Arguing in favor of appropriate MOC


Category : Medical Rants

Dr. Wes has written passionately against MOC – ABIM Pleads for Mercy

But perhaps we should ask first: Why MOC at all?

Contrary to years of propaganda promoted through pseudo-science and journal article citations on the ABIM’s website, might MOC have really been created because the ABIM’s consolidated fund balance dropped 43.2% from $54,009,086 on June 30. 2001 to $30,691,329 by June 30, 2013 while the Standard and Poors 500 index increased 37.7% over the same period? Said another way, maybe MOC was created because the net assets of the ABIM diminished from negative $10,930,327 to negative $43,150,390 from 30 June 2003 to 30 June 2013 while their leadership and board members did little more than pad their resumes so they could apply to the next insurance company or National Quality Forum job opening.

Now I have followed Dr. Wes for many years. He is insightful and passionate. But MOC started in 1990.

Family Medicine started MOC when their board started.

MOC, in my mind, is necessary because CME is generally a failure. We must look at CME requirements honestly. We have to accumulate a certain number of CME points. We can get those points in a variety of ways, and addressing any variety of topics. But we have no quality control and no checking to see if we are really keeping current.

Appropriate MOC should challenge us to really stay current.

For many years, I have had concerns about how we can help physicians stay current. Medicine changes, probably more rapidly than any other profession. The number of studies published each year means that I do not have a good method for picking out what new knowledge I should add.

We need help. We need a roadmap for staying current. We cannot have subspecialists picking our curriculum, but rather need our peers to evaluate suggestions from subspecialists and practicing physicians. We need prioritization.

The goal behind MOC is pure. We can argue about the evolution of the product.

I see that ABIM now understands their errors. They are not evil. They are honorable physicians trying to improve the profession. I have talked with their leaders, and I know that they want to do the right things for internal medicine.

When we worry too much about the money, we run the risk of falling prey to the affect heuristic. We get angry at ABIM, and therefore we disregard any good that they might do and highlight any bad that they might do.

The current leadership is really trying. If we had been criticizing MOC for 25 years, then we would have the right to continue. But the real problems are about how MOC changed and how the grandfathers and grandmothers were added.

I urge everyone to focus on how we can insure that we maintain our knowledge of advances in our field. If you want to investigate finances, please separate that from an honest appraisal of what MOC could become. After all we are all patients eventually, and we want our colleagues to have the best knowledge base upon which they can help us.

I have personally urged the ABIM leadership to consider these goals for MOC. I believe that they are very open to constructive criticism. The CME enterprise could transform into what I envision for MOC, but I have no reason to expect the CME will become more relevant. We all need a roadmap for true improvement. I think MOC could provide that roadmap. If so, then MOC would be most valuable.

Comments (27)

Dr Centor is misrepresenting on behalf of the ABIM interests. The ABIM had tried to get MOC up and running in the late 70’s when lifelong certification was standard. See THEIR publication: Wasserman SI, Kimball HR, Duffy FD. Recertification in internal medicine: a program of continuous professional development. Task force on recertification. Ann Intern Med 2000; 133: 202–8.
They proved that in the mid 1980’s there would NOT be any following voluntarily-and published this in the above article! That is why they changed to time limited certificates-totally arbitrary as we found as the limit was subsequently reduced to yearly and was evident as this was printed on the ABMS certifications

Until these boards return to lifelong certification they will continue to rely on regulatory capture (Street term=Extortion). MOC is not certification but a whole new and very unproven “product” that no one wanted and will not survive in a competitive environment alongside traditional CME as the index of life long learning! The whole ABMS certification industry is archaic and passe’ in modern medicine where government, insurance and about 15 other oversight agencies are controlling practice and collecting data. see:
How much waste will we tolerate- ABMS boards costing over $400 million annually already! And ABIM $40 million in the hole with luxury condos in Philidelphia. Yes the problems go way back before 1990 and these obscenities onto the medical profession must be stopped.
Who died and put ABIM in charge and over all specialties as the leader in extortion techniques?

First, I have no connection with the ABIM. My main point was that the MOC requirement started in the early 1990s and that only now do we have an uproar.

The money discussion in my mind detracts from addressing the potential benefits of maintenance.

My request – please criticize my posts on their merit not based on your biases. Read my proposal, and argue against that. We all have a responsibility to stay current. Perhaps MOC can help us be better physicians. Consider that possibility.

Thanks Dr Centor lets hit the highlights:
“Appropriate MOC should challenge us to really stay current.-only now do we have an uproar. ”

The ABMS/ABIM program has been one of slow increments which have known no bounds. First the 10 year time limit and “grandfathers exempt”. This all changed and we found our certifications of 10 years including statements like “contingent on participation in MOC”. Suddenly the extortion became overwhelmingly evident!

The answer is that the use of Board certification to impose MOC was contingent on the extortion tactic of withholding certification based on continual payments to the boards.

Then there is the absolute lack of outcome based studies to demonstrate MOC or even Board Certification matters. Realize I trained in Europe, have “boarded twice here” and there is ZERO ABMS involved in that continent’s excellence in care which exceeds the USA in longevity, neonatal outcomes and many other areas-including COSTS.

YOU wish to ignore costs? The whole industry is running scared because of WASTE and COSTS to the point of hysteria and government investigations-RACK audits, etc! Board Certification is ADVERTISEMENT and little more if anything-see the prior URL youtube for details!

The current ABMS leadership is trying to CYA because the extortion has evoked a very deep and far reaching disgust among the physician population which HAS been doing lifelong learning, because that is who we ARE and must be to compete in this modern marketplace, where multiple less educated “practitioners” are being given the right to practice MEDICINE from PA’s to doulas!
THE ABMS is making physicians even more expensive and thus less competitive, forcing us to limit patient contact to mere minutes or Telemedicine!
We are disgusted at being held responsible for any failures caused by these private non-profit and government organizations run by and paying huge salaries to politicians with “MD” behind their names who DO NOT SEE PATIENTS! Again:

Until these boards return to lifelong certification they will continue to rely on regulatory capture (Street term=Extortion). MOC is not certification but a whole new and very unproven “product” that no one wanted and will not survive in a competitive environment alongside traditional CME as the index of life long learning!

The whole ABMS certification industry is archaic and passe’ in modern medicine where government, insurance and about 15 other oversight agencies are already controlling practice and collecting data. – See more at:

I hope these are arguments you can appreciate and are not just mine bu overwhelmingly the multitude of physician’s. Strong arguments AND facts lead to bias-especially with a thinking mind. I have repeatedly posted ABMS’s own data as here-have you read the article referenced above? It is ABIM executive’s publications and clearly expose the extortion as long standing.

Dr Centor,

I have been following your posts for a while now. By far, this is your worst post. Actually disgustingly absurd and poorly thought. You are simply ecstatic that ABIM acknowledged some of its mistakes. Why MOC? is indeed the question. When BC was changed to time-limited, the requirement was simply a 10-year exam, no MOC. This was added in 2000, then modified 10 years later. So, if you see, the goal post changes every 10 years. This is simply unacceptable and unnecessary. One would grudgingly accept it if there was a shred of independent verification that MOC truly enhances a clinician’s performance or knowledge. It does not!

As far as I am concerned, either everybody has lifetime certification or everybody has time-limited ones. In the latter case, then MOC can compete with CME and we shall see which one is more effective. And, no more secure exams please. If ABIM is truly reconciliatory, it should change to an open-book exam, where the examinee can actually learn from his/her mistakes.

It is time for you to recant your words, Dr. Centor. Just say your sorry, like the ABIm did yesterday.

Dr. Centor –

Thanks for the mention and I want you to know I appreciate your perspective. You’ve been one of the few folks brave enough to bite off on this topic.

Let’s agree on one thing: that docs need credible life-long continuing education. (Yes, I said that). But who better to teach us than our patients? Granted, there’s crap CME out there – pleasant dinners hosted by drug companies and all – but there’s also good stuff out there – like most national specialty scientific sessions, etc.

So why MOC when we can agree there are very good (maybe superior) CME programs out there that don’t cost a minor fortune? And where’s the data a computerized test with psychometric testing BS is any better than patient care experience? We hang our butts out there every day thanks to the legal community.

Then comes my revelations of the $2.3 million dollar condo complete with a chaueffer-driven Mercedes S-class town car, exhorbitant ABIM leadership salaries that assure cushy insurance or National Quality Forum positions, questionable tax form completion by the ABIM with holes in the alibi’s provided by Dr. Baron on how the condo was used. It’s all very fishy. It’s especially fishy when the MOC program has been thoroughly etched into the Affordable Car Act (that wasn’t read until it was passed, remember?) as a means to assure a continuous cash flow to the ABMS and its subsidiaries.

And the MOC program fails doctors – many of them. Up to 22% on their last disclosure. It fails them without knowing their scope of practice and if they care for nursing home patients, or work in rural communities as the only doctor there. It fails them without recourse or explanation other than “take the test again.” *cha-ching* And it’s increasingly tied to insurance company payments and credentials. It isn’t voluntary at all any longer.

And what happens to patients when their doctor can’t see them any longer? Where do they turn? Is the ABIM responsible to those patients? No. They just collect the money.

And don’t get me started about the fact that they are performing research on physicians without their consent. That’s something we can discuss another day.

The cat’s out of the bag on this one, and there are many pationate physicians like myself who want a full investigation and accounting for the actions of the ABIM leadership and its board.

Until then, they’ll have to wait for me to accept their apology or the legitimacy of the MOC program – all of it.

I and colleagues have criticized the ABIM in the past. I believe that the current apology includes an understanding of the pass rate problem. In my conversations with their leaders, they clearly understand the problems in depth. They are in the process of trying to develop a process that will really help physicians.

Our real disagreement is whether a credible MOC process is possible. I believe it is; you are much more skeptical.

The money is, in my mind, a separate issue. Under Dr. Baron’s leadership they have increased transparency. Give him enough time to correct previous errors.

I am not sorry at all and I resent your attack. They are truly looking to develop a process that will work. I am not naive, but I do believe that with the community’s help they can construct a useful process.

They will consider all testing options, including an open-book exam. To me the meat would be in having a peer group define the clinically important new knowledge that we should absorb.

I have done routine CME and MOC approved courses. The latter trump the former dramatically. I would love a study that could examine that comparison. As far as I know CME studies have consistently shown little if any benefit.

Dr. Centor –

“I am not sorry at all and I resent your attack?”

Were you directing that comment to me? I was trying to give you credit. My beef is not with you or your beliefs regarding what the ABIM is trying to do.

My beef is with the ABIM and their mismanagement of funds and apparent fiscal irresponsibility at the expense of their (presumed) colleagues for their largess. The facts speak. We want answers to the many legitimate questions I have raised.

Give me a break. That’s not too much to ask. They got their hand caught in the cookie jar. Now’s the time to come clean if they’re serious.

The ABIM has honestly been trying their best to develop a progam that will truly help physicians for over 40 years now. How much time do you think they will need to finally succeed?

“I believe that the current apology includes an understanding of the pass rate problem. In my conversations with their leaders, they clearly understand the problems in depth.”

Sorry Dr. Centor, but if this is true (which I doubt), they are very slow on the uptake.

“Once a passing standard for a discipline area is set, pass rates differ from year to year solely because the characteristics of physicians taking the exam change each time it is given. A number of examinee-specific factors — such as examinee motivation, training, preparation, and knowledge — impact pass rates.”

-Dr. David Johnson, MD and Rebecca Lipner, PhD in a Sepember 9, 2014 Medpagetoday article

“SOLELY because the characteristics of physicians taking the exam change each time it is given.”?? It took a revolt to get them to maybe take a look at their vaunted test to consider how it may be something that was a problem. That’s quite a dramatic turnaround in just 5 months.

Sorry, but I doubt their sincerity. Your personal relationships with these people may bias your interpretation of the situation. I’m not faulting you for that, but that is likely why the greater community doesn’t share your optimistic view of the ABIM’s alleged change of heart.

Do you Dr. Centor, give your Residents/Fellows a disclaimer that their training is worth only 10 years, at the end of which they have to re-test everything they have ever learnt in their specialty? If not, you are being untruthful to them and should stop training them. That is, if you believe MOC and lifelong secure exams are truly needed, and you don’t believe in CME. Most practicing physicians, on the other hand, do believe that CME provides more value than MOC. So there is no honest case to be made to continue MOC or secure exams. It is time academics like yourself start admitting this openly.

All residents know that their board certification lasts for 10 years – that is not a secret. Not sure what your point is.

I have written about my concerns about the pass rate in the past. I have repeatedly discussed this on calls with ABIM leaders. They have truly changed over the past several months. I am certain of this, and hope that we will accept their words as true.

Your point is correct, they were slow on the uptake, but I do believe they finally understand. I really doubt that I am biased in this matter.

No Wes, that was directed at someone else.

I hope they address the financial issues to everyone’s satisfaction in the future. The current leadership inherited the current situation. They were not in charge during the time frame of the records that you refer to.

My point is, do your Residents know, or have you explained to them that they will likely be out of a job if they don’t pass their 10-yearly secure exam? Does your training program have a written policy to fully explain the implications to your trainees? Do you have a formal process to allow potential trainees to agree to join your program, with full knowledge that their 11-14 years’ worth of education/training is only valid for 10 years?

How can you convince yourself that this is a fair deal? Apart from an ethical perspective, do you not see the practical, real-life perspective of this process? Are you not aware that physicians-in-training and in practice have the highest suicide rate among all professions, and MOC/lifelong testing is a major factor in this regard? Have I made enough points?

Dr. Centor –

You said “the current leadership inherited the current situation. They were not in charge at the time you are referring to.”

Perhaps not “in charge” but we should recall that the current President and CEO of the ABIM was the TREASURER of the ABIM in 2007-8. As such, he knew the financials at the time of the condo purchase and chose to do nothing. He then became an unpaid DIRECTOR of the ABIM in 2008-9 – perhaps because he had conflicts of interest with CMS as he sat as Group Director, Seamless Care Models, at the Innovation Center at Centers for Medicare & Medicaid Services (CMS). He also served in the National Quality Forum from 2009-2011, the same group the former President and CEO of the ABIM works for now. Now if that isn’t cozy, I don’t know what is.

The conflicts, particularly when one considers the fact that the NQF is in charge of determining “quality standards” for physician payment mechanisms under the proposed value-based payment models proposed ahead, are frightening.

My how deep this goes…

Please, don’t fool yourself for a minute these folks at the ABIM weren’t in on these deals. Perhaps Christine Cassel, MD said it best in her press release when Rich Baron, MD took the helm at ABIM: “Rich’s recent experience in the policy arena will serve ABIM and the ABIM Foundation well.”


The large majority of physicians do not accept the arguments of ABIM. We have unwittingly ceded control of profession to an unelected group of non-practicing MDs that have very little in common with those that they regulate.

Doctors have a long history of passivity despite adversity. Most keep to themselves, just trying to get through their days without hurting anyone, getting themselves set up for a lawsuit or pissing anyone off. In the 20 years I’ve been in practice, I’ve never seen anything like this. The ABIM has finally awakened the sleeping beast. It’s really exciting to read the comments on blogs like this. We doctors are pretty smart, witty and resourceful when prodded. We’re really mad. This isn’t going to go away easily.

Bravo, Wes and all others fighting this fight. It’s time for our proud profession works to take control of itself. We’ve been dealing you external yahoos telling us how to do our jobs for years. It is frankly ridiculous that we have to fight from within our own ranks for control. ABIM has done little over the years to prove that they represent our best interests. Set up a credible alternative and fix the regulatory capture? We’re outta here.

Edward J. Schloss MD FACC FHRS

We will stay DIVIDED and someone else will RULE us

If doctors for adults and as adults cannot have insight and judgement to keep up with their knowledge and profession, this is what I propose as a solution for MOC-
General medicine and sub specialities are required to attend one conference (recognized by their specialities like accp, ats in my case) every 5 years and they take a pretest/ post test as a small proof of their attendance. This will hopefully not be as expensive as current strategy and focus can be on real education. obviously, this can also be gamed but hopefully will be better than cme on a cruise and testing on a computer.

Hey Dr. Centor:
Got any good arterial blood gas cases lately?

I might – let me check

[…] (MOC) program and proposed changes to language and requirements. The move earned praise from some physicians, while others were more […]

I am a physician in private practice, 35 yrs since I graduated from Hahnemann. I’ve had clinical appointments, a daughter in medical school, another, a Georgetown grad in Public Health grad
school in NYC. I teach and mentor students, and like all of us, am a firm believer in Lifelong Learning and understand the need to hold ourselves to higher standards and education.

We are all colleagues, serving our patients in a noble profession. I speak to physicians around the country, many who share my concerns about MOC. These include:

-There is little evidence base that MOC proves anything.
-It was constructed behind closed doors, c little input from the practicing physicians it affects.
->95% of physicians find little or no use for the MOC process and realize many of the problems as shown by a number of surveys.
-It ignores most of what is known about how experienced physicians learn and gather
information, nor demonstrates anything about a good physician’s abilities after 20-30+ years in practice.
-It is a divisive item in an already divided profession. -Can adversely affect costs, access, quality.
-The huge amount of time this takes us away from our patients, Family, friends, avocations.
-Though MOC is called ‘voluntary’, by ABMS, we all know the potential consequences to docs if they don’t comply.
–And this data is being shared c insurers and hospital systems without our authorization.
-There appears to be many COIs and perverse incentives of some who promote this.
-We’re all aware of Congressional investigations of C Cassel, NQF; These could expand.

So, my question:
Realizing above, and c the growing concerns of stress, burnout, family discord, depression, substance abuse, in our profesion (I read a recent blog that suicide rate among physicians is 2X the national rate), understanding the additional stress on physicians the MOC process places;
Why, if MOC is truly voluntary, and c the current high failure rates, would any physicians do a secure exam and potentially put themselves in a situation that could be detrimental to their careers?
Or conversely. Why would ABMS and our Boards, put their colleagues in this situation. How does this improve HC, access, and our ability to take good care of the patients we serve?

DB, I read with interest your comment above:

“I have done routine CME and MOC approved courses. The latter trump the former dramatically. I would love a study that could examine that comparison. As far as I know CME studies have consistently shown little if any benefit.”

I find difficulty in any simple categorization of CME (e.g. within or outside of MOC). For a given individual there may be offerings in both categories that are helpful or not helpful. Your statement about one category trumping another is subjective, based on your personal experience. I too have done CME both in and outside of MOC and could say the opposite.

It is true that studies and metrics do not offer convincing proof of the effectiveness of “routine” CME. Neither, by the way, do they for MOC. I don’t think a comparative study would convince us of anything. The educational process is a multidimensional social interaction with layer upon layer of complexity. These sorts of things cannot be reduced to metrics.

Despite this, the proponents of MOC created for themselves a big burden of proof due to the aggressiveness of their claims and their efforts to force the process on others. It was a burden they could not sustain.

The ABMS certifications are unnecessary self advertisements. The US constitution has given the states the right and duty to regulate licensure. Every state has a State Medical Board (SMB) comprised primarily of physicians if not exclusively to regulate the profession. We ALL pay significant sums to this regulatory body. This is also true of the DEA who regulates our prescribing of narcotics. Again, as a hospital based physician I am “overseen” by numerous federal, state, hospital and other “agents and agencies”.
How many “regulators” do we need? Tort lawyers, families, insurance-denials, forms, preapprovals……….
The ABMS boards do not exist in Europe-excellence in care does. The AMA developed the AMA PRA and subsequently the AACME CME credits resulted and have been the basis of “maintenance of licensure” for well over 50 years, with SMB authority to fine, revoke and renew licenses-something the ABMS has NEVER had and SHOULD never receive.
Those who keep saying “we must perform this regulation BEFORE someone else does” reflects your statement:”I fear that without MOC, which represents professional self-regulation, the government would likely step in – and I would bet large amounts that any government program would be much worse.”

The Capos at Auschwitz also felt if they didn’t run the chambers, someone else would (and again, recognize that I spent 10 years as an American medical student and practicing physician there from 1974-84 and thus am intimately familiar with state and society control of medicine-i.e. from “brownshirts” to waffen SS).
I do not trust government to run medicine and even less, closed groups of physicians behind closed doors completely isolated from the practicing profession who receive lavish payment to “oversee”. This smacks of Jimmy Hoffa era UAW tactics or just plain organized extortion and should not be allowed.
If the board were to revert to time unlimited certification, this WOULD REMOVE the extortion component and allow their MOC to COMPETE with CME on the open market-and then MAYBE even become useful under the competition. Why MUST they force MOC on people with the threat of time limited certificates? Because they tried the voluntary methods and found they did NOT work. Hell, their own leadership refused to do so. many examiners simply left rather than undergo cycles. Robert Wachter, Christine Cassel and Lois Nora only “recertified” to keep/get their jobs and Cassel never recertified for decades in IM in spite of the requirement she was pushing as the leader-only renewing geriatrics and in contrast to ABIM dictates that demanded IM certification to maintain Geriatrics.
Have you read:Wasserman SI, Kimball HR, Duffy FD. Recertification in internal medicine: a program of continuous professional development. Task force on recertification. Ann Intern Med 2000; 133: 202–8.
This is FROM the leadership of the ABIM and clearly states the facts that this organization decided to Force the issue and that is why now there is such heavy opposition. This is America and not Amerika. We believe in free markets and if the ABIM cannot compete without their extortion tactics-they do NOT deserve to exist. Let them return to time unlimited certifications-just like EVERY other profession and THEN if they can make MOC work-more power to them.

Thanks for listening. Board Certification has never been demonstrated to improve healthcare in any outcome based study and again, the ABIM has published that fact which CAN be reviewed at:Sharp LK, Bashook PG, Lipsky MS, Horowitz SD, Miller SH. Specialty board certification and clinical outcomes: the missing link. Acad Med 2002; 77: 534–42.
If you cannot retrieve these article FROM THE ABIM/ABMS-let me know and I will provide these PDFs to you.
you can also read this quotation from the ABMS’s “Myths and facts” response to the NEJM article at:
Iglehart JK, Baron RB. Ensuring physicians’ competence – Is maintenance of certification the answer? N Engl J Med 2012; 367: 2543–9.
‘FACT: ABMS recognizes that regardless of the profession – whether it is health care, law enforcement, education or accounting – there is no certification that guarantees performance or positive outcomes’.

Why would anyone believe otherwise?

DB, I really wanted to respond to the questions you raised on your post from today (Feb 7) but out of respect for your request that responses there be reserved for lurkers I will answer here.

You titled that post “An observation on the MOC debates” but there was no real debate. The criticism was overwhelming but no one defended the MOC process. Now, given their apology, not even ABIM!

I regard the announcement as a welcome first step but only that. I do not think it adequately addressed the concerns but I will adopt a wait and see attitude. I believe vigorous discussion, which holds the board accountable, needs to continue. I elaborated in a post today:


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