By N. Adam Brown, MD, MBA,

When Americans are asked to list their top concerns about the U.S. healthcare system, they are likely to focus on their worries on insurance and out-of-pocket costs.

Affordability is certainly a huge issue, but there is another big problem lurking: doctors leaving the profession. According to a survey released late last year, 40% of doctors are thinking of leaving their current organization. Many will opt for early retirement as opposed to moving to another practice or facility.

The country already has doctor shortages. Further exits will erode healthcare access and, ultimately, lead to higher costs.

Burnout is certainly one reason for physician exits. Another, related part of the problem is an onerous system of redundant Maintenance of Certification (MOC) rules: this system contributes to burnout, while costing doctors thousands of dollars and enriching professional organizations.

It is time to streamline the system -- and, yes, it is possible to do so in a way that does not put patients at risk.

How Maintenance of Certification Is Redundant

About 20 years ago, the American Board of Medical Specialties (ABMS), a member-based organization, established Maintenance of Certification (MOC), a system that allows for periodic examination of specialty physicians' knowledge and practice. As the Maryland Health Care Commission explained, MOC was meant to indicate to patients and hospitals whether a particular doctor has kept up with the latest medical advances in their specialized field.

But the truth is, hospitals and patients can get this peace of mind elsewhere. Indeed, MOC overlaps significantly with state licensure and hospital privileging requirements. Here is how the Federation of State Medical Boards explains the function of state licensing: "Through licensing, state medical boards ensure that all practicing physicians have appropriate education and training, and that they abide by recognized standards of professional conduct while serving their patients." The ABMS, meanwhile, says board certification "signifies how specialists are aiming higher to advance their knowledge, judgement, and skills."

If those descriptions sound eerily similar, it is because they are. If a physician is licensed, patients and hospitals can be assured that caregiver is staying current on the latest advances and that their record of care has been thoroughly examined.

In addition to being redundant, the MOC system is incredibly costly.

The Price Physicians Pay for MOC

While MOC brings in millions of dollars to certifying organizations, these bodies make light of how much their processes cost individual physicians. The American Board of Internal Medicine (ABIM) highlights, for example, that its annual MOC fee "for the first certificate" is $220, "and for each additional certificate you maintain there is a $100 discount, meaning you'll pay $120 per year." (Meanwhile, certification organizations often end up spending the voluminous revenues generated by MOC on lavish conferences and events.) A 2021 paper similarly found the total costs to physicians are much greater than bodies like the ABIM would like to let on:

"The actual cost of MOC is much higher than just the fees paid to organizations providing services," the researchers concluded. "The majority of the cost comes in the form of time cost to the physician." Specifically, the researchers found the average orthopedic surgeon's total cost in time and fees over the decade-long period to be $71,440.61, or $7,144.06 per year, for the oral examination MOC pathway and $80,391.55, or $8,039.16 per year, for the written examination pathway.

The MOC system is voluntary, of course, but doctors who opt out may also pay dearly. In a 2013 lawsuit filed against the ABMS, the Association of American Physicians and Surgeons alleged the MOC program is "a money-making, self-enrichment scheme" that reduces patient access to physicians. One example cited was of a New Jersey physician who lost his hospital privileges because he had not complied with MOC rules in family medicine. The case was eventually dismissed, but physicians would likely agree with many of the claims.

While the costs to doctors mount, there is no evidence that the MOC process actually helps patients.

Certification Does Not Help Patients

As a professional dedicated to healing and helping others, I acknowledge the potential of the MOC to contribute to improved patient care. But it appears the current implementation and structure of the MOC system are so deeply flawed, and the financial and administrative burdens it imposes on physicians so great, that the system detracts from the very essence of medical practice.

A 2018 survey of 515 U.S. physicians found 65% thought the MOC process added no clinical value to the practice of medicine. The survey group included both primary care physicians and specialists, 73% of whom reported taking some form of MOC exam, either the traditional 10-year exam to recertify or a 2-year "knowledge check-in" option.

Ten years ago, Bradley Gray, PhD, and colleagues at ABIM in Philadelphia compared ambulatory care-sensitive hospitalizations in Medicare patients treated by two groups of general internists -- 956 who were subject to MOC and 974 general internists who were grandfathered out of MOC. They found "no difference" in the quality of care provided by the two groups.

As a petition already signed by more than 15,000 physicians states, the MOC system requires a radical overhaul to align its processes with the realities of medical practice today. This reformation should focus on creating a system that truly benefits patients and supports physicians in their ongoing professional development. Simplifying the certification process, reducing costs, and eliminating redundancies with state licensure and hospital privileging are critical steps towards a more equitable and effective system.

As healthcare professionals, we must engage in this conversation, advocating for changes that will enable us to better serve our patients without the undue burdens currently imposed by the MOC process. The goal of continuous learning and improvement in medical practice is one we all share. Achieving this goal should not come at the expense of the well-being and financial stability of the physicians dedicated to this noble profession, however.

It is time for change.