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May 17, 2019

Vision for the Future of Continuing Board Certification

Author Affiliations
  • 1West Virginia University Health System, Morgantown
  • 2US Government Accountability Office, Washington, DC
  • 3American Board of Medical Specialties, Chicago, Illinois
JAMA. 2019;321(23):2279-2280. doi:10.1001/jama.2019.4815

In 2000, the American Board of Medical Specialties (ABMS) adopted Maintenance of Certification (MOC) to ensure that diplomates maintained professional standards throughout their practice careers. MOC included standards for learning, assessment, professionalism, and practice improvement. Diplomates began to raise concerns about MOC that focused on value and relevance to their practices, burden associated with test preparation and redundant practice improvement requirements, time away from practice and family, examination costs, and failure to account for increasing subspecialization.1-5 Additional questions were raised about the failure to integrate advances in learning science and alternative assessment strategies.6 In addition, some diplomates expressed dissatisfaction about the lack of responsiveness and financial transparency of the ABMS.7

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    1 Comment for this article
    Was One-Upmanship Responsible for MOC?
    Edward Volpintesta, MD | Bethel Medical Group
    Board certification was intended to last a lifetime; but in 1969 the American Board of Family Medicine (ABFM) announced that its board-certified physicians must pass a recertification test every 7 years if they wanted to retain their board-certified status. Not to be outdone, the other boards followed suit. Now a half century later physicians are confronting the wisdom of the ABMS’s MOC policy.

    Although the ABFM’s decision can be explained on the grounds that it makes sense to keep up to date, I see it as ‘one-upmanship’ that miscarried.

    Here’s why: during the 1900s general practice was
    taken over by the specialties. Many general practitioners started practice after only one year of internship. They could not compete with specialists who had two or more years of residency training. So family practice residencies and the ABFM were formed. It was a good idea.
    Family medicine (general practice) achieved academic prestige similar to the specialties. The ABFM even went one step further, stipulating that its board certificates had to be renewed every 7 years. This sent a message to the medical community that not only did family physicians have residency training but they had to undergo recertification every 7 years. Of course, the unspoken message was that the ABFM’s standards were higher than the specialists’.

    In 1969 the scope of medical knowledge was more manageable than today. Managed care and insurers’ regulatory intrusions did not exist. The threat of malpractice was small. Overall, the practice of medicine for doctors was simpler. Talk of burnout or dissatisfaction was rare.

    Today, dealing with insurers’ regulations has strained doctors’ endurance to the breaking point Patients’ demands are often unrealistic and the threat of malpractice is a constant concern for physicians. Burnout is widespread and frequently discussed in our journals and in the news media.

    The preoccupation with the academic side of medicine by the leadership of the ABMS blinded it to the harsh realities of practice, particularly primary care. This may explain why the ABIM has been singled out for most of the criticism.

    Most primary care doctors (general internists and family physicians, and pediatricians) customize their practices over time depending on their capabilities, advancing age, availability specialists in the community, or fears of liability.

    There is no longer a one size fits all recertification test compatible with the many different individualized primary care practices. Like many primary care physicians I keep current by studying the knowledge I need and collaborating with my consultants.

    In greater numbers, doctors are expressing their anger and frustration with MOC’s inconsistencies. It is surprising that the ABMS has taken so long to understand physicians’ concerns.

    Doctors would never have supported the creation of the board certification process in the first place if MOC were a requirement.

    That physicians are compelled to participate in MOC if they want to keep their initial board certification is a violation of physicians’ trust.