Dr. Pambianco

My Reflections on ABIM MOC

Daniel J. Pambianco, MD, FACG

Charlottesville Gastroenterology Associates

For full disclosure, I am currently chairing the ACG Task Force on the ABIM MOC since 2016. I am Board Certified in Internal Medicine – 1985, and gastroenterology – 1989. I have chosen not to continue my MOC activity. The views expressed in this blog are my own personal opinions and not those of the ACG or the Task Force.

The American Board of Medical Specialties (“ABMS” the parent board of the American Board of Internal Medicine) says, “board certification is a voluntary process, and one that is very different from medical licensure.”

The ABIM states that, “Initial Certification indicates that physicians have met rigorous standards through intensive study, accredited training and evaluation and that they have the clinical judgment, skills and attitudes essential for the delivery of excellent patient care.” In addition, according to ABIM, “Maintenance of Certification (MOC) is a professionally determined standard that attests that an internist is staying current in knowledge and practice throughout his/her career.” (http://www.abim.org/maintenance-of-certification/default.aspx)

Since 1990, the definition of “Board Certified” has changed from a one-time test to an ongoing series of re-certifying exams, clerical convolutions, and fees to maintain certification through the MOC program –  a process costing up to $25,000. Lack of participation in any portion of the MOC program results in loss of Board certification. Board certification, either as initial certification or 27 years into maintaining certification, is voluntary!

Traditionally, intrinsic to our profession and title “Doctor of Medicine” was and is the incumbent moral imperative to maintain the respect and trust of our patients. This includes the obligation to pursue ongoing education and to provide the best care possible to our patients. Demonstrably, physicians have always committed to continuing medical education throughout our professional lives – and then some. This is one reason state medical societies require documentation of this education for physicians to remain licensed.

What has changed? According to recent proclamations by the ABIM, there is currently a general mistrust of the medical profession by the public, an erosion of the quality of care, and a general incompetence among practicing physicians. Apparently, ABIM has now become the self-anointed societal guardian of this supposed malignancy.

At the recent Liaison Committee on Certification and Recertification meeting in Philadelphia, Dr. Richard Baron, President and CEO of the ABIM, extolled examples of Gastroenterologists, who couldn’t pass their Boards, who have become nutritionists, calling them “quacks.”  I would remind everyone that gastroenterologist Dr. Barry Marshall, who is not Board certified, was awarded the Nobel Prize in Medicine for the discovery of Helicobacter pylori.

Another statement made at the LCCR meeting was that diplomates need to be “at risk” for their knowledge assessments, as this “creates value” and “increases engagement,” i.e., risks of failing the exam and losing Board certification. These egregious statements speak volumes as to the mindset of the ABIM’s leadership, regardless of the platitudes being cited.

Even taken at face value, the ABIM perceived mandate of protecting society breaks down currently as follows: The ACG (and others in medicine) have opposed vociferously any MOC that involve high stakes exams that cost physicians thousands of dollars to comply and take time away from their work. This is on the basis of lack of relevance to the process, i.e., testing knowledge without evidence of testing competence. The theoretical purpose of these exams is to assure competence and evidence of lifelong learning, for which, in fact, there is no psychometric evidence. Universally, it is felt among various disciplines, the MOC exams simply do not relate to the way physicians practice medicine.

Another issue is the ability of the ABIM to withdraw certification or post a diplomate’s status in a critical manner. Clinical practice is continually evolving, based on the health needs of the population, technical advances and physician specialization. Gastroenterology is a grand example of our various sub-specializations. Should you be required to be tested in hepatology when you’re an interventional endoscopist?

The ABIM also should not be able to retract a certification that a physician has earned.  For example, if a gastroenterologist decides to maintain their GI Board certification, but no longer maintain their Internal Medicine Boards, the physician can no longer publicly acknowledge their history of passed IM Board exams.

Hence, while the ABIM may have laudable goals in its sights, and is making efforts to improve their reputation and exam utility (one can read the current proposed iterations of the 2 year alternative knowledge check-in exam, the partnership with the ACP, ACA, ASCO societies on their website www.abim.org), there remain major concerns about this apparent overreach that are not being addressed by the ABIM.

I know that the ACG will continue to work to resolve these significant concerns:

  1. ABIM’s MOC requirements are a massive experiment foisted on practicing physicians at a time when there are unprecedented pressures on us.
  2. The ABIM is in the testing business and should fund and validate its own psychometric testing before launching an undeveloped program, with its unintended consequences of uncertainty and anxiety, upon competent physicians.
  3. ABIM is not in the education business and should therefore not impede the ability of expertise and best practices to be promulgated with ease of access and the already accepted norm of “lifelong learning,” rather the necessity of “risk of failure.”
  4. The ACG and similar professional societies are in the education business and work ardently to produce practice guidelines based on current and evolving research that is more applicable to current clinical practice than exams based on a “Trivial Pursuit” model.
  5. A major incongruence of the current ABIM recertification process and the MOC process is the fact that the production of questions and their use are vastly different from the initial board certifying exam. The cost and process of test administration is therefore vastly different – a point that prevents the ABIM from simplifying the process.

Daniel J. Pambianco, MD, FACG