Maintenance of certification: Working to understand why

Dr. RosevearTo be honest, I’ve never had a beer with a trustee of the American Board of Urology (ABU). But I have had numerous conversations with many other urologists, and to this day, I have yet to find anyone who enjoys the ABU’s maintenance of certification (MOC) process.      

Further, I recently read a letter to the ABU from a fellow urologist, Stephen G. Weiss II, MD, who, because of the MOC process, publicly relinquished his board certificate. The letter, published on the Urology Times website, generated quite a buzz not only among my partners but also among every other urologist I contacted to discuss it. While Dr. Weiss’s actions may be bold, his concerns are widespread, as I learned from the less-than-glowing reaction I received to a blog about my own experience with the oral boards.

Given the current controversy, I thought it might be worth learning about the history of the ABU and MOC to better understand why the ABU finds it necessary for us to jump through the hoops the board has created.

Some background first. The ABU is not a new organization; it was created in 1934, one year after the American Board of Medical Specialties (ABMS) was created. MOC, however, did not exist until 2007, when in cooperation with the ABMS, the Accreditation Council for Graduate Medical Education, the American Medical Association, and the Federation of State Medical Boards, the ABU decided that all physicians “who become certified, recertified, or subspecialty certified will enter a process of Maintenance of Certification (MOC).” The details of MOC can be found here and involve everything from ensuring a physician still has his license to submitting an electronic practice log.

The history and logistics of MOC aside, the big question is still “why?” To find the answer, I reviewed the websites of both the ABU and the ABMS. The ABU states that “MOC is designed to evaluate the continued competence of a Diplomate.” The ABMS’s website states that “Medical specialists who participate in ABMS MOC use the most current evidence-based guidelines and standards in their specialty and are widely recognized as leaders in the national movement for health care quality.”

Sounds reasonable enough; it’s hard to argue that we shouldn’t be practicing the most up-to-date medicine. Yet my two biggest questions about MOC remain. First, what prompted the ABU to start the MOC process in the first place? And second, why don’t all urologists have to participate in MOC?

NEXT: "As urologists, we are not the only specialty that has to deal with either board certification or MOC."

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Before we go any further, let me point out the obvious: As urologists, we are not the only specialty that has to deal with either board certification or MOC. An article by Virginia A Moyer, MD, MPH, vice president for MOC and quality for the American Board of Pediatrics, describes the MOC process in pediatrics and the controversy surrounding it.

Interestingly, in a follow-up article, Andrew J. Schuman, MD, points out two interesting facts. First (and he was quoting an article by anesthesiologist Paul M. Kempen, MD, PhD), 25% of all licensed physicians in the United States are not board certified. Second, while survey data show that patients prefer physicians who are board certified to those who are not (J Pediatr 2010; 156:841-5), it is rare that an unprompted patient takes the time to figure out if a physician is certified (even if doing so is as easy as querying a free online database).

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Members of the internal medicine community have also been vocal opponents of MOC. If you’re curious, they run the best anti-MOC website I have found. It should also be noted that the Association of American Physicians and Surgeons is actually suing the ABMS to stop MOC, claiming MOC does not improve outcomes, it is burdensome for physicians, and patient care suffers as a result.

With all of that in mind, I’ll try to answer my real questions regarding MOC. (Yes, I realize these thoughts will upset some of you, and I encourage you to submit your comments in the comment box below or via email at ut@advanstar.com.) First question: What prompted the need for MOC? The altruist in me says that the ABU was motivated out of concern for patient care. We all know of urologists who graduated from residency 20 or 30 years ago and have not changed how they practice since. We all know urologists who are not even aware that the AUA publishes clinical practice guidelines and, when they’re gently confronted about this, simply state that they know best.

Further, the ABU is a private organization and has every right to change the requirements for certification. The ABU states this very specifically on its website: “Application for certification is strictly voluntary. The Board makes no attempt to control the practice of urology by license or legal regulation, and in no way interferes with or limits the professional activities of any duly licensed physician. The ABU is not a membership organization.”

NEXT: What motivated the ABU to institute MOC?

If the ABU leadership decides that, after almost 70 years, they want to change what it means to be a diplomate of the ABU, good for them. In addition, it is quite possible that their motivation was simply to keep up with the crowd as the other ABMS member specialties were converting to an MOC process and they felt obligated to do so as well (or are even required to do as a requirement for ABMS membership). On the other hand, the realist in me questions this. I fear that the ABU was motivated by the lessons that the medical community learned when residencies were forcibly transitioned to an 80-hour workweek. This may sound like a non sequitur, but stay with me.

In 1984, a young woman named Libby Zion died in a New York teaching hospital. The grand jury felt that her death was related to the 36-hour duty periods worked by the residents involved in her care, as reported in the Washington Post. Over the next 20 years, numerous organizations proposed changes to the residency work hour rules, which culminated in external governmental regulations that many of us now feel are onerous, misguided, and counterproductive. But these regulations are unstoppable.

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The Libby Zion story made me think that the ABU decided to institute MOC to prevent the government from regulating MOC on its own terms. I can easily imagine a case similar to the Zion case where a board-certified urologist practicing 1980s-era medicine in 2015 earns enough bad press that some eager politician decides to take it upon himself to mandate MOC for all physicians. Given the choice between the ABU or the government looking over my shoulder, well, that is not a very challenging decision to make.

While I do believe that part of the motivation to create MOC was defensive, I firmly believe that participation in MOC not only makes me a better urologist but also strengthens my status as a diplomate of the ABU. I work every day to practice up-to-date, modern medicine, and I am proud that the ABU is helping me document this effort.

NEXT: Why are all urologists not required to participate in MOC?

On the other hand, I am confused why not all urologists are required to participate in MOC. According to the ABU's website, "MOC is a requirement for all Diplomates who were originally certified in 1985 or later and have time-limited certificates in order to maintain their certification," which explains who is required to do MOC but not why those physicians certified before 1985 are not required to do MOC. All of the arguments, both the altruistic ones and the less noble ones, support the idea that both individual urologists and the urology community are made stronger by participation in MOC and hence, while it will certainly upset some people, I believe the ABU erred in not requiring all of us to participate in MOC.

Overall, as Dr. Weiss so eloquently pointed out in his recent letter, if you disagree with the ABU about the importance of MOC, board certification is a voluntary process and you may simply resign. Relinquishing your certificate certainly has implications related to your ability to practice medicine and so shouldn't be undertaken lightly, but it is still your prerogative. For the rest of us, while MOC may be a somewhat onerous and expensive process, if it makes us better physicians, great, and if it keeps the government out of our lives, even better.

One request, though, for the board: Will you please provide self-stamped return envelopes? Writing a $200 check is annoying enough if not compounded by having to stamp the envelope myself!

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