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According to the American Board of Medical ľֱ, its program for maintenance of certification (MOC) serves the patients, families, and communities of the U.S. and improves patient care by establishing high standards for ongoing learning, practice improvement, and assessment activities. Whether this is true or not has been a hotly contested topic in the medical profession for more than two decades now.
Proponents claim that MOC fosters lifelong learning and improved patient care, while critics argue that it generates additional monetary expense, saps physician time and energy, and has not been proved to improve practice. One key dimension of this debate concerns the level at which these effects should be assessed -- the profession as a whole or the individual physician.
We believe it is important to look at the effects of MOC at the level of the individual physician, and we present here a case in which the net impact is highly negative -- i.e., harming patients, families, and communities, and undermining patient care through MOC's "high standards."
The physician in question, Dr. D, is an internationally known cancer specialist, a physician-scientist and MD-PhD who has helped to develop many new and effective cancer therapies over the course of his career. He has maintained his certification in the broader field of medical oncology for two decades, although he cares only for patients with a specific type of cancer. He has met all the continuing medical education requirements of his state licensing agency and has functioned as one of only two specialists in his field at a large academic medical center.
When the time came for Dr. D to renew his certification in medical oncology, he found the commitment required to prepare for the certification examination overly burdensome. To ready himself, he needed to review the latest standards of care for a wide variety of different malignancies, even though he devoted his entire practice to the care of patients with a particular form of cancer.
The problem is not that he lacked drive or discipline. The problem is that he would be devoting hundreds of hours to the study of patient care situations that he would never encounter in practice, and doing so would take time and energy away from the patients he cares for, his clinical research, and the teaching he provides to fellows, residents, and medical students.
Believing that it made no sense for him to devote so much effort to recertification, Dr. D reached out to his hospital to request an exemption that would allow him to continue practice despite declining to recertify. His request was denied. He was told that either he must sit for and pass the recertification examination or his hospital privileges would be revoked.
After carefully considering the situation, he decided not to take the examination. Instead of continuing to practice at the academic medical center, he would move to private industry, where he could continue to help to develop and test new cancer therapies.
Today Dr. D is no longer caring for patients and their families in the hospital or clinic; teaching fellows, residents, and medical students; or bringing research (and funding) into the university.
Let us be clear. Dr. D is an excellent physician-scientist. No one who knows him has any doubts about his clinical acumen or his dedication to his patients. Throughout his career, he has remained quite current with the latest developments in his field of cancer medicine, in part because he is participating and driving such changes through his own investigations. Moreover, he is highly respected and sought after as an educator.
The institution he left feels his absence keenly -- in part because it has been unable to recruit a replacement specialist, and partly because all the clinical work he formerly did must now be absorbed by the one remaining physician who cares for the same type of cancer patients. Making one physician bear the workload of two cannot be in the best interests of patients.
In fact, the remaining cancer specialist more recently faced a similar choice. He, too, was up for recertification, and he too felt that the preparation required to retake the certifying examination would present too great a burden -- in part because the absence of his partner meant that he was working harder than ever before.
When he informed his institution that he too would leave practice if required to complete the recertification requirements to maintain his hospital privileges, the medical staff office reached a different decision. They renewed his hospital privileges, perhaps in part because he had completed his primary board certification requirements at a time far enough in the past when "lifetime" certificates were still being granted, a status unavailable to his more junior colleague.
But this begs an essential question about the core of what it means to be a member of the medical profession: Can we trust physicians to remain competent? Specifically, can we trust them to maintain the knowledge and skill necessary to care well for patients, families, and communities?
We know that Dr. D is not only highly qualified, but is an expert in his field, whose departure from clinical practice represents a substantial loss to his patients, colleagues, hospital, medical school, and profession. Literally none of the people he served or worked with is better off because of his departure – in fact, all are suffering from it. To be sure, an examination was not taken, a fee was not paid, and a rule was not broken, but was justice served? Did we as a profession do the right thing?
We believe the answer is no. When a certification requirement inflicts harm on a physician, their patients, their families, the community, physicians in training, a hospital, a medical school, and a profession to no good purpose, then the requirement is flawed. Such arbitrary and unproved requirements only exacerbate high levels of burnout among physicians, propelling many into premature retirement.
In the last 7 years, about two dozen states, from Arizona to Maine, have taken steps to ensure that patients, families, and communities are not deprived of the caring and expertise of fine physicians like Dr. D.
We concur with the implicit determination that losing even one good physician is simply too high a price to pay.
, is chancellor's professor in the Schools of Medicine, Liberal Arts, and Philanthropy at Indiana University in Indianapolis. , is dean of admissions at the University of Florida College of Medicine in Gainesville.
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