EAST CAROLINA UNIVERSITY

FROST
ENGL 7765

Certification Matters
An Analysis of the 2015 Announcement by the
American Board of Internal Medicine on Changes
to its Maintenance of Certification Program
Melissa Lamaffar
5/4/2015

Lamaffar: Certification Matters

Abstract
We got it wrong and sincerely apologize. We are sorry. With these words a shockwave rocked the
medical community for on February 3, 2015, the American Board of Internal Medicine (ABIM) sent out
an open letter of apology to its diplomates and announced substantial changes to its Maintenance of
Certification (MOC) program. Prior to the issuance of the letter ABIM was facing a rebellion in its ranks,
as many of its diplomats felt that the board was out of touch and unresponsive to the needs and the
sentiments of its members. This paper attempts to provide a historical basis and context for the
Mainatenace of Certification program, so that the nature, purpose and those critical of the MOC program
may be better understood. It is through this basis and context, the paper explores the dichotomy of
perception which arose in the understanding of the purpose of the program, and attempts to analyze the
announcement through the rhetorical lens of stasis theory.

Lamaffar: Certifcation Matters

Introduction
We got it wrong and sincerely apologize. We are sorry. These words reverberated across the medical
community for on February 3, 2015, the American Board of Internal Medicine (ABIM) sent out an open
letter of apology to its diplomates and announced substantial changes to its Maintenance of Certification
(MOC) program. Prior to the issuance of the letter ABIM was facing a rebellion in its ranks, as many
diplomats felt that the board was out of touch and unresponsive to the needs and the sentiments of its
members. Further, the American Board of Medical Specialties (ABMS), ABIMs governing board, was
being sued in US District Court by a group which hoped to end the entire MOC program amongst all
ABMS member boards. Once this announcement was made both organizations and individuals across the
medical community scrambled to understand the ramifications of these changes as well as possible
implications for the MOC program in and of itself for all of ABMS member boards. To fully understand
the importance and implications of this letter, both rhetorical conventions and the underlying issues which
brought about this announcement must be first be examined. However, like so much in modern society,
decisions and changes made by entities such ABIM are not final, rather medical certification is constantly
evolving, attempting to keep pace with a society that is only advancing at an ever more rapid pace.

Development of Certification Boards

In todays rapidly changing world, modern medical providers are required to constantly grow
professionally, in order to maintain relevance to patients and communities, and assessments of these skills
need to change to meet these challenges. Certification boards, such as ABIM, grew out of a need for
professional self-regulation under a mandate to ensure that physicians who completed formal training
were competent for independent practice. When many of these boards first began to offer certification,
there was no expiration date, rather once achieved, lifetime certification was granted.

However, in

response to mounting evidence which suggested that many physicians knowledge and skills decline over
time, along with evolving public and political pressures, ABMS and its member boards concluded that
lifetime certification was insufficient to ensure ongoing competence (ABMS, 2015), as a result, ABMS

Lamaffar: Certification Matters

formally approved the MOC program in 2000. However, while ABMS approved this program in 2000,
many of its member boards had already enacted time-limited certification programs prior to that time, in
one form or another. Some boards such as the American Board of Emergency Medicine never offered
lifetime certification, while others transitioned from lifetime to a 10 year recertification exam. However,
the new MOC program which was created and mandated by ABMS, encompassed more than previous
time-limited recertification programs, as it required participation in a variety of activities throughout the
certification cycle, in addition to the recertification examination.

What is certification?
Certification is not a federal or state mandate, nor is it a requirement for practice like a medical license.
However, it is often firmly entrenched in institutional requirements and may be required by the providers
malpractice insurance. Certification is in fact entirely voluntary and many can and do practice without
being certified, however a lack of certification may limit employment prospects. Further, those who are
grandfathered in i.e. have permanent certification are not required to enroll in MOC to maintain their
certification. While each of the member boards establishes their own criteria for certification and
recertification, they all must adhere to the polices put forth by ABMS. Consequently, as a member
board, ABIM is required to have a MOC program in place and can no longer offer permanent
certification. Once physicians have obtained initial certification through ABIM they must continuously
meet numerous requirements to maintain their certification. These steps include enrolling in the MOC
program through ABIM, meeting requirements such as possessing a valid, unrestricted medical license,
and participating in MOC activities through the lifecycle. The four areas of MOC activities as required by
ABIM can be summed up as Medical Knowledge Practice Assessment, Patient Safety and Patient Voice
(ABIM, 2015). In addition to aforementioned, diplomates must take and pass a recertification
examination at an established point within the cycle.

Lamaffar: Certifcation Matters

To fully understand the importance of MOC and its significance both to the member boards and board
diplomates, we must look at views on MOC as espoused by ABIMs governing board, ABMS. ABMS
unequivocally states that board certification is a hallmark of public and professional trust for the past
century. In response to ABIMs letter ABMS reiterated its commitment to MOC, and stated that the
need to demonstrate values such as professionalism, lifelong learning, assessment, patient safety, and
quality improvement does not end with initial certification. Within the statement ABMS addressed the
fact that disgruntlement existed within the medical community to a degree regarding board certification,
however despite this they remain fully committed to all elements of MOC. For in their estimation MOC
as not a final analysis but an evolution of what certification means within the medical profession. Within
the statement of support ABMS identified not only the importance of MOC to the medical profession and
healthcare system, but also to patients, whom are the end receivers of current health practices.
When the members boards of ABMS addressed the concept of MOC in 2000, the boards felt that
certification could not remain relevant and trustworthy without a rigorous system of continuing education
and ongoing assessment. As such the standards for ABMS MOC programs were developed through
inclusive collaboration between member boards, societies and other stakeholders. The standards
developed were meant to provide a framework to ensure that lifelong learning, patient safety and practice
improvement were translated into daily physician practices. While all ABMS member boards were
expected to meet MOC standards as laid out by ABMS, member boards were afforded flexibility in
implementation as the needs of the medical community are complex and diverse. And it is in that
diversity in implementation that we see real differences, not only in requirements or fees, but overall
satisfaction with the MOC programs, in their ability to provide real and meaningful benefit to their
diplomats and the public.

MOC Dissension
Both the letter and ABMS response to ABIMs announcement acknowledged the discord among the rank
in file in regards to the MOC program. But neither letter nor any board responses addressed the extent of

Lamaffar: Certification Matters

that dissension, however it is that disgruntlement expressed by individuals and organizations which
played an important role in both the reason for the changes and the rhetoric employed by ABIM to its
members. Some older physicians resent MOC requirements associated with the board certification, which
have changed radically since they first were certified, while some younger physicians can't understand
why the requirement to prove current competence doesn't apply universally. Others argue that MOC's is
inconvenient and expensive, and the program itself is unjustified in an era when other regulatory
requirements are already unmanageable pulling physicians away from their patients. Even those who find
value in MOC and see the program often as a behemoth that provides little tangible benefit for physicians
in their daily practice.

One of the most vocal opponents of MOC and who has led the charge against the program is the
Association of American Physicians and Surgeons (AAPS), a politically conservative non-profit
association founded in 1943. The organization not only opposes MOC through ABIM, but has filed suit
against ABMS in US district court alleging that ABMS MOC program is "a money-making, selfenrichment scheme" that reduces patient access to physicians (Pittman, 2014). However, it was not only
conservatives groups such as the AAPS which dissented ABIMs MOC changes. Both individual and
medical societies expressed concern regarding ABIMS recertification pass rate and the activities required by
diplomates to maintain certification. For example, ABIMs MOC exam closely resembled its initial
certification, lacked relevance for practicing physicians and had only a 78 percent pass rate, in comparison the
American Board of Pediatrics pass rate for its MOC exam is 95 percent (ABP, 2015). ABIM was also

disconnected from professional societies, and this disconnection exacerbated communication issues
between ABIM and those within the specialty.

The general public has also been a party to the ongoing issue, as two separate articles have been published
in Newsweek regarding ABIMs MOC program. ABIM issued its rebuttal of Kurt Eichenwalds article
on March 11, 2015, in response Mr. Eichenwald published another opinion piece on April 17, 2015,

Lamaffar: Certifcation Matters

hitting hard at ABIMs financials and in Tweets and the articles themselves he expressed a somewhat
surprising amount of vitriol on the matter, considering that he is journalist rather than an internist affected
by the MOC program (Lowes, 2015). However, much of his antagonism may have been due to the
rhetoric employed in ABIMs response to his original article in which ABIM indicated that as his wife is
an internist, he may have a conflict of interest which was not disclosed in the original letter. Further, it is
of note in examining the articles, which were published after ABIMs announcement, that neither article
indicated or addressed the changes that were or would be enacted by ABIM to the MOC program. This
disconnection between ABIM and its critics is symbolic in many ways of the underlying problems
between ABIM and its diplomates, chiefly that too often one party is speaking to rather than with the
other. By understanding the rhetoric employed by the stakeholders through a theoretical rhetorical lens,
we can understand both the motivation for and purpose of the letter.

ABIMs Changes to MOC

ABIMs letter to its diplomats outlined five measurable changes/goals within the announcement. By
addressing existing issues the rhetoric employed was more concrete in nature. The first was the
suspension of the Practice Assessment, Patient Voice and Patient Safety requirements of MOC for at least
two years. These components had comprised some of the core components of providers complaints as
many saw them to be little more than busy work and often redundant in the face of required continuing
medical education courses (CME). The second component was a change in the language used to publicly
report a diplomate's MOC status on its website from meeting MOC requirements to participating in
MOC. This language was often a source of confusion for physicians and source of consternation for
medical boards as physicians who were grandfathered in and not required to meet MOC requirements
took exception to the vernacular employed by the boards. Thirdly, and perhaps the most egregious
complaint as identified by many internists was the MOC exam itself. Unlike many other boards, the MOC
exam administered by ABIM was similar to the initial certifying examination, not reflective of what
practicing physicians were doing. Another complaint was in regard to the payment of MOC fees, which

Lamaffar: Certification Matters

ABIM responded by promising to freeze fees through at least 2017. Finally, ABIM set a target date of the
end of 2015, to create new and more flexible ways for internists to demonstrate self-assessment of
medical knowledge by recognizing most forms of ACCME-approved Continuing Medical Education. In
outlining quantifiable goals, the rhetoric employed appeals to physicians as it has tangible and measurable
results and falls in line with the ideals of quality improvement.

Rhetorical Analysis
Traditionally, communication in the medical field has been hierarchical and terminal in nature, whether
from provider to patient or mentor to mentee. Physicians memorized copious amounts of information
during training, and imparted that knowledge to those who came after them. However, in the latter half
of the 20th century both medicine and communications norms began to incur fundamental changes, as
technology began to grow at an exponential rate. Communication and education transformed and became
a collaborative process, and expectations changed in regard to how that knowledge should be measured
and assessed by credentialing boards. Rather rote memorization, increasingly both students and
experienced physicians turn to electronic sources to assist in diagnosis and treatment in the ever
increasing and evolving field.

As such, the discontent among many physicians regarding the MOC

program can be traced in some ways to the perceived lack of interactive discourse between ABIM and its
members.

In a study published in JAMA Internal in 2015, researchers found that while participants acknowledged
the high-level purposes of MOC and expressed a firm desire to maintain their clinical competence and
professional identity, they simultaneously expressed deep frustration and discontent with the current
MOC system. Participants perceived MOC in its current state as offering little, if any, value to themselves
as individual physicians and questionable value to patients or society (Cook, Holmboe, Sorensen, Berger
& Wilkinson, 2015). In examining the rhetoric, researchers concluded that if physicians must be reminded
of the benefits they receive, perhaps the benefits are not valuable. Researchers suggested that instead of

Lamaffar: Certifcation Matters

marketing and utilization of rhetoric to tell physicians about the potential benefits of MOC, the system
needs fundamental changes that will create tangible, easily observable benefits. However, rhetoric in
itself can be effective, as the lack of stasis between ABIM and its diplomates in part arises from the
differing perceptions about the purpose of MOC. Physicians are concerned not only about the time and
expense involved in the MOC process, they also want any activities that they engage in to have immediate
tangible results. However, ABIM is concerned not only with creating MOC programs which have value
to physicians, but activities which will benefit the public as well.

It is this dichotomy of perception under which it becomes evident that stasis theory is a good starting
point to understand the basis of ABIMs announcement and the response from its diplomates. Stasis
theory was a process developed in ancient Greece by Aristotle and Hermagoras, and was later refined by
Roman rhetoricians, such as Cicero, Quintilian, and Hermogenes. Stasis theory asks the writer (or orator)
to examine four distinct categories; conjectural, definitional, qualitative and translative. To achieve stasis
the involved parties must reach a consensus on the information and conclusions in one or more of the
aforementioned categories. By examining the letter through the lens of stasis theory, one can see the
announcement definitively addresses both conjectural stasis and definitional stasis in the admittance by
ABIM that many of the MOC programs which were launched werent sufficiently ready for consumption
and lacked any meaningful benefit for physicians. In identifying these elements ABIM concisely
identified one of the overarching issues for many physicians, but did not specifically address how these
programs failed to meet expectations or needs. However, to reach conjectural or definitional stasis it is
not necessary to get into specifics, only an acknowledgement of the issues is necessary. The
announcement also attempts to meet the needs of the reader through translatiolational stasis, as the writer
of the letter outlines a myriad of steps to be taken which are meant to help rectify the situation and dispel
the discontent of diplomates. As to whether qualitative stasis is met, the matter is less clear-cut. In
examining the statement ABIM is listening and wants to be responsive to your concerns. While ABIM's
Board believes that a more-continuous certification helps all of us keep up with the rapidly changing

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nature of modern medical practice, it is clear that parts of the new program are not meeting the needs of
physicians like yourself. Some feel the MOC program is an issue in and of itself, and this statement and
perhaps any statements of its ilk do nothing to address the issue at hand.

The letter itself employs three elements in particular in attempts to create empathy and achieve stasis with
the reader. The first is identification and commonality with the reader. Within the letter Dr. Richard
Baron, President and CEO of ABIM and the ABIM Foundation, seeks to find commonality by distancing
himself from previous presidents in his statement As the first non-academic physician to lead ABIM, I
am particularly proud of my 30 years in private, community practice, and I see this letter to you as a start
a new beginning. In utilizing language which emphasizes his practice experience, he seeks to not only
seeks to separate himself from his predecessor by identifying himself as the first non-academic, but create
a sense of camaraderie, as the majority of diplomates are in fact practicing physicians, rather than
academics. In seeking commonality with the reader he can portray an empathic image, an image that
conveys that he understands the needs of practicing physicians.

Next Dr. Baron uses several strategies within the rhetorical decorum, as the letter itself employs both
conciliatory notes as well as outright apologies. Continuously throughout the letter Dr. Baron identified
ways in the past that ABIM did not meet the needs of its diplomates, but will strive to meet those needs in
the future. In the letter Dr. Baron makes several specific references citing upcoming communication
regarding members vision for internal medicine, the MOC program and current opinions about what it
means to be a physician. Further, he notes the creation of a Google + community, in which internists can
ask questions and share ideas, and blog with ABIM. Within the letter one of the chief complaints
regarding ABIM is addressed, that of lack of the lack of voice for its members. I have heard you and
ABIM's Board has heard you. We will continue to listen to your concerns and evolve our program to
ensure it embodies our shared values as internists. By acknowledging the comments and dissatisfaction

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expressed previously by members and societies, and promising to listen to them in the future a tone is set,
not only of conciliation but one of reception to the opinions and ideas of the programs stakeholders.

Just as evidence based medicine (EBM) is a medical model governing professional practice, providing a
justification for clinical decision making, patient centered care (PCC) is a model of professional practice.
However EBM and PCC is not only relevant to clinical and academic practices, but the underlying
concepts are also applicable to the boards and societies which regulate the profession. The member
boards of ABMS are not only there to serve the physician population, but the public at large. As such, the
creation of the MOC program needs to be at its heart patient centered, and while there may be
disagreement in the use of this rhetoric, as evidenced in a study published by JAMA Internal (Cook et al.,
2015), it plays an important role in the mission of the medical boards, and must be conveyed as such to all
diplomates.

Response to the Changes

In response to the changes announced by ABIM, many of the other member boards, as well as ABMS
quickly press releases regarding ABIMs letter. On February 5, 2015, in response to ABIMs open letter
ABMS publically stated their support of ABIMs efforts to make the MOC program more meaningful for
its physicians while maintaining the level of quality ABMS member boards envisioned for the MOC
program. And again on March 5, 2015, ABMS posted a statement on their website reiterating earlier
comments and their continued commitment to the MOC program in their belief that is essential element in
medicine today and that self-regulation, such as the MOC program is owed both to the profession and the
public that they serve. Other medical organizations, including the American Medical Association (AMA)
and American College of Physicians (ACP), reported being very pleased that the ABIM had listened to
physicians' concerns. In response to the letter the AMA issued a written statement saying that "Today's
announcement aligns with the AMA's MOC principles as we have strongly advocated for a process that is
evidence-based and evaluated regularly to ensure physician needs are being met and activities are relevant

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11

to clinical practice,". Similarly the ACP president, Dr. Steven Weinberger, in an email to ACP members
stated that the ACP is extremely pleased that ABIM responded to the concerns expressed by the society
and by internists and subspecialists. Further, he continued that he felt that the changes outlined in the
game-changing communication would provide real and meaningful benefit to internists, however the
job is not yet finished as the MOC process continues to evolve (Weinberger, communication, February 4,
2015).
Another one of the societies who had advocated for change to ABIMs MOC policies, also provided
responded approvingly. We are satisfied that the ABIM has heard our concerns and is responding with
appropriate changes to the MOC program, said Society President Richard J. Santen, MD. We fully
support the concepts of continuous learning, improvement and self-regulation that the ABIM espouses
and recognize that the changes outlined are designed to enhance these processes. (Endocrine Society,
2015). ABIM incorporated many of the changes the Endocrine Society requested, including adjustments
to the MOC programs fees, exam structure and approved activities. In doing so, the Endocrine Society
felt that these changes would provide tangible benefits as they would relieve bureaucratic issues on
physicians and allow them to devote more time to providing patient care.

While most responses to the changes announced by ABIM have been generally positive, not all have been
quite so encouraging. Ron Benbassat, MD, the founder of the anti-MOC organization Change Board
Recertification was reported as calling the announcement "just a small step;" however he pledged to
continue to working until the MOC "scam" has been revealed and abolished. Further while medical
societies and other boards may be aware of the various factors which are involved in the development of a
MOC program, most individual physicians do not understand the totality of the program. In a study
published in JAMA Internal in January 2015, researchers determined that most physicians view MOC as
an unnecessarily complex process that is misaligned with its purposes and largely fails to meet their
needs. Researchers concluded that while certifying boards cannot escape their ultimate accountability to

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societal needs and priorities, it seemed unlikely that current tensions would resolve until physicians
needs have been adequately acknowledged and addressed and the misalignments between purposes and
processes corrected (Cook et al., 2015). While this study was conducted and published prior to ABIMs
announcement, it remains to be seen if the steps that are and will be taken by ABIM will prove
meaningful to physicians. However, this study does provide insight into the issues which plagued
ABIMs MOC program prior to the implementation of outlined in ABIMs letter to its members and can
provide a recognition that other changes which may be required at a future date.

Future of MOC
While for many of the stakeholders involved, it appears that stasis has been reached in the majority if not
all of the categories, the issue of recertification and the MOC program is anything but resolved. As
pointed out in the article penned by Drs. Iron and Nora, certification and the certification process is
constantly evolving to meet the needs of society and the medical profession, as society affords the
profession substantial autonomy to self-regulate it is the duty of these boards to uphold the rigorous
standards of assessment of certification in and of itself becomes meaningless. As studies indicate that
physicians are not always able to accurately self-assess and as evidence mounts to the efficacy of MOC
programs and activities, the concept of the MOC program will not be going away anytime soon (Irons &
Nora, 2015).

In mid-May of 2015, the American Board of Pediatrics, one of ABMS member boards, hosted the Future
of Testing Conference, to explore innovative ways to measure knowledge, learning and competency.
This conference brought together approximately 75 leaders from the educational and pediatric
communities to hear speakers and presentations, and work in small discussion groups to explore new
methods to better assess physician competencies (ABP, 2015). Conferences such as this can have far
reaching ramifications for the MOC program in areas such as performance-based assessments, online
testing and a host of other issues currently up for debate within the medical community. And it will be

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from conferences like this that concrete ideas will emerge for the future of MOC and certification as a
whole for all of ABMS members boards.

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References
American Board of Internal Medicine. (2015, February 3). ABIM Announces Immediate Changes to
MOC Program. Retrieved on April 22, 2015, from http://www.abim.org/news/abim-announcesimmediate-changes-to-moc-program-aspx
American Board of Medical Specialties. (2015, February 5). ABMS Comments on ABIMs MOC
Announcement. Retrieved on April 22, 2015, from http://www.abms.org/news-events/abms-commentson-abim-moc-announcement
American Board of Pediatrics. (2015, February 24). 2015 Future of Testing Conference. Retrieved on
April 30, 2015, from https://www.abp.org/news/2015-future-testing-conference
American Board of Pediatrics. (2015, February 6). Message from ABP President regarding ABIM MOC
announcement. Retrieved on April 22, 2015, from https://www.abp.org/news/message-abp-presidentregarding-abim-moc-announcement.
Cook, D.A., Holmboe, E.S., Sorensen, K.J., Berger, R.A. & Wilkinson, J.M. (2015) Getting Maintenance
of Certification to Work a Grounded Theory Study of Physicians' Perceptions. JAMA Internal
Medicine. 175(1):35-42
Endocrine Society. (2015). Endocrine Society Praises ABIM's Overhaul of MOC Requirements.
Retrieved from https://www.endocrine.org/news-room/current-press-releases/endocrine-societypraises-abims-overhaul-of-moc-requirements
Irons, M.B, Nora, L.M. (2015) Maintenance of Certification 2.0 Strong Start, Continued Evolution
New England Journal of Medicine, 372 104-106
Lowes, R. (2015, March 25). ABIM Says Newsweek 'Civil War in Medicine' Story Inaccurate. Medscape.
Retrieved on April 27, 2015, from http://www.medscape.com/viewarticle/842040
Pttman, D. (2013, April 25) AAPS Sues to End Recertification Program. Medpage Today. Retrieved on
April 27, 2015 from http.medpagetoday.com/PublicHealthPOlicy/GeneralProfessionalIssues/38683
Wallan, S.W. (2015, February 3). MOC Watch: ABIM Says 'We Got It Wrong'. Medpage Today.
Retrieved on April 25, 2015 from http://medpagetoday.com/PrimaryCare/GeneralPrimaryCare/49858