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To Kill a MOC(kingbird)

January 9, 2024

January 2024

Matthew Matasar, MD, is a medical oncologist specializing in lymphoma and is chief of the Division of Blood Disorders at Rutgers Cancer Institute of New Jersey and RWJBarnabas Health.

Matthew Matasar, MD, is a medical oncologist specializing in lymphoma and is chief of the Division of Blood Disorders at Rutgers Cancer Institute of New Jersey and RWJBarnabas Health.

 

 

 

When I last was up for recertification for medical oncology, I realized with a sense of long-suppressed dread that I was going to fail. After all, I’m an academic oncologist who focuses on one thing and one thing only — lymphoma — and that’s not good when it comes to the boards. Hematologic malignancies make up a whopping 14% of the test — and lymphoma, of course, is just a fraction of that. Like I said, gonna fail.

So I signed up for a boards course, at personal expense, taking time away from my family and actual professional responsibilities. I remember trying to explain this to my kids. They were (flatteringly) unconvinced, figuring that I know what I’m doing well enough to pass. As I explained to them that about 90% of the test is about stuff I don’t do for a living, haven’t done for years, and will never do, the absurdity of the situation was laid bare. I joked with colleagues that there should be a box that you can check that lets you skip all the breast cancer questions if you solemnly swear never to try to treat breast cancer.

But, increasingly, we as a profession are moving beyond wry humor and willing obedience to a recertification system that is woefully misaligned with its avowed purpose: to ensure that practicing physicians possess and retain clinical competence. Nowhere is this clearer than in the flawed maintenance of certification (MOC) program from the American Board of Internal Medicine (ABIM). Currently, we are required either to sit for the boards every 10 years or participate in the understatedly named “Longitudinal Knowledge Assessment” (LKA) program. The truth, though, is that neither option is tenable.

It’s self-evident that the boards are a poor proxy for a subspecialist’s ability. If doctors learn anything along our paths, it’s the uselessness of a multiple-choice test in subjects that are, at best, tangentially related to our practice. Cramming for such a test does little to advance or promote clinical skill or improve patient outcomes. Certainly, evidence that such programs have any beneficial effect is lacking — and why do we not hold our certifying agencies to the same standards to which we hold ourselves and our clinical interventions? The same is true of the LKA pathway. In an open letter, American Society of Hematology President Robert Brodsky, MD, stated that the LKA “does not reflect real life practice, nor does it target each individual’s scope of practice.”1

Dr. Brodsky called for real, albeit modest, improvements to the MOC, including:

  • Lowering the stakes by removing the time limits for answering questions
  • Allowing us to consult colleagues
  • Reducing the number of questions that the LKA demands of participants

ABIM publicly rejected these modest requests the very next day — something that Vincent Rajkumar, MD, often the voice of conscience in our community, pointed out on X (formerly Twitter) as “not a sign of good faith.” Indeed.

Other medical societies have pursued more definitive action. Our cardiology friends know this; interventional cardiologists (Society for Cardiovascular Angiography & Interventions), electrophysiologists (Heart Rhythm Society), heart failure experts, and the American College of Cardiology jointly announced plans to create a new certification process independent of the ABIM MOC process. Other professions with evolving knowledge and skill bases — pilots, lawyers, accountants, even the military — have no systems analogous to MOC. All rely on continuing education, just as we could. Continuing medical education, or CME, is a requirement that we are all (appropriately!) subject to.

The value of MOC beyond CME is at best unclear, but the costs are real, not just in time and distraction from our actual jobs (you know, what MOC is supposed to make us better at?), but in real dollars. Annual fees run $220 (or $340 if you’re double-boarded in hematology and oncology), and if you want to take the 10-year test instead of participating with the LKA, that’s an additional $700. Figure that an average hematologist or oncologist is board certified at age 28 and works until age 64,2 napkin math says that’s somewhere in the $12,000 to $14,000 ballpark. For what? Dunno.

We’re approaching a tipping point. Public voices are coalescing, like Aaron Goodman, MD, whose petition to abolish MOC on the website change.org has gathered more than 21,000 signatures; like Dr. Brodky’s missive; like an anticipated statement from the American Society of Clinical Oncology. But if we can recognize — as my kids did — that the current system is ridiculous, and if we can take the consistent and collective public stance that the status quo serves neither doctor nor patient, then change is possible.

Matthew Matasar, MD
Associate Editor

References

  1. American Society of Hematology. ASH Letter to ABIM President and CEO. Sept. 27, 2023. Accessed November 15, 2023. https://acrobat.adobe.com/link/review?uri=urn%3Aaaid%3Ascds%3AUS%3Ab1842c4c-22d9-3e59-be50-22e811ce5b70.
  2. Erikson C, Salsberg E, Forte G, et al. Future supply and demand for oncologists: challenges to assuring access to oncology services. Jour Oncol Prac. 2007;3(2):79-86.

The content of the Editor’s Corner is the opinion of the author and does not represent the official position of the American Society of Hematology unless so stated.

Have a comment about this editorial? Let us know what you think; we welcome your feedback. Email the editor your response, along with your full name and professional affiliation if you’d like us to consider publishing it, at ACNEditor@hematology.org.

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