guest editorial
MOC: the ABO's Search for Relevance

I read with great concern recently an editorial in Archives of Ophthalmology on the controversial subject of recertification in ophthalmology.¹

In this editorial, titled "Maintenance of Certification and the Outside World," Dr. Denis O' Day, the American Board of Ophthalmology (ABO) executive director, states that "Those of us who hold certificates without an expiration date cannot be forced to participate in MOC or lose our certificates. However . . . as the public begins to understand the significance of a certificate awarded on the basis of a commitment to continually improve the care offered, the advantage will be to diplomates who have recertified through participation in MOC."

After reading Dr. O' Day's editorial, I e-mailed a response to Archives of Ophthalmology. No acknowledgement was ever given that the journal received the response. After waiting 3 weeks with no response, I approached other journals. The universal reply from those that responded was that this should be in Archives of Ophthalmology. After 4 weeks, I re-contacted Archives. A return e-mail from a representative stated, in part, "We can't consider it if it is under consideration elsewhere."

Archives never addressed why I never received a response to my initial e-mail submission. I had the feeling that they did not respond in the hopes that if they didn't respond, I would get discouraged and just go away gracefully. Not me! I responded to their response as follows: "I did not hear from you and, other than your comment above, I still have not heard from you, including even that you have received my letter and are considering it. The MOC is an extremely thought-provoking subject. Because I did not hear from you in over 2 weeks (how long does it take to acknowledge that you received an e-mail?), I sent it out to other forums. Personally, I thought that you just did not want to print another person's opinion on the MOC since you had imposed a deadline of 2 months on responses to editorials, and I had not heard anything from you. However, I have not and will not give anyone authorization to print anything unless you cannot or will not consider the letter. I feel that the letter belongs in Archives. The final decision is obviously yours. Please get back to me."

To this date, no response has been forthcoming. Therefore, I moved the response to Ophthalmology Management. It is as follows.

What is the ABO's Real Motivation?

Why is the ABO attacking its own diplomates, especially those who are grandfathered in? Those of us who have had the privilege of practicing ophthalmology for more than 11 years and are grandfathered in are being told by Dr. O' Day ".... the advantage will be to diplomates who have recertified...." When we went into ophthalmology, we went in with the understanding that if we wanted to be board-certified, we had to pass the stringent testing that was required. We did not contract to be retested every 10 years. It is despicable that Dr. O' Day and the ABO are now telling us that we will be disadvantaged in the public's eye because they are choosing to change the rules in midstream.

What is the real motivation of the ABO's actions? Is it a response to a public outcry? That is doubtful. There is no public outcry that any of my fellow ophthalmologists that I have spoken to have heard about across this country. What is the problem? Is there actually one to begin with or does the ABO perceive one for self-preservation and personal gain? They are the few who are trying to impose their wishes on all ophthalmology practitioners.

Is the motivation of the ABO's MOC to insure that the M.D.s keep up to date in their education? That is also doubtful. If this is the case, then they are saying that the current CME concept has failed. Is the ABO saying that the AAO and ASCRS are doing a poor job with CME? If this is true, then what has the ABO done to remedy the current CME failure? They have done nothing because there is no failure.

Is the ABO preparing to try to eliminate our CME requirements, or is the MOC going to be an added burden to be placed on the backs of physicians? Surely the MOC cannot be a replacement for the CME that we now take. CME is updated with all new advancements in ophthalmology. The MOC core information will be far outdated before its cycle is completed. CME has not failed nor have I ever heard from anyone that CME has failed. Since the information on the MOC will come from the information supplied from the AAO committees that are working on the questions, the knowledge base is the same. The same physicians who present, lecture and instruct at the AAO and ASCRS meetings will be the ones supplying the information for the MOC.

Is the real motivation of the ABO's MOC a response to a threat on its self-existence? Is the ABO concerned that the pedestal that it stands on is being chipped away by other organizations, such as the ACES/ABES or by the National Board of Ophthalmology (NBO)?

In fact, what the ABO has done is help to divide ophthalmology into two distinct groups: those who have and those who have not been grandfathered in. What it did not expect is that now there are other organizations out there that are willing and able to have you take a test to be board-certified, such as the online test that is offered by the NBO. The NBO's test is cheaper and far more appealing to the younger ophthalmologists with a time-limited certification. Why would anyone in his or her right mind want to spend an incredible amount of time, money, and energy on recertification with outdated information when this same group of self-motivated physicians is now already constantly striving to better themselves with a proven educational tool such as CME. Why should they do it? Because they are required to by the ABO, an entity which is quickly becoming irrelevant and trying very hard to justify its own continued existence.

This Will Hurt, Not Help Us

The ABO has become archaic and outdated. It has already realized that it has failed in its attempt to develop a test for MOC and has now come to the AAO for the knowledge base that it will use. However, as was stated earlier, these are the same AAO educators who are already educating the same people with the same knowledge base via CME. The ABO is causing a further division in the masses by having a third group of ophthalmologists who are NBO-certified. This will only make us look ridiculous in the public's eye as the public begins to understand the significance of this. The ABO is not helping ophthalmology in the public's eye; rather, it is making us a potential laughing stock in the public's eye!

No other professional (lawyer, engineer, etc.) has to recertify. With all the woes that medicine is facing vis-à-vis managed care, declining reimbursements, increasing regulations, etc., medicine is becoming less attractive to the bright young superstars of the future. With this push towards recertification with closed-book testing every 10 years, fewer and fewer qualified applicants are going into medicine.

Dr. O' Day says that MOC is designed to enhance quality of care. However, we already have rules to protect the public and maintain quality of care. If doctors practice below the standard of care of the community, there are civil means to protect the public as well as State Boards of Medicine to police the substandard physician. Actually what the ABO is doing with the MOC is besieging ophthalmology. The ABO should be stopped before it sows such terrible disunity that our profession never recovers!

Here's a Better Idea

If Dr. O' Day, the ABO and Medicine in general want to police themselves and look better to the public's eye, then let them institute a "must-pass policy" for all future ophthalmology residents (and all medical and surgical residents) who are currently entering into their residency training. Let us make sure that all practicing ophthalmologists in the future are board-certified.

In essence, let us send a message to the public that every doctor in ophthalmology (and every resident in the future who is trained in any specialty) is board-certified. There would be no more board-eligible ophthalmologists who either never take or cannot pass the certification testing after a reasonable period of time (such as 2 years). If residents finishing their training do not take and pass the written and oral certification testing, then they would no longer be able to practice ophthalmology.

The public would feel very reassured if they knew that all doctors who are specialty trained are board-certified. We already have the mechanisms in place to continue lifelong education. That is the purpose of CME. Let us not penalize those self-motivated people who have passed the residency specialty boards and continue to educate themselves through reading journals, going to meetings and taking the required CME. Why would the ABO need to create a solution (MOC) to a problem when no problem with our educational system exists? In the future, let us instead take the rather large percentage of specialty-trained people who have not passed the boards and make them pass the boards and be certified.

Let the public know that we are policing ourselves by making everybody board-certified and that they can rest assured that when they go to an ophthalmologist, that ophthalmologist is board-certified. There is no specialty at this time that can make the claim that it has 100% board-certified specialists. The public message would be extremely powerful, and the ABO would be doing the right thing, rather than retesting and constantly re-penalizing those who have already passed the boards, or potentially publicly demeaning those elder ophthalmologists who are grandfathered in.

The goal of 100% board certification is simple in its construct and would be the right message to send to the public. We should not be divisive by pitting the elders in ophthalmology against those out in practice for 11 or fewer years. We must unite!

This proposal should be brought to a vote before the full body of the American Academy of Ophthalmology. A motion should be introduced at the business meeting of the AAO requiring a survey of the membership's feelings on MOC as well as how the AAO should respond to the ABO about its intent to time-limit every ophthalmologist's certification with the requirement of closed-book extensive examinations to recertify. An opinion of the AAO membership will serve to guide the AAO power structure and give the ABO better direction to unite rather than divide ophthalmology.

Stanley Braverman M.D., F.A.C.S., is in private practice in Hallandale Beach, Fla. He is also a voluntary clinical instructor at the University of Miami School of Medicine, Anne Bates Eye Hospital, and Bascom Palmer Eye Institute.

REFERENCES
1. O' Day, D. Editorial: Maintenance of Certification and the Outside World. Arch Ophthalmol. May 2004; Vol.122: 767-769.