Maintenance of Certification and Licensure

I grew up in a blue collar inner city “broken home,” and worked continuously from age 14 onward. I paid my way through catholic high school and public university, learning German as a premedical prerequisite. Financial aid allowed me to go to Germany as a “Junior Year Abroad” student. I was admitted after 1 semester into a premier medical program of the Albert Ludwig Universität Freiburg, founded in 1457, completing my American Bachelor of Science in Biology in Germany over the next 3 semesters. I then traveled to New Zealand for medical externship for 6 months. As a medical student, I was qualified to work as a nurse after completing a 2-month rotation in clinical nursing as required by my program. During my semester breaks, I often worked 11-hour shifts as a night nurse on the surgical ward. My record was 30 consecutive 11-hour night shifts. This work, along with periodic red cell and plasma donations, allowed me to finance my medical study in Europe. I am a foreign medical graduate. I completed the required Educational Commission for Foreign Medical Graduates, Federation Licensing Examination, and multiple English tests to secure U.S. licensure (despite being U.S. born and raised and graduating with a Bachelor of Science degree from the University of Michigan), as well as certifying in Anesthesiology (1989) and recertifying in 2005. None of this makes me a better physician, I do that personally. As a better physician, I can simply pass these tests without preparation. The waste of time and money to jump these hurdles seems unnecessary and possibly even offensive. While currently in full compliance and participating in Maintenance of Certification (MOC), I decided to investigate this certification and recertification process. I passionately, actively learn every day. Today, at age 59, 12-hour workdays, including night, weekend, and holiday calls, are not only common but are expected contract parameters of an employed physician. This is still amazingly better than the 24/7/365 demands on rural primary care physicians. Learning has been mostly limited personally over the years by access to journals and time to read. I have never learned specifically or systematically for or from the board certification process. Who has the time? While mine may be a unique story, these efforts merely demonstrate typical histories of many, and perhaps most, contemporary colleagues and trainees pursuing any medical career. We physicians are driven, intelligent, and self-sufficient professionals. We seek and learn the information needed to improve and maintain the clinical knowledge and skills needed to practice safely and avoid patient detriment and lawsuits. My personal story and international experience has relieved me of most American-centric limitations on perspectives (i.e., that the American Board of Medical Specialties [ABMS] certifications are only important in the United States and play no role in European practice). Clearly, many other countries provide health care at less cost and higher standards and provide greater longevity to citizens. I have experienced this in Europe personally. I have never in 30 years of professional endeavor been asked by any patient whether I was certified. I doubt any significant capture of board certification market share in Europe will occur, even as the American Board of Anesthesiology (ABA) launches the ABA international LLC as a separate entity to this end.1 During my 30 years of primarily academic practice, I have seen the Federation of State Medical Boards (FSMB) successively increase their testing market scope and share using regulatory capture of licensing and credential verification (Fig. 1). The United States Medical Licensing Examination has expanded into 3 parts, increasing costs and complexity for all physicians. The FSMB, in 2010, attempted to introduce their pilot Maintenance of Licensure (MOL) program in Ohio as the premier state, proposing continual testing programs to capture physicians repeatedly for life. Although certification is a major industry in the United States, serving only to reassure citizens of “quality” in most areas of life and medicine in particular, recertification is a relatively new and unproven phenomenon. Lawyers would sue to prevent any such attempt to impose such mandates and with good reason, while physicians have typically remained passive and compliant. This is changing.Figure 1: Federation of State Medical Boards (FSMB) Annual Meeting prospectus—testing, regulation, and no physician teaching.The FSMB’s program, and subsequently the MOC program, has been actively and rapidly opposed by state medical organizations in Ohio and now other states. I personally chose early to investigate the issues and review the Ohio’s Medical Board’s 2011 data. My review demonstrated that the main issue with problem doctors was not competency, but overwhelmingly due to alcohol or substance abuse (48%), criminal actions (17%), or bootstrap (referral) actions from other state boards (7%). When I specifically requested under the Freedom of Information Act all documents from the Medical Board’s fiscal year 2011 that documented any issue of incompetency, I was forwarded 6 records from 5 physicians. One doctor was retired (all information was protected). Three doctors had problems with “sexual boundaries.” One left the state and remained in active neurosurgical practice after reaching “state threshold of 2 lawsuits/license cycle.” With 182 disciplinary actions from >42,000 licensed physicians in Ohio, incompetency remained clearly a rare instigating problem. Review of the records indicated that only 2 of these disciplined physicians were actually incompetent among all licensed physicians, an incompetency rate of 0.005%. What evidence supports the view that testing all 42,000 doctors in Ohio would have identified the 2 doctors who were allegedly incompetent? Unless there is unequivocal evidence that testing and recertification is both accurate and sensitive in identifying incompetent physicians, I believe testing every physician at significant cost to identify the rare physician with significant knowledge deficits wastes our increasingly rare resources. Lacking data on sensitivity and efficacy, recertification is little more than an unproven and likely unneeded medical test. I wish to present my findings for review and refer readers to www.changeboardrecert.com for a comprehensive listing of articles and information regarding this topic. Like most physicians, I favor lifelong learning and board certification requirements (as a tool to expand the scope of residency training beyond mere on-the-job training and into a scientific endeavor) documenting “achievement of consultant status,” as was true of my 1989 lifelong certification. I and others have clearly found recertification and the associated prescribed MOC programs to be individually diverse in implementation, untested, unnecessary, ethically questionable, and lucrative to academic-based physicians, board corporations, and national medical specialty societies. In my view, this latter triad can be thought of as the “certification industrial complex.” The certification industrial complex produces board products that we are compelled to purchase. The cost of these products includes the financial profits to corporate entities producing tests and MOC products for purchase. However, the costs also include reimbursement to our academic colleagues’ travel to resort areas to function as oral examiners or administrators of these programs. While continuing medical education (CME) credits have become readily available over the Internet, less expensive and even free of charge, in 2007, CME gross receipts totaled U.S. $2.5 billion, representing a significant opportunity for financial capture and growth to this certification industrial complex. While MOC has been a self-asserted “gold standard” of competency by the ABMS, the justification for this costly bureaucratic and anticompetitive program remains theoretical, rather than scientific. The lack of evidence supporting this expensive medical test has resulted in increasing opposition from working physicians. The virtual absence of the ABMS programs outside the United States is testimonial that excellence is possible without the imposed costs of that bureaucracy. The ABMS has lobbied Congress to demand their products of all physicians to avoid financial disadvantage in payments, while simultaneously declaring the whole program to be voluntary. Perhaps they have pressured Congress into ensuring their monopoly, rather than providing scientific evidence that supports their position, because no one can or wishes to finance attempts to scientifically validate the usefulness of the certification industrial complex. A recent press release from the ABMSa in response to an article in the New England Journal of Medicine was questioningly entitled: “Is Maintenance of Certification the Answer?”2 The question whether recertification is of any value has remained surprisingly unanswered, despite decades of attempts to validate this theory by the many leaders of the ABMS and especially the American Board of Internal Medicine (ABIM).3 Any discussion of MOC requires understanding that the ABIM pioneered recertification, first proposing voluntary recertification in 1970. In 1986, after concluding that many physicians refused to comply with voluntary recertification, the ABIM introduced time-limited certification in 1990. In 2000, the ABIM mandated recertification of all of their executive personnel. This year the ABIM pioneered the concept of continuous MOC, proposing it as the industry standard for all medical specialists. Similarly, the MOL agenda of the FSMB parallels the ABIM trajectory with ever-increasing testing impositions and regulatory capture of foreign and American medical students and licensure applicants founded in the programs of the FSMB over the past 4 decades. The recertification of physicians now presents an opportunity for FSMB to expand into repeated testing throughout a physician’s career, that is, a United States Medical Licensing Examination part IV as the Special Purpose Examination, because currently 25% of all licensed physicians in the United States are not board certified. Less than 1% of physicians with lifelong certificates have recertified. The ABMS indicated in 2010 that less than half of all physicians were enrolled in MOC. Primary certifications remain the mainstay of the $374 million cumulative board income reported on Internal Revenue Service 990 forms in 2011 most available for 1: 2011 from Internal Revenue Service 990 from to costs and in patient We would never that every patient or even and We because these tests are only in be to many or physicians and to but is not the has been found is that the ABIM is their ABIM the to unnecessary medical and while at the time their expensive and unproven high recertification on all physicians. What would the program the recertification or even board certification that are expensive and lack any evidence of The lack of scientific significant regarding While my lifelong in 1989 me be qualified to as a consultant in my more recent recertification me merely of Certification in the of The ABMS boards have now from documenting consultant competency to being a to in their corporate of lifelong The ABMS that multiple articles MOC. A review of these ABMS articles readily the as overwhelmingly ABMS paid paid corporate scientific and introduce significant into these as would for any medical or they can only and not may never be in journals or by organizations by ABMS or national significant financial in and products associated with recertification of ABMS boards are found to as of all national medical associated and many academic of both FSMB and ABMS with the $374 million in gross repeatedly a significant corporate without significant opportunity for from In the ABMS attempted to validate board certification by 2 ABMS and for the and one to be learned from this review is the to this recertification to Review also to MOC or board certification The only study found in the from ABMS regarding primary from the specifically practice significant scientific limitations supporting of the ABMS program, despite ABMS to the MOC practice physicians to in their practice, patient care be A is introduced for and in care are are to specifically demonstrate in practice to the ABMS to This practice is to the physician’s personal that is, personal an practice to demonstrate a This without any review or the costs and of the and practice the of from and the of This a significant review of or costs is mandated or As a physician working for an of medical I not be allowed to with merely to ABMS requirements for my personal recertification perhaps I to my practice to improve I become more with to this However, we that of can be and the of associated with complexity and of with with to personal recertification may in such with standard practice or even likely to improve attempts by the the FSMB to MOC with testing every 5 years regulatory or or regulatory to their While board certification is a for and physicians are now to that recertification compliance as documented by at the of the American Medical in of in New New and Ohio’s State Medical in recent are of the among working physicians that unproven certification and costs are mandated by and corporate efforts to time-limited on with lifelong physicians. the of American and and for have the by actions at the in in of physicians the to with programs including over recertification have been This the of American and to a on of the national the ABMS in of on multiple issues regarding and of United States for the of New While the FSMB’s MOL program to the to than the ABMS currently voluntary certification while both from physicians and physician compliance with ABMS The ABA has now expanded requires of their part 1 test of any residency training program. This any of voluntary and a for the contemporary medical leaders simply never MOC to secure their or next position, their certification is mostly a for required by industry and overwhelmingly and by the ABMS have to or in MOC, only it has become a recent as ABMS executive been paid 6 and The of the American Board of as in the corporate the Internal Revenue Service 990 was documented at in to the $374 million for ABMS The ABMS and FSMB physician were not enrolled in MOC and have never as of as by ABMS found at the ABMS and ABIM to a physician’s certification. This any personal regarding of personal value corporate profits from ABMS programs. One that these are no However, the many physicians be required to to the MOL or MOC and costs to maintain to work in or the in the certification industrial along with our academic colleagues for are typically not full time and their clinical This for certifications by in the certification industrial complex may be simply their from their academic from practice, often only or at physicians may be and to rather than to maintain a full and ABMS certification With the certification may become an at from first certification. The ABMS actively and lobbied Congress to pass ABMS MOC compliance for The ABA that the would not the costs of MOC, is to become a for specialty boards had requirements to become all other physician to only because is the prescribed year required for such the ABA despite to do in 2010, declaring then on understanding of the the ABA not believe that the requirements for the MOC will have a on patient will the reimbursement the time and on ABMS specialty opposed to time-limited programs but to ABMS corporate to comply or ABMS and these While the ABMS that MOC is the cost of time from patient and are However, these costs are the is a in patient The of for any with the the ABMS there is value to the then it has the of to this and this remains to be demonstrated by and The on are also The ABMS value ABMS that of the it is health education or is no certification that or The ABMS testing industry be to with CME programs on a to medical without regulatory The ABMS, with certifications and and comprehensive lifelong learning programs for every physician in every the of practice patient and medical to or maintain multiple certifications to limitations in the scope of an physician’s certification hurdles are or personal the personal of physicians, and As certification programs typically travel to major the cost and will and and patient especially in rural With pass rate from to among the of ABMS certifications MOC be a and for licensure under payments, or This is likely to most physicians in rural practice who beyond 1 specialty to provide As more certifications for increasingly practice parameters are and be then under the on the scope of practice will increase in to the certification requirements that scope of As the certification industrial complex increasingly more will also The American Board of Specialties has been a relatively entity certifying physicians now certifying including The American of also has been certifying physicians now in American Boards can be found for 1). Boards have after first an national certifications are only of value to who or demand The public at is of any to the board has only to medical The by the ABIM found that less than of all whether their physicians were certified. recertification tests knowledge from and testing in testing at significant but not patient and clinical clearly do not as are readily found with physicians. The of physicians remains a major for the FSMB MOL program. 25% of all U.S. physicians including who have never are providing and care throughout this is of knowledge is often at with in only months. with practice are in MOC we have seen and in a of and other for the of medical of medical practice on not only one to question the value of but also to question the on ABMS have their The concept of MOC the increasing regulation, and the of medical care to with less education nurse nurse The imposed MOC costs the of the physician with early physician and physician is to increase demands on the most of health while to practice medicine after programs and licensing under often outside the state medical boards costs in health care be by increasing the of to provide medical is simply a without any while costs in paid and time to comply with these programs are In our the American of to actively of care at a cost and has significant with of to in for medical practice in States of and of New England Journal of Medicine and physicians whether voluntary recertification was was This of discussion and among every specialty to the of the regarding this When voluntary recertification time-limited certification was introduced ABMS of lifelong ABMS executive has been and well to the value of recertification to this CME programs $2.5 in in 2007, representing a significant financial testimonial to physician lifelong MOC is no simply a board but clearly attempts to capture the market by education through by The American of is overwhelmingly by Maintenance of Certification in while only a years only of board review were to be MOC is an of unproven products under of the ABMS The ABMS to that board certification is while practice with this is and has been with lifelong certification residency training and consultant The of time-limited certificates regulatory capture on who pass the test with every patient but and certificates every are in money and patient and are the requirements of and physicians to significant simply to to the ABMS certification are not of their or into practice and remain of certification that the ABMS is to medicine from the of outside regulatory will impose on physicians. the past board of the MOC it would be by more regulatory that would be more to The only is that physicians do not actively these will organizations patient and state health the The CME program and state licensure requirements for decades to continuing I am of scientific evidence specifically documenting of this program, especially as have no CME requirements New provide medical care to their including multiple of have been to lifelong and competency is demonstrated by not by the of doctor in every or certificates the has never been despite with ever-increasing impositions demand all with to and from and in increasingly practice demands to knowledge of and preparation. is under multiple of for are with work little opportunity to in increasing and certification process. MOC programs physicians from patient and increase are in rural areas and primary care With and doctors do not physicians into expensive program without by the of physicians As a and corporate ABMS MOC is from or by The ABMS standards free of any professional or the of unproven physicians simply ABMS that such testing is of value and by the In the of cost less by are physicians, and while the physicians as medical education is while of physician and nurse is for every physician to of value to professional impositions in this age of more for less under the of MOL requires opposition to and physician Ohio physicians demonstrated opposition and MOL in is being repeated in other states. Ohio medical organizations representing physicians and the FSMB, MOL Ohio pilot program and the State Medical Board of Ohio’s executive medical that Board is past and lifelong learning in the on the Internet, in or as physicians remain without to State medical boards impose significant and requirements on continuing ABMS and FSMB currently no physician only and tests and without public (Fig. 1). The or or of ABMS programs is by their the CME program be or to the ABMS of testing to reassure the this can be and multiple throughout possibly with or would this and ABMS is no that the certification industrial complex have a training at standard This that complex medical training for the or practice access and over the to 5 and medical using using physicians by personally new and not knowledge in of and important or and of past with access to all clinical journals after would information to and discussion are needed in all to the of readily and for physicians in their and continuing or corporate programs is not the of medical excellence or We in the age of and medical records provide access the in medicine is while and will to due to physician, and patient in the medical from care are testing to be the of our (ABA) corporate program. and recertification testing using in Examination and as well as patient remain of to experienced physicians. This may also expensive and in this age of The ABA a new with testing including Examination Examination are for and the in of all ABMS gross while to only of all physician specialists. The is into testing as ABA ABA pass from to and were from to all are and be allowed to work nurse by are all with the physician and increasing ABMS of are currently with of not all are currently enrolled in The ABMS indicated that only half of all physicians were enrolled in MOC in will never the and of patient in practice and as by patient care As is an of practice in the United States, only time-limited certifications have been 2000, and with residency and the rate of of physicians through is of limited in data clearly in opposition to founded in board data and While I have never been asked by a patient in 30 years of practice whether I was board many were to they were under my care as an experienced a student, or with especially one with and I will my of personal and professional but without personal to the corporate physicians of the now to and patient at the of the clinical We the of patient we will as as a in the medical I am I with the health care in the available to in my personal practice, This the This the This was