Maintenance of Certification: A New Way to Control Docs?


Is board certification, the decades-old process by which physicians prove their clinical chops within their specialties, becoming a back-door way to micromanage them? Many doctors think so, and they’re planning to debate the subject tomorrow in Philadelphia. You’re invited.

Herbert Kunkle, an orthopedic surgeon in Pennsylvania, argues that board certification is overrated as a means of demonstrating clinical acumen, unproven as a way of driving healthcare quality, and is lately becoming intolerably onerous.

He acknowledges that board certification is “a time-honored thing” that physicians accept as part of the job, even though many feel “tortured by” it. “No one’s ever shown [a clear link between] board certification and clinical acumen and quality,” Kunkle says. “But it’s there and it’s accepted.”

What is angering the critics now are the boards’ implementation of plans to transform what started out as a once-in-your-career certification into something that’s “always on,” watching you. So-called “maintenance of certification” (MOC) was introduced, in principle, more than a decade ago when the 24 member boards of the American Board of Medical Specialties (ABMS) agreed to it, but the actual MOC programs are only now being implemented by the specialties.

The purpose is to ensure “that the physician is committed to lifelong learning and competency,” by “requiring ongoing measurement of six core competencies,” according to the ABMS. Only two of those competencies seem, by my reading, directly related to clinical knowledge. The others appear aimed more at ensuring that you work and play well with others. For example, you’ll now be expected to “demonstrate awareness of and responsibility to [the] larger context and systems of healthcare” and “call on system resources to provide optimal care.” You’ll also by judged on “interpersonal communication,” including your “active listening” skills.

These are nice ideals but they’re subjective. Many physicians worry that requirements like that are just thinly veiled attempts by hospitals, academics, and associations — what Kunkle calls healthcare’s “artificial aristocracy” — to control the way doctors work and interact with the healthcare system, not just how effectively they treat patients.

“If you think about lawyers, they pass the board once, that’s it,” says Beth Haynes, a family doctor in San Francisco and executive director of the Benjamin Rush Society, the physicians’ group that’s putting on the debate at the University of Pennsylania. (Can’t make it? Stream it live at 6 pm ET.) Haynes is referring to the bar exam, of course. “That’s what we used to with board certification. It was a lifetime mark of achievement, period. But now it’s becoming this very intrusive way of trying to tell people how to practice. … It’s just complete micromanaging of physicians.”

The boards are technically voluntary. You’re not required by law to be board-certified to practice, and as many as a quarter of U.S. docs aren’t. But outside of rural areas where doctors are sparse, board-certification is a prerequisite for hospital privileges and payer credentialing. You can’t work without board certification, so attempts to broaden certification requirements to include the kind of “soft” skills often valued by administrators, as well as the fact that measurement is now “ongoing” rather than periodic, strikes some as an attempt by bureaucrats to control docs.

Kunkle’s assertion, by the way, about the lack of firm evidence of the boards’ value in driving healthcare quality is a matter of debate. There are studies that demonstrate a correlation between the boards and quality, though proving causation requires the ability to control for other factors that might affect quality, and that’s a very difficult thing to do. Yet even if one accepts the premise that it makes sense to measure a physician’s skills related to her chosen specialty, what’s needed is evidence of how well and by much board-certification drives quality. Otherwise it’s hard to see a scientific basis for new and expanded requirements.