USPhysicianandSurgeonPerspectivesonContinuousBoardCertification–ANationalCross-specialtySurvey

WestbyG.Fisher,MD,FACC1,TimothySanborn,MD,MS,FACC1,andCharlesCutler,MD,MACP2

RunningTitle:USPhysicianandSurgeonPerspectivesonContinuousBoardCertification1NorthShoreUniversityHealthSystem,Evanston,ILandUniversityofChicago,PritzkerSchoolofMedicine2EinsteinMedicalCenterMontgomery,Norristown,PACorrespondingAuthor:WestbyG.Fisher,MDDirector,CardiacElectrophysiologyNorthShoreUniversityHealthSystem2650RidgeAvenue,WalgreensBuilding3rdFloorEvanston,IL60201Office:847-570-2640Fax:847-570-1865Email:wfisher@northshore.orgCo-AuthorEmails:TimothySanborn,MD,MS,FACC:tsanborn@northshore.orgCharlesCutler,MD,MACP:drcharlescutler@gmail.comFundingSource:Self-funded.WordCount:2887

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USPhysicianandSurgeonPerspectivesonContinuousBoardCertification–ANationalCross-

specialtySurvey

Background:ClinicalUSphysicianandsurgeonopinionsregardingABMSandAOAContinuous

Certificationprogramsareunknown.

Objective:Toassesspracticingphysicians’opinionsofABMSMaintenanceofCertification®

(MOC)andAOAOsteopathicContinuousCertification(OCC).

Design:AnInternet-basedvoluntarysurveyofUSphysiciansandsurgeons.

Setting:Aself-selectedcross-specialtysampleofUSphysiciansandsurgeonsfrom21January

2018through19March2018.

Participants:USphysiciansandsurgeonsengagedinclinicalpractice.

MainOutcome(s)andMeasures(s):Self-reportedperspectivesoftheABMSandAOABoard

initialandcontinuouscertificationprogramsincludingperceivedvalue,costs,conflictsof

interest,researchmethods,contributiontoburnout,andnegativeconsequences.

Results:Ofanestimated759421clinicalUSphysicians,avoluntarysampleof7007uniqueUS

physicians(0.92%)representing47subspecialtiesfromeverystateandnearlyeveryUSterritory

werereceived.6048(93%)wereBoardCertifiedbyatleastoneABMSmemberboardand4793

of6004respondents(80%)participatedinMOCorOCC.5831of6477(90%)feltABMSorAOA

BoardCertificationshouldbealife-longcredentialusingContinuousMedicalEducationcredits

todocumentongoingmedicaleducation.Costsforcertificationorrecertificationexceeded

$6000for2027of6477(31%)oftheparticipants.4059of4697(86%)feltMOC/OCCcould

interferewiththeirrighttowork.390of4697(8%)physiciansparticipatingincontinuous

3

certificationperceivednegativeconsequencesfromtheprocess.4436of4697(94%)of

recertifyingphysicianswereunawaretheircertificationstatuswassoldtothirdpartieswhen

enrollingforMOC/OCC.4624of5812(80%)expressedconcernthatMOCresearchwas

conductedonphysiciansortheirpracticewithoutinformedconsent.Perceptionswerenot

differentbasedongender,thetimefollowingtraining,orpracticesetting.

ConclusionsandRelevance:WhilemostphysiciansvaluedinitialBoardcertificationwith

lifelongcontinuingmedicaleducation,dissatisfactionandperceivednegativeconsequencesto

USphysicianswithcurrentABMSMOCandAOA“continuouscertification”programsexist.As

ABMSmemberboardsarecurrentlyredesigningtheentireMOCprocess,thesefindings

reflectingtheopinionsofUSphysiciansandsurgeonsshouldbecarefullyconsidered.

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Background

Forthefirst33yearsofexistence,theAmericanBoardofMedicalSpecialties(ABMS)andits

memberboardsissuedlifetimecertificatesfollowingpassageofaone-timeboard

certificationexam.Todemonstratetheircommitmenttolife-longlearning,physicians

participatedincontinuingmedicaleducationprogramstoenhancetheirknowledge.

Somearguedthatone-timecertificationdidnotprovidesufficientevidencethatphysicians

couldremaincompetentthroughouttheircareers.1,2,3,4,5Atitsinceptionin1969,theAmerican

BoardofFamilyMedicineissuedtime-limitedcertificationslasting7years.In1976,the

AmericanBoardofSurgeryandAmericanBoardofThoracicsurgeryinstitutedarbitrarytime-

limitedcertificationsforsimilarreasons.TheAmericanBoardofInternalMedicine(ABIM)

implementedtime-limitedcertificationforcriticalcarespecialistsin1986andforallother

internalmedicinesubspecialtiesafterJanuary1990,afterphysiciansupportforacompelling

accoladefromvoluntarycontinuouscertificationprogramfailedtoemerge.6,7,8

In1998,theABMSestablishedtheirTaskForceonCompetence,whichledallABMSmember

boardstocreateanexpandedandmorestandardizedformoftime-limitedboardcertification

calledMaintenanceofCertification®(MOC).Thefour-partMOCprogramencompassed:(1)

licensureandprofessionalstanding,(2)life-longlearningandself-assessment,(3)cognitive

expertisethroughformalexamination,and(4)practiceperformanceassessment.By2006,all

24ABMSmemberboardshadreceivedapprovalfortheirindividualMOCproducts.9The

5

AmericanOsteopathicAssociationinstitutedasimilarcontinuouscertificationprogramcalled

OsteopathicContinuousCertification(OCC)forDoctorsofOsteopathyin2013.

PracticingPhysicianConcernswithMOCandOCC

Controversyeruptedwiththeimplementationofthenewfour-partMOC/OCCrequirements

forcontinuouscertification,mostprominentlyfromtheInternalMedicinecommunity.10

Whilemostphysicianssupportcontinuingprofessionaldevelopmentandlifelonglearning,11

substantiveconcernswereraisedabouttheprogram’seffectiveness,12,13finances,14cost,15

researchmethods,1undisclosedlobbying,16andbusinessconflictsofinterestexposedthrough

Congressionaltestimony.17InJuneof2015,Resolution309waspassedintheAMAHouseof

DelegatesadvocatingforamoratoriumonMOCrequirementsforallmedicalandsurgical

specialtiesuntilithasreliablybeenshowntoimprovepatientcare.18

InSeptember2017,afteracknowledgingphysicianconcernswithMOC,theABMSconveneda

“VisionInitiativeCommission,”comprisedofbothphysiciansandnon-clinicalprofessionals.

TheCommissionistaskedwithmakingrecommendationstoimprovethecurrent

recertificationprocess,however,theirfindingswillnotbepubliclyavailablefor12-18months.

ThereisstillcontroversyrelatedtowhetherABMSMOCimprovespatientoutcomes.12,19,20,21

Weundertookanindependentnationalsurveytoassessrecentphysicianperceptionsof

continuouscertification.

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Methods

PracticingPhysiciansofAmerica,aphysicianmembershiporganizationwithitshomeofficein

NewBraunfels,TX,conductedaself-selectedInternetsurvey(SurveyMonkey,SanMateo,CA)

amongabroadsampleofboard-certifiedUSphysiciansfromJanuary12throughMarch19,

2018.The8-page,32-questionquestionnaireincludeddemographicvariablesandspecific

questionsregardinginitialcertification,maintenanceofcertification(MOC)andOsteopathic

ContinuousCertification(OCC)programs.

SamplingandHumanSubjects

Physicianswerevoluntarilyrecruitedusingsocialmediaandweb-basedchannels.According

tothelatest2016AssociationofAmericanMedicalCollegesPhysicianWorkforcereport,

thereare759421totalpatientcarephysiciansintheUnitedStates23.Weusedthisnumberto

estimatethetotalpopulationofUSphysiciansinclinicalpracticeandtodeterminethemargin

oferrorofoursurvey.Nomonetaryorin-kindincentivewasofferedforsurveycompletion.

Atthebeginningofthesurvey,physiciansweretoldtheywouldbeaskedfortheirnameand

emailattheendofthesurveytoverifytheirresponsesbutwerenotrequiredtoprovidethis

information.Thesurveyincludeddemographicvariables,Likertscalesfrom1to5toquantify

responsesofattitudesoninitialboardcertificationandcontinuouscertification,andother

nominalyes/noresponses.Priortodistribution,twelveABMSBoard-certifiedphysiciansfrom

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varyingsurgicalandmedicalsubspecialties(anesthesia,surgery,pediatrics,dermatology,

internalmedicine,cardiacelectrophysiology,interventionalcardiology,familymedicine,

osteopathicfamilymedicine,emergencymedicine,andpsychiatry)wereinvitedtoreview

surveystructureandwordingpriortodistribution.Toavoidmultiplesurveyresponsesfrom

thesamerespondentandtogeo-locaterespondents,Internetcomputeraddresseswere

tracked,andresponseslimitedtouniqueIPaddresses.Locationsofrespondentswere

assessedandquantified(BatchGeo,LLC,Portland,OR).Anonymoussurveyresponses

completedfromIPaddressesoutsidetheUSwerereviewedtoassureparticipantswereUS

physicians(e.g.,military,charitymissions,etc.).Skippagelogicwasusedinsomesurvey

questionresponsestodirectparticipantstoappropriatequestionsandtolimitresponsesto

physiciansinactiveorrecentclinicalpractice.Non-physicians,non-clinicalphysician

researchers,industry-employedphysicians,andphysiciansnotyetboardcertifiedwerepre-

specifiedtobeexcluded(Figure1).ThesurveywaspublishedtothePracticingPhysiciansof

Americawebsite(PracticingPhysician.org)andspreadthroughasecuresharableweblink

(https://www.surveymonkey.com/r/PPA_MOCSurvey)andsharedviasocialmediachannels

(Facebook,Twitter,LinkedIn).Dropoutsweretrackedforeachsectionofthesurveyexcept

theinitialdemographicssection,wherea100%completionrateoccurred(Figure1).After

release,thePennsylvaniaMedicalSocietydirecteditsmemberstothesurvey,asdidanonline

healthcareprofessionalnetwork(Doximity.com,SanFrancisco,CA).Theverbatimsurvey

questionsarelistedinAppendixA.

Statisticalanalyses

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Weappliedstandardunivariatestatisticstocharacterizethesample.Respondent-reported

demographicinformationwasobtainedfromallparticipants.Wecomparedtheprimary

surveyresponsesofthoserespondingneartheendofthesurvey(thelast10%ofthe

responses)withthoserespondingearlierbecausepriorresearchsuggeststhosethat

respondedlatercloselyapproximatesthosewhoneverrespond.22Toassessnonresponse

bias,wecorrelatedthepercentageofself-reportedspecialtiesofourrespondentstothe

percentageofspecialtiesofpracticingUSphysicianpublishedinthelatest-availableAmerican

MedicalCollegesPhysicianSpecialtyDataBook2016.23Wepre-specifiedsub-analysesby

specialty,timesincecompletionoftraining,certificationstatus,andgenderwithoutspecific

hypotheses.Surgicalsubspecialtieswerepre-specifiedtoincludeanesthesiology/pain

management,cardiothoracicsurgery,generalsurgery,neurosurgery,obstetricsand

gynecology,oralandmaxillofacialsurgery,ophthalmology,orthopedics,otolaryngology,

otorhinolaryngology,plastic/reconstructive/aestheticsurgery,andurology.

GenerallinearmodelswereusedtotestassociationsbetweenMOCopinions(outcomes)and

respondentcharacteristics.IBMSPSSVersion25wasusedforstatisticalcalculations.

Hypothesistestingusedapre-specifiedtwo-tailedalpha=0.05.

RESULTS

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SurveyResponseandSampleCharacteristics

Wereceived7125surveyresponses.Afterexcludingduplicateornon-USanonymous

incompleteresponses,7007surveyresponseswereavailableforanalysis.Attheconclusionof

thesurvey,3619of7007(52%)physiciansincludedtheirnameandatleastoneemailaddress

forverification.PhysiciansfromeverystateandUSterritory(excepttheNorthernMarinas

Islands)contributed.DemographicinformationofrespondentsisreportedinTables1and2.

Toverifyrespondents,arandomlyselected100respondentswhosubmittedtheirnameand

atleastoneemailaddresswereverifiedagainstanABMSdatabase(CertificationMatters.org).

All100randomlyselectednon-anonymousphysiciansreportedtheirpracticesettingand

certificationstatusaccurately.

SurveycompletionrateofissuespertainingtoABMSboardcertificationwas90%(5812/6477)

(Figure1).Generalperceptionsofboardcertificationandcontinuouscertificationprograms

andtheirestimatedcostsareoutlinedinTable3andFigure2.Theoverwhelmingmajority

(5831/6477,90%)ofphysiciansfeltBoardcertificationshouldbealifetimecredentialusing

continuingmedicaleducationtodemonstrateacommitmenttolifelonglearning.Almostall

physiciansfeltMOC/OCCcontributedsignificantlyorverysignificantlytophysicianburnout

(5516/5805,95%)andposthocanalysisbyspecialtyshowednodifferenceinperceptions

betweensurgicalormedicalspecialties.Similarly,astrongmajorityacrossallspecialties

perceivedparticipationinMOC/OCCasnolongervoluntary(5787/6453,90%).Perceptionof

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MOC/OCCcostsexceeded$4000forthemajorityofUSphysicianswitheachtestingcycle

(3477/6477,54%).

Whilefewerinnumber,doctorsofosteopathyinvolvedinOCCfelttheAmericanOsteopathic

Associationshouldacceptalternaterecertificationboards’credentialsforcontinuous

certification(686/755,91%)andthevastmajoritydidnotthinktheprocessshouldbetiedto

statelicensure(685/754,91%).

Ofthe4793physicianswhodescribedthemselvesasparticipatinginMOCorOCC,3262of

4697(69%)didsobecausetheirhospitalrequiredthemtoparticipate,2141of4697(46%)

becausetheirinsurancecompanyrequiresparticipation,andonly903/4697(19%)didsoto

keepupwiththeirspecialty.Themajorityofphysiciansdisagreedorstronglydisagreedthat

MOC/OCCtestedconceptsrelevanttotheirpractice(2753/4697,58%),hadstrongscientific

evidencebasetoimprovepatientoutcomes(3973/4691,85%),accuratelyreflectedtheir

abilitytopracticemedicine(4180/4691,89%),orwasofferedatanacceptablecost(4307/

4692,92%).

Themajorityofphysicians(4303/4697,92%)didnotfailaMOCexamination,losetheir

Boardcertification(evenbriefly),orexperiencenegativeconsequencesbecauseofMOC/OCC

requirements.Forthe394physicianswhodid(Table3),psychologicalandeconomicalharms

predominatedand17%werecontemplatingretirementratherthanparticipateinMOC/OCC.

Ofthissamegroup,4059of4697(86%)felttheprogramcouldaffecttheirrighttoworkasa

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physician.MostphysiciansparticipatinginMOC(4436/4697,94%)wereunawarethatAMBS

Solutions,LLC(Atlanta,GA),awhollyownedsubsidiaryofABMS,sellstheirphysiciandatato

thirdparties.

OfallABMSboard-certifiedphysiciansparticipatinginMOCornot,only2065of5812

respondents(36%)feltphysiciansshouldbeautomatically“optedin”toaHIPAABusiness

AssociateAgreementasaconditionofenrollinginMOCand4624or5812(80%)ofphysicians

felttheABMSandAOAshouldofferphysiciansinformedconsentbeforeconductingresearch

involvingMOCorOCC.

Discussion

ThissurveyrepresentsthelargestassessmenttodateofpracticingUSphysiciansfroma

cross-sectionofsubspecialtiessincetheintroductionofcontinuouscertificationbyABMSand

theAOA.Socialmediaandsmartphoneusebyphysicianshasgrownrapidly,particularly

amongstyoungerphysicians,leadingtothedemocratizationofvoicesandpeerreviewby

crowd.24The7007responserateapproachesnearly1%ofallUSclinicalphysiciansin2016.

93%ofrespondentswereorareBoardcertifiedinatleastonesubspecialty.Only19%of

physiciansheldonelifetimeBoardcertificationissuedbefore1990(“grandfathers”).While

moremenrespondedthanwomen,thelargerproportionofwomenphysiciansreportingin

thisstudy(48%)isconsistentwiththetrendofagrowingfemalephysicianworkforce.25Ina

2006nationalsurveyonMOCconductedbymembersoftheAmericanBoardofInternal

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Medicine,only23%ofrespondentswerefemale.26Posthocanalysesshowed1530of2330

(66%)ofphysicianrespondents0-10yearsfromtrainingwerewomen,whileonly152of912

(17%)ofphysicianrespondents30yearspost-trainingorretiredwerewomen.

PerceptionsofInitialBoardCertification

Ninetypercentofallphysicianssurveyedfeltinitialcertificationshouldbealifelong

credentialwithcontinuingmedicaleducationcreditsbeingadequatetodocument

maintenanceofcompetency(Table3).Thisperceptiondidnotchangebasedontimefrom

training.Thisfindingisconsistentwithearliersurveysofboard-certifiedphysicians27and

anesthesiologists.28Only666of6453(10%)USphysiciansfeltconfidentABMSboard

certificationwasavoluntaryprocess.Despitetheseconcerns,perceptionsregardingthe

integrityoftheinitialboardcertificationprocess,theeducationalcontent,andtheabilityto

maintainpracticeprivacywereneutral(Figure2).Posthocanalysissuggestedmostsurgical

subspecialtiesheldaslightlymorefavorableopinionofboardcertificationthanmedical

subspecialties.

PerceptionsofMOC/OCC

Mostphysicianswhoparticipatedincontinuouscertificationdidnotfeeltherewasastrong

evidencebaseforMOC/OCCtoaffectpatientoutcomes,theirabilitytoprovidegoodcareor

toimprovepatientsafety(Figure2).Mostphysiciansdisagreedorstronglydisagreedwiththe

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abilityforMOC/OCCtotestrelevantconceptsbasedontheirspecificpracticesetting(Figure

2).86%ofphysicianrespondentsfeltcontinuouscertificationcouldinterferewiththeirright

toworkasaphysician,perhapsbecauseBoardcertificationisincreasinglytiedtohospital

credentialing29andinsurancepanelinclusion.Intermsofcost,themajorityofphysiciansfelt

theMOC/OCCfeesweretoohigh.2027of6477(31%)ofphysiciansestimatedtheir

expenditureswereinexcessof$6000,anamountthatcorrespondscloselytoten-yearcosts

forMOCreportedbyothers.15

WhilefewerrespondentswereDoctorsofOsteopathy(DO)thanMedicalDoctors(MD),91%

feltthattheAmericanOsteopathicAssociationshouldrecognizealternatere-certification

boards.Only9%ofDO’sfeltOCCshouldbetiedtostatelicensurerequirements.

ConflictsofInterest,ResearchConcerns,andPerceivedHarms

Mostphysicians(94%)wereunawarethatAMBSSolutions,LLC(Atlanta,GA),awhollyowned

subsidiaryofABMS,sellsphysiciandatatothirdpartiesandthatthisisaconditionof

enrollmentincontinuouscertification30.Likewise,80%ofphysiciansfelttheyshould

understandtheresearchbeingconductedonthemortheirpracticeandsigninformed

consentforresearchasrequiredbyDepartmentofHealthandHumanServicesProtectionof

HumanServiceregulations.31Finally,inthissurvey,95%ofphysiciansagreedorstrongly

agreedthatcontinuouscertificationcontributestophysicianburnout.(Figure2)Cooketal

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foundasimilarcorrelationbetweenburdenandburnoutintheirsmallercross-specialty

nationalsurvey.32

Tothebestofourknowledge,priorsurveyshavefailedtoassessphysicianattitudesand

perceivednegativeconsequencesfromcontinuouscertifications’businessarrangementsand

researchmethodssincetheprocesswasintroduced.Inthissurvey,perceivednegative

consequencescausedbycontinuouscertificationwereexperiencedby8%ofMOC/OCC

participants(Table3).Psychologicalharmswerethemostcommon,with56%ofaffected

physiciansbecoming“depressed,anxious,embarrassed,orsuicidal”and44%ashamedto

sharetheirMOC/OCCfailureorlossofBoardcertificationwiththeirworkplace,family,or

friends.Economically,23%ofthosewhofailedMOClosttheirhospitalprivileges(10%),

insurancepanelpayments(8%),orjob(5%),andsome(4%)hadtorelocateasaresultof

failure.Asubstantialnumber(67/390,17%)ofphysiciansplannedtoretireearlyinlieuofre-

certifying.PosthocanalysisshowedthosewhofailedMOCorlosttheirboardcertification,

evenbriefly,geographicallydistributed,morelikelytobemale,older,andlaterintheir

career.

IntegrationwithPreviousResearch

Ourfindingsofdissatisfaction,lackofevidencebase,andconcernswithconflictsofinterest

areconsistentwithpriorcross-specialtysurveysperformedinPennsylvania33,andwith

nationalsurveysinpediatrics34.Likethesmallercross-specialtynationalsurveyperformedby

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Mayoinvestigators32,theuniformdiscontentacrosssurveysubgroupsandmostsurveyitems

suggeststheproblemswithMOCarepervasive.Themajorityofphysiciansandsurgeons

agreedthatthesaleofpersonalMOCdata,researchmethods,andlackofevidenceto

supportimprovedpatientoutcomesorsafetysignificantlycontributestoburnoutand

physiciandissatisfactionwithMOC/OCC.GiventhesefindingsandtheperceptionthatMOC

haspotentialtoadverselyaffectaphysician’srighttoworkmayleavelittleroomfor

practicingphysicianacceptanceofalternativestoMOCthatdonotaddresstheseissuesinthe

future.

Limitations

OursurveyitemsdidnotaddressallcurrentissueswithMOC/OCCbutattemptedtogauge

thevaluephysiciansperceivefromtheprocess,physicianawarenessofpotentialconflictsof

interest,researchmethods,andnegativeconsequencesexperiencedbyphysiciansfromthe

process.Whilewecannotverifyhowmanysurveyresponseswerebasedonpersonal

experience,observations,orotherinformationsources,theseinsightsremainrelevanttothe

discussiononcontinuouscertificationprocesses.

Allsurveyssufferfromnon-responderbias,measurementbias,andresponderbias.The

voluntarynatureofthissocialmedia-promotedsurveysubjectsdatacollectiontovoluntary

responsebias.Assuch,thissurveymayover-representindividualswhohavestrongopinions

oncontinuouscertification.Whilethelargesamplesizeofphysicianrespondentstothis

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surveyhelpsreducesamplingerror,itdoesnotmitigateundercoverageandnon-response

bias,especiallysinceweareawareofonlyonestatemedicalsocietythatcirculatedthis

surveytomembers.However,posthoccomparisonsoftheperceptionstowardMOC/OCC

fromPennsylvaniaphysicianswerenodifferentfromphysiciansfromotherstateswithalarge

numberofrespondents(CA,TX,NY,FL).

Itispossiblethatsomenon-physicianscompletedthesurvey,butthecorrelationofthe

percentofsubspecialtiesreportedbysurveyrespondentstothirty-twopublishedAAMC

specialtypercentages,coupledwiththerandomverificationof100non-anonymoussubjects,

suggestedrespondentswerelikelyclinicalphysicians.Responderbiasmayhavecontributed

tounderreportingoftheperceivedharmsofMOC/OCCbecauseofsocialandprofessional

concerns.Everyeffortwasmadetopermitrespondentanonymitytolimitthisbias.Finally,

ourestimatedtotalpopulationofpracticingphysicianswasreportedin201623andmaynot

representthetotalnumberofpracticingphysiciansin2018.Still,posthocanalysisusingan

estimateof10%morephysiciansforthetotalpopulation(835,362)estimatedaworst-case

surveymarginoferrorforsurveyresponsesof±1%atthe95%confidenceintervalfor

questionswithasamplesizesexceeding4247(Figure2).

WhilethebeliefsexpressedinthissurveycouldreflectmisunderstandingsaboutMOC/OCC

programrequirements,finances,conflicts,orbenefitstoselfandpatients,theseconcernsmust

beacknowledgedandaddressed.Beforetrustincontinuouscertificationformedical

professionalself-regulationisrestored,solidevidencemustbeproduced.

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CONCLUSIONS

WhilemostphysiciansvalueinitialBoardcertificationwithlifelongcontinuingmedical

education,thislarge,cross-specialtynationalsurveysuggestswidespreaddissatisfactionand

evenperceivednegativeconsequencestoUSphysicianswithcurrentABMSMOCandAOA

“continuouscertification”programs.AsABMSmemberboardsarecurrentlyredesigningthe

entireMOCprocess,thesefindings,reflectingtheopinionsofUSphysiciansandsurgeons,

shouldbecarefullyconsidered.

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Acknowledgment

Dr.FisherisanunpaidboardmemberofPracticingPhysiciansofAmericaDr.Sanbornhasnoconflictstodisclose.Dr.CutlerisPastPresidentofthePennsylvaniaMedicalSocietyandwasappointedasa

memberoftheAmericanBoardofMedicalSpecialties’VisionInitiativeCommissiontaskedwith

improvingthecurrentre-certificationprocess.HeisalsoanunpaidadvisortoPracticing

PhysiciansofAmerica,Inc.

TheauthorswouldliketoacknowledgeTedFeldman,MDandNiranAl-Agba,MDfortheir

editorialassistancewiththismanuscript.

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Figure1.SurveyStructure,Logic,andNumberofRespondentsForEachSectionoftheSurvey

Degree

DO

MD or Non-US Med

Other

Survey ExitThank you

(Optional Name andEmail Entry)

DemographicsGender, Age, Practice set-

ting, State/Territory, Practice Specialty, Years post-training

Doctor Osteopathy (n=755)

1) Should AOA allow recert by others (NBPAS)?

2) Should FSLB require OCC for state licensure?

Ever ABMSBoard Certified?

No

Yes

Initial ABMSCertification DetailsTotal number, Number before 1990,

State license disclosure,Perceptions, Cost

Participatein MOC®/OCC?

No

Yes

Reason for participation,Perceptions of

Relevance/Value, COI’s, Effect right to work?

Failed MOC® or experienced

harm from it?

Perceived Harms from MOC®/OCC

(n=390)Fees, loss of adm privileges,

loss of employment, relocated, etc.

Thoughts on contract terms, burnout, monopoly,

CME enough?

MOC®/OCC

No

MOC®/OCC

Yes

(n = 7007)

(n = 801) (n = 33)

(n = 6173)

(n = 429)

(n = 6048)

(n = 4793)

(n = 1211)

(n = 394)

(n = 4697)

(n = 4303)

(n = 5812)

Non-clinicalResearcher or

Teacher?

No

Yes (n = 70)

(n = 6477)

( n = 6004 )

20

TABLE1.DemographicCharacteristicsoftheSurveySampleGender No.(%)Male 3632(52)Female 3373(48)Other 2(0) Age 21-35 771(11)36-50 3378(48)51-65 2307(33)66orolder 551(8) PracticeSetting PrivatePractice 1865(27)GroupPractice/Independent 1199(17)Hospital/University/HealthSystemEmployee 2939(42)GroupPractice/Contracted 637(9)Other 369(5) StageofSpecialtyTraining HaveMD/DObutnotfinishedwithclinicaltraining 120(2)Clinicalphysicianpost-training0-10years 2330(33)Clinicalphysicianpost-training11-20years 2048(29)Clinicalphysicianpost-training21-30years 1527(22)Clinicalphysicianposttraining>30years 760(11)Retiredclinicalphysician 152(2)Teachphysicians,don’tseepatients 32(0)Non-clinicalresearchphysician 38(1) PhysicianDegree MD 6084(87)DO 801(11)Non-US 89(1)None 33(0) CurrentlyorEverPreviouslyABMSBoardCertified? n/N(%)Yes 6048/6477(93)No 429/6477(7) NowmanyvalidABMSBoardcertificatesdoyoucarry? 0 437/6477(7)1 3998/6477(62)2 1515/6477(23)3 437/6477(7)4ormore 90/6477(1) HowmanyofyourABMSBoardcertificationswereacquiredbefore1990? 0 5258/6465(81)1 852/6465(13)2 299/6465(5)

21

3 50/6465(1)4ormore 6/6465(0)

22

Table2.SurveyParticipantDemographicsbyState/TerritoryandSubspecialty

US State/Territory

Survey Specialty

Survey AAMC

Clinicala No. %

No. % No. %

All Locations 7007

All Specialties 7007

759421 Alabama 78 (1)

Adolescent Medicine 5 (0)

Alaska 32 (0)

Allergy / Immunology 91 (1) 4019 (1)

American Samoa 1 (0)

Anesthesia / Pain Mgmt 325 (5) 38749 (5)

Arizona 131 (2)

Cardiovasc Diseases / EP 519 (7) 20275 (3) Arkansas 56 (1)

Cardiothoracic Surgery 29 (0)

California 506 (7)

Critical Care Medicine 76 (1) 8849 (1)

Colorado 123 (2)

Dentistry 0 (0) Connecticut 65 (1)

Dermatology 338 (5) 11062 (1)

Delaware 28 (0)

Emergency Medicine 433 (6) 36607 (5)

D.C.c 32 (0)

Endocrinology 117 (2) 5682 (1)

Florida 406 (6)

Family Medicine 879 (13) 103235 (14)

Georgia 181 (3)

Gastroenterology 124 (2) 13014 (2) Guam 2 (0)

General Surgery 192 (3) 22043 (3)

Hawaii 25 (0)

Genetics 9 (0) Idaho 67 (1)

Geriatrics 31 (0) 4422 (1)

Illinois 262 (4)

Gynecology and Obsterics 232 (3) 38690 (5) Indiana 124 (2)

Hematology / Oncology 107 (2) 12234 (2)

Iowa 66 (1)

Hospice / Palliative Care 24 (0) Kansas 79 (1)

Hospital Medicine 151 (2)

Kentucky 82 (1)

Infectious Disease 55 (1) 6548 (1)

Louisiana 86 (1)

Internal Medicine 624 (9) 101281 (13)

Maine 35 (0)

Neonatology 102 (1) 4406 (1)

Maryland 132 (2)

Nephrology 77 (1) 8885 (1)

Massachusetts 144 (2)

Neuromusc Med / OMM 6 (0) Michigan 174 (2)

Neurology 203 (3) 4920 (1)

Minnesota 106 (2)

Neurosurgery 43 (1) 11501 (2)

Mississippi 44 (1)

Occupational Medicine 12 (0) Missouri 118 (2)

Ophthalmology 145 (2) 17413 (2)

Montana 21 (0)

Oral and Maxillofacial Surg 1 (0) Nebraska 44 (1)

Orthopedics 138 (2) 18292 (2)

Nevada 45 (1)

Otolaryngology 56 (1) 8894 (1)

New Hampshire 27 (0)

Otorhinolaryngology 12 (0)

(0)

New Jersey 176 (3)

Palliative Medicine 3 (0)

(0) New Mexico 35 (0)

Pathology 81 (1)

(0)

23

New York 409 (6)

Pediatrics 756 (11) 52163 (7)

North Carolina 190 (3)

Physical Med / Rehab 121 (2) 8352 (1) North Dakota 15 (0)

Plastic/Reconstr/Aesthetic 45 (1) 6727 (1)

N. Marinas Is. 0 (0)

Podiatry 13 (0)

(0)

Ohio 326 (5)

Preventive Medicine 8 (0) 4091 (1)

Oklahoma 72 (1)

Psychiatry 330 (5) 33051 (4) Oregon 101 (1)

Pulmonary 94 (1) 4830 (1)

Pennsylvania 910 (13)

Radiation Oncology 5 (0) 4499 (1)

Puerto Rico 16 (0)

Radiology 255 (4) 24784 (3)

Rhode Island 46 (1)

Rheumatology 62 (1) 4831 (1) South Carolina 110 (2)

Sports Medicine 22 (0)

(0)

South Dakota 27 (0)

Toxicology 1 (0)

(0)

Tennessee 144 (2)

Urology 55 (1) 9325 (1)

Texas 504 (7)

p = 0.74 Correlation: 0.87

Utah 47 (1) Vermont 19 (0) Virginia 210 (3) Virgin Islands 1 (0) Washington 168 (2) West Virginia 33 (0) Wisconsin 108 (2)

`

Wyoming 18 (0)

p-value=Pairedt-testofthepercentageofphysiciansinthirty-tworeported2016AAMCsubspecialties23andthepercentagesofsimilarself-reportedsubspecialties.Correlationcoefficientreportedisbasedonthissamecomparison.aAAMCClinicalUSPhysicians2016bNorthernMarinasIslandscDistrictofColumbia

24

Table3.SurveyedPerceptionsofUSBoardCertificationandContinuousCertificationUSBoardcertification Shouldbealife-longcredential,usingCMEcreditsforcontinuingeducation 5831/6477(90)Shouldbeatime-limitedphysiciancredentialrequiringperiodicrenewal 646/6477(10)MostrecentestimatedcosttobecomeABMSBoardcertifiedorrecertified Employersubsidized 226/6477(3)$1-2000 580/6477(9)$2001-$4000 1731/6477(27)$4001-$6000 1450/6477(22)$6001-$10,000 1089/6477(17)$10,001-$20,000 615/6477(9)>$20,000 323/6477(5)I’mnotsure 463/6477(7)WhenenrollingforMOC®,IwasmadeawarethatABMSSolutions,LLC,afor-profitsubsidiaryoftheABMS,sellsmycertificationstatustothirdparties.

Yes 177/4697(4)No 4436/4697(94)NotApplicable 84/4697(2)HaveyoueverfailedaMOC®examination,lostyourBoardcertification(evenbriefly)orexperiencedharmbecauseofMOC®/OCCrequirements?

Yes 394/4697(8)No 4303/4697(92)PleasecheckalleffectsofMOCforfailingorlosingyourBoardcertification(checkallthatapply)

Paidforare-scoreofmyexamination 41/390(11)Re-tooktheexaminationforfree 28/390(7)Re-tooktheexaminationforanadditionalfee 218/390(56)Neverattemptedtoretaketheexaminationandletmyboardcertificate“expire”

56/390(14)

Lostmyhospital/admittingprivileges 38/390(10)Lostmyjob 21/390(5)Wasdis-enrolledfromaninsurancecompany’spaymentplan 30/390(8)Eventuallypassedmyrepeatexamination 204/390(52)Failedtotellmyworkplaceofmyexaminationresults 67/390(17)Failedtotellmyfamily/friendsaboutmytestresults 107/390(27)Becamedepressed,anxious,embarrassed,orsuicidal 220/390(56)Relocatedasaresultofthisfailure 15/390(4)PlantoretiretoavoidMOC/OCC 67/390(17)Iretiredbecauseofthisfailure 1/390(0)DoyoubelieveMaintenanceofCertification®(orOsteopathicContinuousCertification)couldthreatenyourrighttoworkasaphysician?

Yes 4059/4659(86)No 638/4659(14)PhysiciansshouldbeautomaticallyoptedintoaHIPAABusinessAssociateAgreementasaconditionofenrollinginMOC®orOCC.

Agree 2065/5812(36)Disagree 3747/5812(64)ShouldtheAOAorABMSmemberboardsconductingresearchonphysicians(ortheirpractice)berequiredtoobtaininformedconsentfromdiplomates?

Yes 4624/5812(80)

25

No 1188/5812(20)

26

Figure2.PerceptionsofInitialBoardCertificationandMaintenanceofCertification(MOC)

AplotofmeanandstandarddeviationsofphysicianresponsestoLikert-typescalesonattitudesaboutBoardCertificationandMOC/OCCusingrangesfrom1(“Verypoor”or“stronglydisagree”)to5(“verygood”or“stronglyagree”).Theestimatedmarginoferrorwas±1%atthe95%confidenceinterval.

Confidence in the integrity of the ABMS Board Certification process (n = 6459)

Confidence in Practice Improvement Modules to Improve my practice (n = 6459)

Confidence in preserving the privacy in my practice (n=6441)

Confidence that Board Certification is truly voluntary(n=6453)

MOC/OCC tests concepts relevant to my practice (n = 4696)

There is a strong scientific evi-dence base that MOC/OCC improves patient outcomes(n = 4691)

MOC/OCC accurately assesses my ability to provide good medical care (n = 4691)

Participating in MOC/OCC im-proves my patients’ safety(n = 4686)

MOC/OCC costs are acceptable(n = 4692)

MOC contributes to burnout(n = 5805)

Very Poor Neutral Good VeryPoor Good

Strongly Disagree Neutral Agree StronglyDisagree Agree

Physician Perceptions of MOC®/OCC

Physician Perceptions of Board Certification

27

FigureLegendsFigure1.SurveyStructure,Logic,andNumberofRespondentsForEachSectionoftheSurveyFigure2.PerceptionsofInitialBoardCertificationandMaintenanceofCertification(MOC)AplotofmeanandstandarddeviationsofphysicianresponsestoLikert-typescalesonattitudesaboutBoardCertificationandMOC/OCCusingrangesfrom1(“Verypoor”or“stronglydisagree”)to5(“verygood”or“stronglyagree”).Theestimatedmarginoferrorwas±1%atthe95%confidenceinterval.

28

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