Reasons to MOC®: Board certification revisited

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Bob Wachter has written a lengthy defense of the American Board of Internal Medicine (ABIM) and its Maintenance of Certification (MOC®) program, addressing contentions that the ABIM may have engaged in questionable financial practices, and that MOC® is irrelevant, time consuming, and onerous.

These allegations, however, are not the only questions board organizations may need to confront.  Along with several recent articles devoted to the topic of professionalism, Wachter’s piece provides us with an opportunity to examine three foundational arguments that board leaders invariably bring forth to justify the commerce of certification.

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Is medicine a scientific enterprise?

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I was recently involved in a Twitter tiff triggered by the following Mayo clinic announcement:

Readers were promptly outraged:

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The history behind the MOC®kery

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For those affected or scandalized by the way MOC® programs are being foisted on doctors, the following Wikipedia entry may provide an explanatory frame of reference:

A union security agreement is a contractual agreement, usually part of a union collective bargaining agreement, in which an employer and a trade or labor union agree on the extent to which the union may compel employees to join the union, and/or whether the employer will collect dues, fees, and assessments on behalf of the union.

Of course, the American Board of Medical Specialties (ABMS) is not a physician union in the strict sense of the term.  From the vantage point of ABMS executives, the situation is far better.  ABMS bosses can impose enrollment into MOC® without needing to grant doctors membership—and therefore voting rights—in the organization.

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“Intolerable” laissez-faire in medicine: the early years of the Mayo Clinic

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Shortly after its initial posting on this site, this article was also cross-posted on the website the Ludwig von Mises Institute under the title “The Mayo Clinic and the Free Market.” I have made some very minor edits since then. MA. April 18, 2015.

Neoclassical economists such as Kenneth Arrow and Joseph Stiglitz tell us that the health care market is imperfect (or “Pareto inefficient”), meaning that the allocation of services is not optimal from the standpoint of social welfare.   They point to information asymmetry as an important cause of this imperfection: patients cannot distinguish on their own the physician from the charlatan, the surgeon from the butcher, the remedy from the snake oil, the hospital from the coop.  This may lead to moral hazard where the party with the most knowledge can provide inferior service with impunity.

To provide the necessary counterbalance for this “knowledge gap,” experts must be in charge of social institutions that tell patients where to go, who to see, how to be treated, and how much it should cost.  This has been a principal and virtually unchallenged argument underpinning health care legislation in the last 100 years.  In a famous paper he wrote on the subject in 1963, Arrow declared that “It is the general social consensus, clearly, that the laissez-faire solution for medicine is intolerable.”

But for those who wonder how intolerable the “laissez-faire solution” really is, a short booklet published in 1926 may prove instructive. 

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