A petition demanding an end to maintenance of certification (MOC) requirements from the American Board of Internal Medicine (ABIM) gained traction among oncologists in late July, garnering nearly 7500 signatures in 10 days.
The MOC program, “originally intended to uphold the standards of medical practice and promote lifelong learning, has evolved into a complex and time-consuming process that poses significant challenges to practicing physicians,” according to the petition, launched on July 21 by hematologist-oncologist Aaron Goodman, MD. The MOC “has become burdensome, costly, and lacks evidence to support its effectiveness in improving patient care or physician competence.”
In 2 days, Goodman, assistant professor at the University of California, San Diego, is scheduled to debate the matter with ABIM President and Chief Executive Officer Richard J. Baron, MD, during a Healthcare Unfiltered podcast recorded and hosted by Chadi Nabhan, MD. In the August 3 podcast, Goodman and Baron will respond to questions posed via tweets, Goodman said.
A Twitter survey posted by Nabhan in advance of the debate asked physicians whether the cost of the MOC, the time required for testing, or data sharing by ABIM is most bothersome. Of 158 respondents, 71% selected “all of the above.”
ABIM Touts MOC “Values”
The ABIM requires an initial certification assessment that costs thousands of dollars and must be repeated every 10 years. The annual MOC requirements, which were tacked on within the last decade, involve tests that cost $220 for the first certificate a physician holds and about $120 for each subsequent one.
Over the course of his career, Goodman estimates he will spend over $40,000 to maintain his three ABIM boards in medicine, hematology, and oncology.
The ABIM did not immediately respond to a request for comment on the petition and debate, but a page on the ABIM website touts the “values of MOC” and says there is “compelling evidence” that the MOC improves the value of care without sacrificing quality and that board-certified physicians earn more.
According to the website, the MOC program “provides doctors with a pathway to know that they are staying current in the medical knowledge they use to treat patients and make important care decisions daily.” The ABIM also says that the “program has evolved to include new assessment options and an increased recognition of the work doctors do every day” and that the ABIM “continuously collaborates with doctors to increase the relevance of exams.”
Aniruddha Singh, MD, also weighed in on the value of MOC in a July 13 ABIM blog post. Singh is a member of this year’s Cardiovascular Disease Traditional, 10-Year MOC Exam Approval Committee and program director for the General Cardiovascular Fellowship at Drexel University College of Medicine, Reading, Pennsylvania.
In his post, Singh states that the MOC “facilitates a broader perspective on a range of topics [and] enables me to delve deeper into relevant areas, fostering a comprehensive understanding that enhances my quality of care.”
Growing Resistance
Although Goodman acknowledged the merit of board testing every decade or so, physicians already do continuing medical education (CME) to keep up-to-date on their specialties. Goodman believes that most physicians, other than those who work for ABIM, would agree that MOC is a waste of time and money.
“It’s a pain-in-the-ass module that you sit at home and Google — it’s not really any sort of assessment,” nor does it help protect the public, said Goodman. The MOC is ultimately “just a money grab.”
According to the ABIM’s website, the nonprofit has net assets of more than $73.2 million as of June 30, 2022. Last year, the ABIM’s revenue hit $71.9 million, with more than half coming from MOC fees and 48% from certification.
The ABIM also says it spent $58 million in 2022. A breakdown shows about 63% of that money went to administering (28%), researching (13%), overseeing (4%), and developing (18%) the certification and MOC exams and program. ABIM’s CEO Baron makes about $1.2 million a year, according to recent tax filings. The COO makes about $550,000 from the ABIM and “related” organizations.
Fed up with the requirements and cost, Goodman decided to launch the petition to see if others agreed and how many.
His petition, addressed to the ABIM, expresses “deep dissatisfaction” with the ABIM MOC program and “respectfully request[s] that the ABIM take immediate action to eliminate the MOC program and adopt alternative, less burdensome methods of ensuring physician competence and continuous professional development.” Goodman, alongside Vinay Prasad, MD, a hematologist-oncologist and professor at the University of California, San Francisco, reiterated these points in a piece highlighting the petition.
Shortly after the petition went public, Goodman said he received an invitation to join the ABIM Board of Governors. “My hypothesis is they are trying to ‘friend’ me, so I get credentialed, and they get me to stop yelling. It just made me more pissed off. I don’t want to be any part of that,” he said.
H. Jack West, MD, a thoracic oncologist and associate professor at City of Hope Comprehensive Cancer Center, signed the petition without hesitation.
West agreed with Goodman that the 10-year ABIM recertification is sufficient. He also denounced the ABIM testing process, costs, and content, saying he found the questions “so ambiguous that even knowing everything about the subject, I found the assignment of the ‘best’ answer to be a Talmudic interpretation.”
“The questions seem to have a sadistic level of complexity and ambiguity baked into them, rather than being a direct assessment of knowledge,” he explained.
The ABIM is also “completely opaque” about their process of developing questions and defining answers, West said. And “the ABIM offers no data to support that their processes improve any clinical outcomes.”
Yet, the MOC “forces physicians to spend several hundred dollars every year as well as an incredible amount of their time jumping through hoops at the behest of ABIM to satisfy these imposed requirements,” West said. The time spent satisfying these requirements is also “strip-mining physician morale” by taking time away from families and personal lives.
As for ABIM finances, West said the organization offers no justification for “the extortionate costs imposed by this de facto monopoly.”
The glimpses we do see, however, “indicate an organization spending on a lavish condominium and offering conspicuously generous remuneration to its own leadership. The only thing that is assured by the ABIM’s MOC program is that it is wildly profitable for the ABIM,” he added.
In a tweet, he called on physicians to take a stand: “If you think MOC is good, say it. Otherwise, if you don’t sign [the petition], ask yourself why you don’t have the courage & character to do so.”
Next Steps?
Goodman’s petition lays out potential alternatives to the MOC that “would better support physician competence and continuing education without imposing unnecessary hurdles.”
Alternatives include encouraging voluntary, accessible, and evidence-based CME programs to promote lifelong learning among physicians, establishing a system for peer evaluation and feedback, encouraging self-assessment, and fostering a culture of continuous quality improvement.
Goodman’s goal is to garner at least 10,000 signatures and reach out to credentialing committees around the country with the results to promote alternatives to MOC. As of the morning of August 1, the petition had more than 7900 signatures.
He also gives Baron credit for his willingness to have a conversation about the MOC and intends for that conversation to be a civil, respectful debate.
“I can’t think of anything he could say that will convince me [MOC] is the right thing to do, but we’ll see what he has to say,” Goodman said.
Sharon Worcester, MA, is an award-winning medical journalist based in Birmingham, Alabama, writing for Medscape, MDedge, and other affiliate sites. She currently covers oncology, but she has also written on a variety of other medical specialties and healthcare topics. She can be reached at [email protected] or on Twitter: @SW_MedReporter.
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