The controversy surrounding the Maintenance of Certification (MOC) program of the American Board of Internal Medicine (ABIM) continues, as two experts argued whether the program is necessary in a debate held at TCT 2014.

As of this year, all physicians certified before 1990 and not given time-limited certificates must begin actively participating in MOC activities or risk being listed as “not meeting MOC requirements” on the ABIM website. Medical societies have asked ABIM to make changes to the program; some requesting suspension of the program entirely. Beginning in 2015, physicians who have not participated in the Physician Quality Reporting System will be penalized by Medicare — MOC is included in the system.

Pro: MOC improves clinical outcomes 

James E. Tcheng, MD, of Duke University Health System, Durham, N.C., said the MOC program is grounded in learning and education theory and improves clinical outcomes.

“The overall goal of education is to begin with strategic goals, followed by an understanding of needs at the individual level,” Tcheng said. “The learning objectives grow out of these needs, and then as a closing, learning needs to be assessed and the curriculum evaluated. We are overconfident in our ability to make a diagnosis and our clinical skills decline over time. Fewer than 30% of physicians examine their own performance data and try to improve.”

In making his case, Tcheng said a theoretical framework and select manuscripts exist, providing an evidence base that suggests MOC is useful.

“At the end of the day, we as health care providers and clinicians have a social contract with our communities and patients to provide the best care possible, and we have a social contract with society to provide improvements in population health,” he said. “The MOC program embraces the six principles of adult learning — adults are internally motivated, bring life experiences and knowledge to learning experiences, are goal oriented, relevancy oriented, practical and like to be respected. Assessment really needs to drive learning. You cannot improve what you do not measure, and this requires appropriate metrics and the corresponding processes to improve.”

Con: MOC program is flawed   

Paul S. Teirstein, MD, of Scripps Clinic in La Jolla, Calif., said physicians are already subjected to an enormous amount of annual testing, including continuing medical education (CME) — a large, multi-billion dollar industry.

“CME is a much better lifelong approach to learning — there is a lot of education with the CME program. Don’t be naive, MOC and CME are highly competitive. Many perceive MOC as an attempt by the American Board of Medical Specialties and ABIM to divert some of that revenue to its own organizations,” Teirstein said. “The irony of ABIM’s ‘Choosing Wisely’ program is that the program is said to reduce unnecessary medical testing and cost, while recertification and MOC is expensive with no evidence of efficacy. ABIM has to focus on value, just like we all do in our hospitals.”

According to Teirstein, if meaningful changes are not made, a noncompliance movement will increase among senior physicians. In turn, mass noncompliance will result in certification losing its gravitas and competing organizations will begin to offer certification. Furthermore, he said there are no data supporting the program’s use. In making his case, he said all studies in the literature evaluate board certification, not specifically recertification or MOC.

 “Should it be surprising that successfully completing years of training in an Accreditation Council for Graduate Medical Education approved program and then passing a closed book board exam makes us better doctors?  Just the drive to complete a training program should correlate with improved patient care,” he said. “It is simply absurd to equate the busywork of MOC ... clicking on computer modules for 10 hours each year … to the many years of training required for initial certification.”

Teirstein started a petition in March asking for changes to the new requirements.

Disclosures: 

• Tcheng reports having a financial relationship with ABIM and the American College of Cardiology.

• Teirstein reports participating in and directing CME activities in cardiology.