The ABIM charges $1,940 for a 10-year basic internal medicine certification, which includes a secure examination for each specialty the diplomate chooses to maintain, access to all ABIM self-evaluation products, and any CME credit a physician can claim through completion of an ABIM module. There are basically four requirements: MOC participants take a secure exam; they have to complete a self-assessment of knowledge; they have to assess their practice by applying quality measurement and using the resulting data to improve their practice; and they must assess patient safety and/or include the "patient voice," which could, for instance, consist of a survey of patient satisfaction.
The fee is $2,060 for a focused practice in hospital medicine for 10 years, and $2,560 for any subspecialty for the 10 years.
But it’s more than just a financial cost, say physicians. There’s also an opportunity cost, said Dr. Eric Green, chair of the MOC Task Force at the Society of General Internal Medicine. "When you are doing MOC, what are you not doing?" he asks.
"It’s about a process that seems arbitrary, a little bit burdensome, and perhaps not achieving what we all want, which is the best care for our patients," said Dr. Christopher White, professor and chairman of medicine, the Ochsner Medical Center, New Orleans, in an interview.
Dr. White, who is a founding member of Physicians for Certification Change, has signed the Pledge of Non-Compliance. He is currently certified, and at age 63, wonders if it’s worth the time and effort to recertify in 2019, when he is next due. "It is a good idea that we continually educate physicians and that physicians have continuous improvement," said Dr. White, but he said he questions whether the ABIM process is the best way. "There’s no evidence that this works, or there’s value," he said.
The American College of Cardiology has offered to partner with the ABIM in getting some answers to the evidence question, said ACC President Patrick O’Gara in an interview. "I’m hopeful that our offer to partner to do research will be taken seriously," he said. Although more evidence will "go a long way toward answering this question about relevance," it would be a long-term project, said Dr. O’Gara, who is also director of clinical cardiology at Brigham and Women’s Hospital, Boston.
The ABIM said in its July 28 letter that extensive evidence does exist – with more than half of the studies coming from non-ABIM researchers – but that maybe it hasn’t done the best job of communicating that to diplomates. However, it does say it welcomes partnering on new projects "and a broader discussion" of potential research agendas.
Many say that they are in favor of requiring lifelong learning, but that the ABIM has gone about it the wrong way.
The ACC would like to find a way "to modify the methodology" ABIM is using to achieve that goal, Dr. O’Gara said. Cost is also a big concern for cardiologists, and especially subspecialists, he said. An interventional cardiologist, for instance, not only has to pay for and pass the general cardiology exam, but also a secure board exam in the subspecialty. In an ACC survey this spring, 90% of the 4,400 respondents said they were concerned about the cost of MOC.
The Society for Cardiovascular Angiography and Interventions (SCAI) is concerned about the impact on its members, too, and has formed a work group to "develop an action plan to spur MOC reform," according to a statement. "We believe that maintaining physician competence is of the highest importance," said Dr. Alan Yeung, chair of the MOC Working Group, in the statement. "It is the current process and products for facilitating maintenance of board certification that are not acceptable."
"The problem is not the lofty goals of maintenance of certification, it’s the implementation of it," agreed Dr. Green. The SGIM is also concerned about the one-size-fits-all approach that ABIM seems to be using. The SGIM has a lot of members who are administrators or physician scientists, and the MOC modules as constructed currently aren’t necessarily meaningful to their practice, said Dr. Green, who is also the program director for the internal medicine residency at Mercy Catholic Medical Center, Philadelphia.
Dr. Weinberger of the ACP said that his organization also wants to see more customization of the secure board exam "so that it’s more relevant to a particular physician’s practice."