Wow. For those who think MOC isn’t a big deal, my Open Letter to the American Board of Pediatrics just hit 70,000 views. That’s stunning.
For those commending my bravery, realize efforts like this are not done in isolation. I am not alone. I have the most amazing partners. I can’t even express how blessed I am to work with the ten doctors in our private practice. Not only do we share a common faith, we share a fierce independence. They know that in the end, I may lose my MOC battle even on the way to winning the war. Blue Cross Blue Shield of Michigan may force me to be certified through the ABP, and rather than lose access to care for my patients, I will pay $1300 plus a $200 late fee to the ABP to regain my certification. But I certainly won’t lose quietly.
I have the support of my state medical society. Michigan State Medical Society has the strongest state policy on MOC in the country: MOC should not be tied to licensure, hospital privileges or insurance participation and it should not be the monopoly of one organization. It helps knowing there’s a 15,000 member society on my side. And they’re doing the impossible. But more on that in another post.
I have the support of thousands of Sermo doctors, over 5,000 signatures on our pediatric MOC petition and now 70,000 views on the letter without one single doctor opposing my stand. I am not alone. Numbers are clearly on our side.
Since writing my original letter, my inbox has been flooded with hundreds of heartbreaking stories. Physicians with cancer, on chemotherapy and immunosuppressed, are denied waivers to delay testing in the public facilities, losing their certification and their jobs. Parents of children with cancer are denied waivers while their children are undergoing treatment, losing their certification and threatened with job loss. Physicians are retiring early to avoid another costly and demeaning cycle of MOC. Physicians are feeling isolated and embarrassed after failing their re-certification and are falling into depression and suicide.
My eyes are wide open now, and I realize this is more than mere annoyance or financial inconvenience. MOC is a toxic stress that is literally killing doctors. The worst part is the boards have heard our voices, yet they keep pressing forward. Their unflagging defense of MOC in the face of what they know it’s doing to our colleagues is not a simple error of knowledge, this is a breach of morality. This is something we cannot participate in.
It appears we’ve come to the divide in the road. If you’ve had enough and are ready for a revolution in MOC, there are some very simple things you can do. This applies to all ABMS specialties, but I speak directly to my pediatric colleagues here.
1.) If you really don’t need MOC to practice medicine, please stop participating. Continuing to financially support the ABP harms your colleagues, and it harms children as experienced doctors retire early. Paying fees to the ABP harms more than just pediatricians, as the ABP turns around and gives $837,000/yr to the American Board of Medical Specialties Foundation which develops MOC programs to inflict upon your colleagues in other specialties. When you give up your certification, send a letter to the ABP explaining exactly why.
The ABP has threatened to sue any doctor who calls themselves “board certified” in print or on the web if they don’t do MOC, so getting certified through the National Board of Physicians and Surgeons is probably a wise move if you still want to call yourself “board certified.” Note that you can still keep the “FAAP” in your title, even if you don’t do MOC, as the AAP only requires initial board certification to be a fellow.
2.) If you think you need MOC to practice, please make sure. Check your insurance contracts. Check your hospital privileges. We had a local pediatrician harassed by the children’s hospital when he didn’t participate in MOC. Turns out, our staff bylaws only require initial board certification. The harassment was completely unfounded.
3.) If MOC is required for your job, insurance contracts, or hospital privileges…this is where the fun starts and is going to require more information than I can give in this post. It’s going to require politics, organized medicine, and some hard work. I will post soon on exactly how this is done, but for now, if you’re really forced into MOC just start by asking questions. Call up your state medical society to see if they have written policy opposing MOC and resources to help. Find a few colleagues, and ask if hospital policy or office policy can be changed to either only require initial board certification or NBPAS as an alternative. You might be surprised by how much support comes out of the woodwork.
And finally a word to those who are “grandfathered” and exempt from MOC. I harbor no bitterness toward my grandfathered colleagues. Indeed, the requirements enjoyed by grandfathered pediatricians should be the standard for all. But to those grandfathered doctors who now know what is happening to your younger colleagues, yet turn your backs on us or even worse, enforce MOC requirements for our employment but not yours, I do hold you accountable.
There is a reason the “grandfathered” class exists. Established in your careers, and trained in an era that encouraged oppositional defiance, MOC wouldn’t have lasted 2 months if you were included. You would have fought and shamed the ABP into immediate apology and retraction. Instead they targeted younger doctors facing significant education loans, newly employed with young families, just trying to make partner and not interested in making waves.
We all want to leave medicine better than we found it and this is the chance for our grandfathered doctors to step up in your circle of influence. It is likely you or your contemporaries are in hospital administration and on medical society boards. You or your contemporaries are the ones making employment guidelines for your university department or private practice. Rather than breathe a sigh of relief that you’re exempt or nearing retirement, fight for us. Don’t show solidarity with us by voluntarily participating in MOC, show leadership by fighting for our right to self-education without coercion. Use your hard-earned status and influence to end MOC employment requirements for all pediatricians.
It’s no wonder the ABP has been successful at pushing us so far, yet listening so little. Pediatricians are a tolerant lot. We have nearly unending patience. We can tune out incredible distractions to get our job done. We are literally pooped on every day, yet we show up day after day, with white coat pockets full of Star Wars stickers and love our jobs.
It’s because we’re viewed as such tolerant happy doctors that I started to worry what my patients would think if they read my letter as it was spreading quickly on social media. A friend forwarded a comment one of my patients made on the article, something I wasn’t intended to see. The mom said, “A doctor that fights this hard, will fight for us if we need her to.”
See, that’s what the American Board of Pediatrics forgot. Pediatricians have devoted our lives to fighting tirelessly for the little guy. And this time, we’re the little guy. If we can give even a fraction of that passion, tenacity, and love fighting for our fellow pediatricians, the ABP better hold on. They’re in for one bumpy ride.
Photo by anjan58 
MOC can’t be tied to hospital privileges, it’s called Code of Federal Regulations Title 42, 482.12(7) “Ensure that under no circumstances is the accordance of staff membership or professional privileges in the hospital dependent solely upon certification, fellowship, or membership in a specialty body or society.” Point this out to the MEC if your medical staff privileges are to be revoked. MEC is supposed to be separate from the hospital organization. If the MEC members persist in enforcing its provision in the bylaws (though it contradicts federal law), you sue each of them as individuals and get an injunction against enforcement of the provision. File the paperwork yourself. As for the Ins. Co you and all your partners should dump the Blues since you’re 10 members strong.
This is actually the first time I’ve heard of this. Very interesting Steve. Thank you!
I looked into this some months back after reading a comment on a Sermo blog. I keep a copy of that page of the code in my office desk and include it in all relevant posts. I’m sure those on MEC’s either don’t know or won’t admit they know about it. They need to know though since they need to adhere to all applicable federal law. They can’t claim it doesn’t apply to them since it’s about them. Please pass it along.
Because of the word “solely” in the regulation CMS has issued this unhelpful interpretation:
Interpretive Guidelines §482.12(a)(7): In making a judgment on medical staff membership, a hospital may not rely solely on the fact that a MD/DO is, or is not, board-certified. This does not mean that a hospital is prohibited from requiring board certification when considering a MD/DO for medical staff membership, but only that such certification must not be the only factor that the hospital considers. In addition to matters of board certification, a hospital must also consider other criteria such as training, character, competence and judgment. After analysis of all of the criteria, if all criteria are met except for board certification, the hospital has the discretion to decide not to select that individual to the medical
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R37SOMA.pdf
One simple fix might be to remove the word “solely” or to modify it to read: :
Ensure that under no circumstances is the accordance of staff membership or professional privileges in the hospital dependent upon specialty recertification status or solely upon initial certification, fellowship or membership in a specialty body or society.
I wonder if it would be worth asking Dr. Price to consider fixing this regulation.
Bravo to Dr Edison, I am a Family Doc who gave up on MOC but am now certified by the National Board of Physicians and Surgeons. I have a very busy practice and I don’t have the time and will to go through the MOC nonsense. I applaud her courage and hopefully more of our colleagues will come out of the shadows and join the rebellion.
And to you as well. See one, do one, teach one. Let’s keep multipling.
Dr Meg Edison is my hero! 100% support!
Thank you Viana. Florida Medical Society has a very strong anti-MOC policy in place. Florida docs need to start calling them and asking to support docs discriminated against for not doing MOC. Their number is 800-762-0233
Resolution 14-201
Combating the Medical Certification and its Attempt to Capture Into Unproven Certification Programs with its Regulations South Florida Caucus
House Action: Adopted Amended Substitute Resolution 14-201 in lieu of original 14-201, 14-202, 14-203 and 14-204.
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RESOLVED, That the FMA acknowledges that the certification requirements within the MOC process are costly, time-sensitive, and result in significant disruptions for the availability of physicians for patient care, and therefore, the current MOC programs should be modified; and be it further
RESOLVED, That the FMA opposes any efforts to require Maintenance of Certification (MOC) program as a condition of medical licensure, or as a pre-requisite for hospital/staff privileges, employment in State of Florida/county medical facilities, reimbursement from 3rd parties, or issuance of malpractice insurance; and be it further
RESOLVED, That the FMA advocates that the lack of specialty board recertification should not restrict the ability of the physician to practice medicine in Florida.
RESOLVED, That the FMA monitor the American Health Legal Foundation who is seeking legislation to prevent hospital staffs and insurance companies from refusing to credential physicians who do not participate in the MOC program.
RESOLVED, That a copy of this resolution be transmitted to the AMA House of Delegates; and be it further
RESOLVED, That the FMA produce a yearly report to the FMA House of Delegates regarding the activity and progress in the Maintenance of Certification process, and be it further
RESOLVED, That the FMA Delegation to the AMA request a yearly report regarding the Maintenance of Certification process.
http://www.hcma.net/Docs/HOD_Final%20Actions_2014.pdf
As a grandfathered physician, I believe we must all work to stop the testing/assessment monopoly and the outrageous salaries of board chairpersons
Thank you Marc. I am actually amazed by how many grandfathered docs ARE taking the time to fight this for us.
Like you described, in order to keep my job I have to play this game for the hospitals, insurance companies, and the medical school faculty appointments. I applaud you! Please see/review what I have been posting about my experiences with MOC and ABIM:
So I am the kind of person that does not like things hanging over me. My last ABIM cycle ended in 2012. So with passing the re-certification test, in January of 2013 I did 100 plus MOC credits (100 every ten years was the standard at the time). Whew, I thought I had this behind me until I have to take the test again around 2020. ABIM announces in April of 2013, that starting in 2014 you need 100 MOC credits every five years and oh by the way anything you have done prior to January of 2014 will be erased! UGH!
So in early 2014 I got 100 credits again, knowing that I will have to satisfy their parochial nonsense of getting 20 every two years. But more importantly, just to get it off my back, I did a patient voice, practice improvement, and patient safety activity to once again, get this busy work behind me.
As I am doing this the outcry mounts and ABIM capitulates saying they have suspended the patient safety, practice improvement and patient voice requirements through 2017, now with this it is 2018. You have got to be totally kidding me! I played their silly games and this is what I get. I am still pissed off. I have personally written Dr. Barons. No one from ABIM has written back. If these functions are so goddamn important to patient care and outcomes, how can they just arbitrarily and now repeatedly suspend them. The whole thing is looking more and more like a money making sham off the backs of American Physicians. Hospitals and insurance companies need to quit relying on ABMS certification as a measure of quality – especially through their own actions, ABIM has proven that this is all arbitrary and capacious and they are making it up as they go along. No evidence to back it up.
Quality medical care needs to be measured through the lens of a trusting physician patient relationship. Not, MOC, PQRS, HEDIS, EHRs and meaningful use. These are all cheap and lazy surrogates for what really matters, a quality trusting physician patient relationship. When physicians and patient really know one another, patients will buy into what their physician tells them and won’t necessarily rely on expensive tests; compliance will improve. More importantly quality (true quality) will go up and over all costs will go down. Up front, this will cost some investment, insurance companies and policy makers do not have the foresight, the gumption, or the willingness to invest in this to make real health care reform work. Instead we have a broken system that got even more broken with all of this nonsense busy work. When is someone really going to see the light of what real medical practice is all about?
I loved this article by Dick Armstrong on determining quality in healthcare. Just freaking good common sense.
https://d4pcfoundation.org/who-determines-quality-in-health-care/
I am totally in agreement that as physicians we need to continue our education through CMEs and other activities with peers when available. The MOC research activity I did not find that helpful. The fees are astronomical and I don’t see what we are getting for our money except complicated websites that exhaust an already overworked Dr just to decipher what the requirements are and when they are due. If that much of our money is just going to a corporation that makes money off designing MOCs and paying these salaries, I agree. We need to rise up in protest. The IM folks are making a dent. We need to as well. Thanks for your thoughtful post. _ Private Pediatrician in Covington, GA.
Thanks Lisa. I look forward to choosing my own CME now. Imagine that.
I’m a Family Doctor who has reached the stage that the next requirement for Board recertification will be after I plan to be retired. That was remarkably freeing when I figured out that the only reason to do the MOC was to qualify for the Board re-exam. I actually talked to one of our national board members and asked him what data they had that showed that the MOC requirements had improved practice. He admitted that they didn’t have any. So then I asked what programs they had to study the outcomes of the MOC. He said they didn’t have any and didn’t plan any. That was when it became clear that the primary concern was the cash they got from doctors having to jump through those hoops. I think every state medical society should get the same resolution that the Florida society has gotten.
Meg: Thanks for all your efforts on behalf of physicians – you are a beacon for us. I look forward to your upcoming post going into the details of dismantling or working around MOC. Unfortunately, in Oregon where I live and practice, the leadership of the Oregon Medical Association, including Nancy Hutnak, DO, have blown off my inquiries and attempts to rally their support in opposition to MOC. They claim to be progressive here in OR, but alas…I need help with next steps.
Thanks, Paul
1/19/16
Hi Dr Meg Edison:
I agree with your letter to the ABP.
on 1/13/16 I responded to the ABP as follows:
1/13/16
ABP:
I am not going to participate in MOC any more in my life. I already being board by NBPAS.
This is a money making issue for your CEO. We pediatrician are the lowest paid in USA yet the salaries of previous CEO is ridiculous high!!!!
I am including information via PDF of 2011 Board officers.
http://www.medtees.com/content/ABMSBoardMemberSalary.pdf
Who was the first in the list: James A Stockton III, MD; $ 933.964.00. To refresh the Board memory read the following information
http://rebel.md/american-board-of-pediatrics/
I agree with the following comment from Meg Edison MD (January 11, 2016)
http://rebel.md/open-letter-the-american-board-of-pediatrics/
I will not give a single Pennie to the Board of Pediatrics or AAP.
I am sure the ABP does not have the nerve to publish this response. I tried in the past to include it in the Board website , it was rejected.
Sincerely,
Tomas de Brigard, M.D
Brandon, FL
I am an internist but honestly don’t know how Drs Cassel, Stockman etc sleep at night given how badly they have sold out other MD
I am an internist having worked 20 years in my private practice as a solo practitioner caring for patients in the office and the hospital. My boards after 2 recertifications finally lapsed on 12 of 2014. I could no longer make it running the office so I became a nocturnist working in Arizona and Ohio. The Ohio hospital decredentialed me last month after I gave them 5 years of service at night every other week that no one wants to do. Now they use nurse practitioners to do what I did for them. Unbelievable. I guess they take our boards.
Anyways I am thankful I can still find work in those hospitals desperate enough to risk having a decertified physician on staff. Ha ha .
The only way this is going to end is NOT through lawsuits or legislation, but by doctors, good doctors who care, not the ones out there just raking it in for themselves with no care to the profession, and by WALKING OUT NOW but together as one to take back medicine from the fascists who we have allowed to do this to us. I don’t think it would last long. A day, maybe 2 with out offices, OR’s, ER’s etc and the outcry would be too loud to bare. There would be no coming back to work until we told JACHHO, ABMS, hospital CEO’s, malpractice attorneys and the govt to get out of our way! If they don’t, they can take care of the sick and dying. If this does not happen and soon, the profession is gone. There is no time left to do this any other way as too many doctors , many fine doctors above the age of 60 will be forced to retire, leaving the physician workforce in dire straits.
Good luck to all.
Great work Meg! It is real physicians who can stop this coercion that has no scientific proof of improving patient care. Always emphasize first that MOC /recertification is a corporate coercion that is not backed by any major studies published in any major peer reviewed medical journal.
I’m a “grandfathered” oncologist who still does 70+ hours of CME/year on my own dime. Like you, I’m a “refusenik” on the MOC issue, and I’ll continue to fight it until the day comes when someone might deny me the opportunity to practice. Unfortunately, a lot of my gray-beard contemporaries are succumbing to this MOC nonsense. I think some of them believe it’s a way to stay “relevant” to younger colleagues. Others are fearful they’ll be “forced” into retirement a couple years sooner than they’d like, or look bad in court if they’re ever dragged into a lawsuit and an attorney questions them on it. However, a lot of them are just type A++ folks who like to perpetually take tests!
I’m not sure what an attorney will be able to make of not renewing board certification without asking at some point an open ended question thus giving the physician the opportunity to pontificate on its meaningless other than as an exit exam from residency and slipping in the question of when the lawyer last retook the bar exam.
1/25/16
I sent you a letter that I wrote to the ABP. it was not publish.
1/13/16
ABP:
I am not going to participate in MOC any more in my life. I already being board by NBPAS.
This is a money making issue for your CEO. We pediatrician are the lowest paid in USA yet the salaries of previous CEO is ridiculous high!!!!
I am including information via PDF of 2011 Board officers.
http://www.medtees.com/content/ABMSBoardMemberSalary.pdf
Who was the first in the list: James A Stockton III, MD; $ 933.964.00. To refresh the Board memory read the following information
http://rebel.md/american-board-of-pediatrics/
I agree with the following comment from Meg Edison MD (January 11, 2016)
http://rebel.md/open-letter-the-american-board-of-pediatrics/
I will not give a single Pennie to the Board of Pediatrics or AAP.
I am sure the ABP does not have the nerve to publish this response. I tried in the past to include it in the Board website , it was rejected.
Sincerely,
Tomas de Brigard, M.D
Brandon, FL
I am sending you the response from the ABP. !!!!
On 1/21/2016 9:22 AM, Virginia Moyer wrote:
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> Dear Dr. de Brigard,
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> Thank you for taking time to write to the American Board of Pediatrics with your thoughts regarding Maintenance of Certification. Your comments will be shared with the MOC committee and staff here at the ABP as we attempt to improve the process.
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> The ABP is comprised of our colleagues who volunteer their time to ensure that certification remains the public’s most used marker of competence – of the over 250 pediatricians who do the work of the ABP, only five of us are actually employed by the Board. Both practicing general pediatricians and sub-specialists are very well represented on all the committees at the ABP, including the MOC committee. The current Chair of the Board of Directors is a general pediatrician in private practice; the immediate past Chair is a subspecialist. They continually remind us of the financial pressure and time demands of working in the “trenches”, and the need to show that certification, and maintenance of certification, help to improve the healthcare of children.
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> You have decided not to continue participation in MOC. However with respect for your long career in pediatrics, and without trying to sound defensive, I thought you deserved at least an attempt at an explanation regarding what I consider to be the value of Maintenance of Certification, and a response to some of your concerns.
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> Not to change your plans regarding your participation in MOC, but to make you aware that the fees you have already paid cover your exam fee during your current “exam cycle”, which ends in December, 2016. That “ticket” for an exam expires at the end of this year. If you then decided you needed to take the exam, you would have a fee.
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> I’m sorry that you have not found MOC to be of value. There are certainly others who agree with you, but many have found the experience valuable. The four part MOC program was born after the public outcry over the Institute of Medicine publications, “To Err Is Human” and “Crossing the Quality Chasm” around the year 2000. The public demanded that physicians rethink their processes for assuring safe and high quality medical care. A key element of the changes made was the knowledge that improvements in patient care could only come with measurement of how one was currently practicing, identifying gaps in quality through that measurement, designing intervention to close those gaps, and then re-measuring to see if improvement has occurred. This is what Part 4 is all about. So, MOC is about “staying current”, but it is also about attempting to improve the care we are giving, even if that care is at a high level. Our Board is continually trying to develop new Part 4 activities, which can be more meaningful to the many constituents in our specialty. And more than that, the Board is making every attempt to encourage people to engage in quality improvement activities which will give credit for work already being done in their offices. We encourage diplomates to take the responsibility of choosing activities in areas that might be helpful in their specific practice; those who choose activities just to get things done are less happy. Many more are now finding satisfaction in identifying areas in which they might improve; they are much happier.
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> It may be of interest that nearly all of the presently approved performance in practice (Part 4) activities have demonstrated significantly improved patient care, that the vast majority of those who have completed an activity found it a very useful activity, and most would recommend the activity to a colleague. So those who have participated and responded to the post-activity surveys have seemingly enjoyed the experience. Let me emphasize though that the Board is continually trying to develop new performance in practice activities, which can be more meaningful to the many constituents in our specialty. MOC has been awarded to thousands of pediatricians who collectively have improved the health and healthcare of tens of thousands of children. This has been done in projects involving children with inflammatory bowel disease, asthma, blood stream infections, ADHD, autism, developmental screening, obesity, and mental health issues, among others. These have involved institutional projects, but also many private practices.
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> You have expressed legitimate concerns about the cost. First, I would acknowledge that the current fee of $1304 is not cheap, even every 5 years, I will try to offer some explanation regarding the MOC fees. The ABP is nonprofit, and works very hard to steward the resources we have. MOC is not a “money maker” for the ABP; it actually loses money. The ABP produces over 50 separate examinations as well as many Part 2 and Part 4 activities that can be used to complete MOC for both generalists and subspecialists. Unfortunately, most of the subspecialty examinations cannot cover their expenses given the small numbers involved (just 20 or so rheumatology fellows exit training each year for example, but the costs remain the same). Although most people tend to equate the cost of certification and maintenance of certification with the perceived costs of exam development and administration (for the ABP, that cost is about $3000 dollars per question, slightly less than the industry standard), the fees for certification and maintenance of certification must support all of the Board’s operations of which development of multiple examinations is only one part. These include, but are not limited to: development of initial and recertifying examinations in general pediatrics and for each of the 16 subspecialties; the staff who review eligibility requirements, work with residency and fellowship program directors on details related to resident and fellow tracking, and develop and administer in-training examinations; development of instruments to assess the general competencies of trainees in both general pediatrics and its subspecialties; examination psychometric analysis; participation in national efforts related to competence, quality improvement, and standard setting; participation in all functions of the Residency Review Committee in Pediatrics of the Accreditation Council for Graduate Medical Education; and membership in the American Board of Medical Specialties (ABMS) just to name a few of the less visible activities.
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> In comparison to other Boards of the American Board of Medical Specialties, the American Board of Pediatrics has the third lowest fee structure (fees for some of the other twenty-three Boards are as high as $3,700). There is no separate fee just for MOC, but rather a fee that includes the MOC activities, and also includes the exam fee for one exam every 10 years. As a reminder, Part 2 activities also earn CME credit at no additional charge. Many outside CME activities cost more than the approximately $260 per year MOC fee.
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> Regarding the appropriateness of staff salaries: the Board currently employs only five pediatricians. The salaries for senior management positions (physician and non-physician) are benchmarked to corresponding leadership positions in health care and medical education settings. The CEO salary is benchmarked to the 50th percentile of Private Medical School Deans’ base salary. There are no bonuses. As mentioned above, over 250 pediatricians do the work of the ABP on a volunteer basis. As a nonprofit, and as you know, this information is readily available to the public.
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> You wondered if the ABP would publish your letter – you would be welcome to post this on Dr. Nichols’ blog, with the same caveat that you know from previous communication: you would need to remove the hyperlinks before submitting it, since hyperlinks are known to be subject to malicious viruses. We invite both compliments and criticism on all aspects of the MOC program, as we try to make it better.
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> You will need to decide the value of Maintenance of Certification for your own career. It sounds like you have made contributions to the healthcare of children. I hope this will continue. We actually do thank you for writing and want to engage in constructive dialogue as we continue to try to improve this process.
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> Sincerely,
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> Virginia A. Moyer, MD, MPH
> Vice President, MOC and Quality
> The American Board of Pediatrics
> 111 Silver Cedar Ct.
> Chapel Hill, NC 27514
> vmoyer@abpeds.org
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