The ABMS Vision Commission report notes that CME alone is “insufficient to ensure [certified physicians] remain up to date” [22]. Representatives of the ABR assert that the exponential growth of knowledge in medicine requires more effective methods to ensure a physician’s skills, knowledge, and judgement remain current [25]. MOC proponents also emphasize that patients expect their physicians to continue to show competence. In 2003, the American Board of Internal Medicine contracted the Gallup Organization to perform a telephone survey of the public. Results showed that “most adults (79%), once informed of what certification involves, feel that recertification of physicians is very important” [26]. In 2010, the ABMS commissioned another such survey by the Opinion Research Corporation. Respondents were informed that MOC is “a process by which doctors who are Board Certified continue to participate in a continuous process of lifelong learning and self-assessment in their specialties” [27]. Of respondents, 91% stated that this was important, but only 23% correctly defined MOC prior to being informed. Informing survey respondents about board certification in advance represents unblinding and introduces a potential for unexplained variance. Although board certification is one factor in selecting a physician, our focus groups and an informal in-person survey suggest that the public prioritizes other factors as well.
The efficacy of MOC is controversial. A cross-specialty survey of physicians in 2016 found that 81% felt that MOC was a burden, and only 9% believed that patients care about their MOC status [28]. The 2018 Survey of America’s Physicians: Practice Patterns & Perspectives, conducted by Merritt Hawkins on behalf of The Physicians Foundation, found that more than two-thirds disagreed or strongly disagreed that MOC accurately assessed their clinical abilities. Also, 95% indicated that MOC contributed significantly or very significantly to burnout, and over 68% of physicians “do not believe that the criteria on which they are judged to maintain board certification, which is a critical component of sustaining their livelihoods and reputations, is valid” [4].
Time-limited certificate-holders have also expressed dissatisfaction that older radiologists are exempted from MOC, demonstrating discrepancies in board certification standards [29]. A study of more than 20,000 radiologists found that nearly all radiologists with time-limited certificates participated in MOC, but only 14% of “grandfathered” diplomates in diagnostic radiology chose to enroll [30,31]. It is unknown whether grandfathered diplomates believe MOC can help maintain skills and knowledge, whereas others are mandated to do so.
ABR “Agreement”
The ABR recently asked all candidates for initial certification and diplomates participating in MOC to sign an “Agreement for Candidates and Diplomates” (see Appendix 8). Not signing could have damaging consequences, possibly revoking the right to continue OLA or to complete the initial certification process; however, the ramifications of refusing to sign were not clear. The ABR acknowledged concerns and withdrew and revised the agreement.
In response to this controversy, at the 2020 ACR Annual Meeting, the ACR Council unanimously adopted Resolution No. 50, establishing the official ACR position that certifying boards should minimize power imbalance by committing to representative, inclusive and transparent decision making and should never require radiology professionals to waive their fundamental due process rights. It also stated that certifying boards “should seek … input from the ACR Council Steering Committee as a representative body of candidates for certification and diplomates prior to … implementing new and/or existing policies …” [32].
ABR Examination Delays Due to COVID-19
As the effects of COVID-19 became apparent in early March 2020, the ABR appropriately announced plans to delay the normal in-person administration of its written and oral examinations to ensure the safety of candidates and staff. Many individuals and organizations expressed concerns that continued delays, uncertainty, and lack of remote testing options were disruptive to both candidates and training programs, and a letter was sent to the ABR from the Multispecialty Early Radiologic Career Coalition, signed by 17 constituent organizations and followed by an ACR letter of support [33].
The ABR was responsive to these concerns and, after further consultation with stakeholders including the Association of Program Directors in Radiology (APDR), announced on June 22, 2020, that it will be “moving all currently unscheduled and future oral and computer-based exams to virtual platforms beginning in the first half of 2021” [34]. This is a positive outcome that came from communication and collaboration with stakeholders.
Testing Accommodations for Pregnant and Lactating Candidates
There are concerns that the ABR does not have sufficient accommodations for pregnant and lactating candidates [35]. Magudia et al (2020) write: “We hope the ABR’s openness to embrace virtual examination will further drive the development of a fair and equitable examination process, including the consideration of multiple testing dates throughout the year to accommodate family planning or other major life events” [35]. Testing accommodations for lactation are based on a 2013 ABR policy, which allows lactating women an additional 30 minutes and states that private rooms with electrical outlets are not guaranteed [36]. Following the editorial by Magudia et al, the ABR responded “it hopes future plans to offer online test-taking will begin to allay some of these challenges,” eliminating “the need to travel, making the process safer during and after the pandemic.” They pledged to "actively" seek input from stakeholders and focus on similar concerns in its analyses,” also stating “we remain committed to fully supporting nursing mothers in the radiology community” [37]. With the transition to virtual testing, this is an opportunity for the ABR to review and revise their lactation accommodation policy to further support nursing mothers.
Growing Use of Certification Requirements for Practice
The requirements for board certification have accompanied an increasingly complex healthcare system. Because patients are covered by a variety of carriers, if even a small number of patients in a health system are insured by a company that requires certification, likely they will require all of their physicians to be certified. Because licensing, employment, participation in provider panels and clinical privileging all must align, it is rarely practical for a physician with a time-limited certificate to decline to comply with MOC [7,38,39].
The National Committee on Quality Assurance (NCQA) is a private, nonprofit organization that accredits most major insurance plans in the US. NCQA’s Healthcare Effectiveness Data and Information Set, which includes board certification, partially determines insurers’ accreditation [40–43]. Presumably, health systems require MOC partly because NCQA evaluates insurers based on their physicians’ compliance with MOC.
The change in terminology of certification to include MOC has created ambiguities in regulations for many organizations because innumerable legacy bylaws and regulations that refer to “certification” may now unintentionally refer to initial certification plus MOC. Potential consequences of noncompliance include termination, losing credentials as an insurance provider and being denied as an expert witness. Interestingly, these publicized consequences have largely resulted from physicians refusing to pay their MOC fees, not because they paid and failed to meet requirements [11,14,15].
AMA Policy Principles on MOC
Given the controversies surrounding continuing board certification, the American Medical Association (AMA) adopted AMA Policy H-275.924, which states that “The CBC [Continuous Board Certification] program should not be a mandated requirement for licensure, credentialing, recredentialing, privileging, reimbursement, network participation, employment, or insurance panel participation.” Also, “Our AMA will continue to work with the national medical specialty societies to advocate for the physicians of America to receive value in the services they purchase for CBC from their specialty boards. Value in CBC should include cost effectiveness with full financial transparency, respect for physicians’ time and their patient care commitments, alignment of CBC requirements with other regulator and payer requirements, and adherence to an evidence basis for both CBC content and processes” [44].
Activities Related to State and Federal Anti-MOC Laws
In recent years, multiple physician groups have initiated efforts to pass state laws limiting or outlawing the use of MOC for various purposes. Such groups claim that MOC requirements 1) overlap with existing state-imposed continuing medical education (CME) requirements, 2) are costly, and 3) have become a mandatory prerequisite to medical practice [45,46]. Multiple states have passed laws restricting the use of MOC with varying levels of strength and often with substantial exceptions.
While debating an anti-MOC bill being considered in the Maryland state legislature [47], the U.S. Department of Justice Antitrust Division was asked to provide an opinion. The response letter [48] included a recommendation to consider facilitating competition among board-certifying bodies, and to redefine board certification, so physicians still qualify as certified if they do not participate in MOC.
Federal lawsuits, mostly class-action, have been brought against ABMS and several member boards, including the ABR. Arguments include 1) antitrust violation, 2) restraint of trade, 3) unjust enrichment, 4) fraud, 5) racketeering under the Racketeer Influenced and Corrupt Organizations (RICO) Act and 6) illegal tying of initial certification to a “Continuous Professional Development” product (MOC). (See Appendix 9 for details on legislative actions and federal lawsuits.)
Cost
A key complaint of radiologists is high fees for ABR services [49]. Residents and fellows, who are often burdened by large student debts [50], pay $640 per year, which on average represents about 1% of their annual income. If they do not pass the original examination, they are charged an additional re-examination fee. Historically, residents also paid for travel and lodging expenses.
The detailed budgets of the ABR are not accessible. However, according to the ABR’s IRS Form 990 for the fiscal year ending December 2018, the total assets of the ABR were $42.6M. Revenue in 2018 was about $14M with $13.4M from certification fees. Diplomates currently pay an annual fee of $340, accounting for a majority of the ABR’s revenue, which predictably increases because all newly certified radiologists must enroll in MOC [50,51]. Fees have remained unchanged for initial certification since 2016 and MOC since 2015. We acknowledge there is a cost of doing business and reserves are necessary but increased transparency and cost effectiveness are encouraged.
Evidence of Value
Radiologists are also concerned that there is absence of scientific evidence of value. Most studies of MOC or even initial certification are nonblinded and retrospective, often conducted by representatives of the ABMS and other member boards. One review suggested that “physicians who are board certified provide better patient care, albeit the results have modest effect sizes and are not unequivocal” [52]. Literature reviews for nonradiology specialties did not uncover any study that highly associated MOC with improved patient outcomes or better physician processes. Even studies that suggested equivocal improvement usually found poor performance by both physicians who did and did not comply with MOC [53–56]. No available studies address radiologists’ performance associated with MOC. One of the ABMS-constituted Vision Commission’s recommendations was that the ABMS and member boards undertake research to evaluate the effectiveness of MOC.
