Anesthesiologists and other physicians are becoming increasingly concerned that conditions for maintaining board certification may also become unofficial requirements for maintaining state licensure, turning what has been voluntary into something that is mandatory to practice medicine. Many physicians also worry that they may have to duplicate the expensive and time-consuming board maintenance of certification requirements to retain their medical licenses.

Physicians who became board-certified during the past decade must pass a closed-book written examination and provide medical practice performance evaluations in addition to obtaining traditional continuing medical education (CME) credits in order to maintain certification, generally every seven to 10 years. The enhanced requirements, enacted in 2000 by the 24 medical and surgical specialty boards belonging to the American Board of Medical Specialties (ABMS), have garnered mixed reviews, ranging from grudging acceptance to vehement opposition.

Supporters claim the process keeps physicians up to date in knowledge and practice and improves patient safety. Critics complain that the testing methodology does not represent current practice because it prohibits access to reference materials and forces doctors to spend unnecessary time and money cramming for tests in specialty areas that they do not practice and have no intention of doing so.

“The last thing we need is to have our primary care physicians retire rather than take on the board recertifications that are being forced on them,” said Stanley H. Block, MD, medical director of Providence Community Health Centers, in Rhode Island.

Critics also say there is no objective evidence to support claims of improved patient outcomes. “I’m a champion test-taker. I’ve taken all kinds of tests throughout my medical career and I can tell you that a test does not measure whether you are any good or not. It merely tells you whether you are good at taking a test,” said Jane Orient, MD, an internist in Tucson, Ariz., and executive director of the Association of American Physicians and Surgeons, which represents doctors in private practice. “Maintenance of certification is a waste of time and money.”

From MOC to MOL

In April 2010, the Federation of State Medical Boards (FSMB), which represents the approximately 70 medical and osteopathic boards in the United States and its territories, enacted a new framework for maintenance of licensure. Currently, most state boards require renewing doctors to merely update information about their certifications, training and malpractice claims, provide proof of their CMEs and pay a fee. The new framework would require physicians to also pass periodic knowledge and skills tests, and to demonstrate performance standards using patient data from their own practices. Their results might then be compared with local and national statistics.

Early next year, the FSMB will initiate pilot projects with 11 state medical boards to test various approaches to maintenance of licensure, said Drew Carlson, communications director for the group. New standards would be enacted sometime after that.

The maintenance of licensure framework tracks so closely to the maintenance of certification requirements that FSMB “strongly supports having physicians who are already engaged in maintenance of certification [be] recognized as being in compliance with any state’s MOL [maintenance of licensure] program,” said Humayun J. Chaudhry, DO, president and chief executive, in a statement posted on the organization’s Web site.

Although the American Medical Association (AMA) supports lifelong learning, delegates at the AMA’s annual meeting in June expressed concern that new rules for maintenance of licensure would force them to duplicate CME and other maintenance of certification requirements. The delegates voted to ask the ABMS not to require physicians to pass numerous examinations in order to maintain their certifications.

“There is widespread concern about these multiple certifications and licensure examinations that are starting to chew up more and more expense,” said Gregory Threatte, MD, professor and chair of pathology at the State University of New York, Syracuse, according to American Medical News.

Show Them the Money

Some physicians believe maintenance of certification has less to do with improving quality of care than with collecting additional fees for examination and other services on the part of specialty medical boards and their related societies and associations. Contributing to this perception is the fact that some of the larger boards collect millions of dollars in annual testing fees, have assets totaling tens of millions of dollars, and pay their officers and executives high salaries. Individual physicians can expect to pay several thousand dollars to complete the maintenance of certification process.

The medical boards, all not-for-profit corporations, deny having a profit motive and maintain that the new requirements encourage lifelong learning, support physician competence, and improve clinical outcomes and patient safety. In addition to the AMA, many organizations including the Joint Commission and the Accreditation Council for Continuing Medical Education, endorse professional assessment, continuous learning and lifelong practice improvement.

Nevertheless, financial conflicts of interest, or at least their appearance, can arise because medical boards and their affiliated societies are financially intertwined in the recertification process. “For some of the other boards, a significant amount of their revenue comes from maintenance of certification because they’ve created products that fit some of those requirements,” said David L. Brown, MD, secretary of the American Board of Anesthesiology (ABA).

“Unlike some of the boards that have developed products to sell to their physicians, we made a very conscious decision not to do that so it wouldn’t be perceived that we were somehow trying to increase revenues with products,” Dr. Brown said. “We purposely tried to stay away from having that conflict.” The ABA last year collected $912,000 in maintenance of certification fees, less than 10% of the organization’s $9.5 million annual revenue, he said.

Mark A. Warner, MD, president of the American Society of Anesthesiologists (ASA), said the ASA is not the exclusive provider of educational materials and activities for the maintenance of certification in anesthesiology (MOCA) process.

“Any other organization may develop materials and activities for the MOCA process, presumably working with the ABA to ensure that these meet their guidelines,” Dr. Warner said. Thus far, however, only the ASA has sought approval to supply these materials. “It seems likely that this will change in coming years, as I know of at least one anesthesiology subspecialty organization that is discussing the possibility of doing so,” said ABA President Glenn P. Gravlee, MD.

The ABA has been implementing MOCA over the past decade. Anesthesiologists who were originally certified prior to 2000 are “grandfathered” or exempted from the process, but they are encouraged to participate in it. In addition to CMEs, diplomates must submit a four-step case evaluation and complete an anesthesia simulation course at an ASA-certified simulation center. The “cognitive examination” consists of 200 multiple-choice questions, 150 of which are general and the remaining 50 are specific to pediatrics, cardiothoracic medicine, neuroanesthesia, critical care, obstetrics/gynecology and pain medicine.

Forcing all anesthesiologists to study for these subspecialties is wasteful, said Paul Kempen, MD, PhD, a general anesthesiologist at the Cleveland Clinic, in Ohio. “They want us to test every 10 years in all areas of anesthesia, including chronic pain management, which is a whole new specialty in itself. It’s a waste of time and money.”

The ABA’s Dr. Brown explained that preparing separate specialty examinations would have been too costly. “So we’re trying to bridge it to make it pretty commonsense stuff that actually has applicability for most people,” he said.

But so far, it appears that nearly all anesthesiologists who are required to undergo MOCA are in the process of doing so. According to Dr. Brown, 99.6% of the 2000 cohort of ABA diplomates is expected to complete the MOCA program by 2013. Dr. Warner added, “The ASA is not aware of any information on anesthesiologists who are critics of the MOCA process. Some individuals have expressed concern to ASA that the MOCA process is either not clear to them or is an activity that they do not wish to pursue. However, there are no survey data, to our knowledge, on the interest or disinterest of anesthesiologists in the MOCA process.”

Widespread Criticism

Yet, although some physicians say maintenance of certification is worthwhile, this sentiment does not appear to be widespread. In March 2010, the New England Journal of Medicine asked readers to vote on whether they thought a physician who holds certificates of unlimited duration from the American Board of Internal Medicine (ABIM) should voluntarily enroll in maintenance of certification (N Engl J Med 2010;362:948-952).

The results were overwhelming: 63% of more than 2,500 respondents recommended against enrolling. Strikingly, more than 80% of the respondents were themselves board-certified physicians (N Engl J Med 2010;362:e54-e55). Many of them commented that the cost outweighed the benefit, and that the program was a money-generating activity for ABIM. Many respondents who reported having gone through the process said it was only marginally beneficial and took time away from caring for patients and other learning activities. Others argued for keeping the requirement but revising the process to make it less burdensome.

Martin S. Dubravec, MD, an allergist in Cadillac, Mich., completed his maintenance of certification with the American Board of Allergy and Immunology in 2008. “The material did not reflect my practice,” Dr. Dubravec said. “It was unduly burdensome and made it harder for me to provide high-quality care to patients, since I had to spend many hours and thousands of dollars preparing for clinically irrelevant tests.”

Ron Benbassat, MD, an internist in Beverly Hills, Calif., said he is hoping to be a catalyst for change. “We are all for staying current with medical changes,” he said, “but the onerous [maintenance of certification] program is no way to achieve this.”

Dr. Benbassat runs a Web site (www.changeboardrecert.com) in an effort to mobilize physicians to petition their boards, hospitals and state medical organizations to reform or abolish maintenance of certification requirements. “Doctors are collectively apathetic and afraid to make waves,” he said. “Doctors need to take their heads out of the sand, unify and take control back of our profession.”

The controversy over maintenance of certification is not limited to physicians. The National Board on Certification and Recertification of Nurse Anesthetists (NBCRNA), in August, announced proposed new rules for continued certification, including a standardized examination every eight years. The response has been vocal and about evenly split, said Wanda Wilson, PhD, CRNA, executive director of the American Association of Nurse Anesthetists. Karen Plaus, PhD, CRNA, executive director of the NBCRNA, said her organization would consider the feedback and comments before making a final recommendation to its board.

When it comes to anesthesiologists, Dr. Brown said the ABA has tried to make MOCA “the least onerous we can for our docs, with as much clarity and transparency as we can for society.”

“It’s a balance to try to get it right,” Dr. Brown continued. “Do we get it right for everybody? I would guess that we don’t. But the worst thing would be to have some group that doesn’t know anything about medicine trying to make these rules instead of us.”


Simulation Centers Get Boost From MOCA

One of the requirements of maintenance of certification in anesthesiology (MOCA) is to attend an approved anesthesia simulation course. The American Society of Anesthesiologists (ASA) has endorsed 27 simulation centers nationwide, including at such major institutions as Mount Sinai, Stanford University and Vanderbilt University. ASA president Mark Warner, MD, said the centers were selected based on their educational programs, facilities, and instructor experience.

Participants work as part of a small team but take turns being the primary anesthesiologist. Scenarios recreate challenging clinical cases, including “the management of hypoxemia and hemodynamic derangement and to emphasize teamwork skills in resolving such events,” Dr. Warner said.

Each participant’s performance is videotaped and reviewed afterward, but is neither graded nor scored. “This is not a pass/fail exam, but an experiential learning opportunity that is designed to stimulate practice improvement,” the ASA says. According to David Brown, MD, president of the American Board of Anesthesiologists, past participants viewed the experience as positive, with 92% indicating it would change their practice.

Paul Kempen, MD, PhD, a general anesthesiologist at the Cleveland Clinic, in Ohio, remains critical. “The installation of simulators in university settings requires the investment of tremendous amounts of money. Now they want to create repeat and paying customers to use this equipment at preferred sites and finance it,” he said.

“There is no protocol (yet) as to what should be simulated in terms of recertification, nor validation that it is effective in this setting,” Dr. Kempen added. “There are no tests required for simulation. It’s almost as if they are saying, ‘Just come, pay for it, and you’ll have a good time.’”

—Ted Agres