Published 1/1/2007
Marybeth Ezaki, MD; G. Paul DeRosa, MD

What you need to know about Maintenance of Certification

Initial board certification and recertification are built upon education, peer review, continuing medical education, and a secure examination. Both are, and always have been, a voluntary process.

Renewal of board certification for all medical specialists in this country is evolving into the Maintenance of Certification (MOC) process. We will explain the reasons for these changes and what the American Board of Orthopaedic Surgery (ABOS) is doing to bring the orthopaedic profession on board for this new process.

What is MOC and what’s the rationale behind it?

The ABOS is the certifying body for the medical specialty of orthopaedic surgery. The ABOS, in turn, is a member of the American Board of Medical Specialties (ABMS), colloquially known as “the mother board,” composed of 24 member boards representing all the specialties of medical practice. ABMS member boards are recognized as the legitimate certifying boards for American medicine.

During the past decade, the public, the government and non-government organizations have advocated for reforms in American medicine. As part of these reforms, an ABMS task force defined the following six core areas that a physician should be judged on to determine competence:

  • Professionalism
  • Communication skills and cultural competence
  • Patient care
  • Practice-based learning and improvement
  • Systems-based practice
  • Medical knowledge

Consumer and watchdog groups then led a push to evaluate physicians accordingly. The specialty boards, working with the ABMS, defined four components that could be evaluated by the certifying boards during a recertification cycle. The ABMS member boards approved the transition to MOC, a process that evaluates applicants on the following four components on a continuing basis:

  • Evidence of professional standing
  • Commitment to life-long learning and self-assessment
  • Evidence of cognitive knowledge
  • Evidence of performance in practice

What are some details about the MOC requirements?

Please refer to the timeline on this page for examples of a possible 10-year MOC process. In addition, the ABOS offers the following specifics about the four components of MOC and the requirements for applicants:

Evidence of professional standing:

The credentialing process and verification of licensure will remain largely the same as during the ABOS’ prior process for recertification.

A stringent system of peer review will continue.

Diplomates will submit a surgical case list from their practice. Diplomates who elect to take the written or computer-based examination must submit either a cumulative three-month sequential list, or 75 cases, whichever is fewer. Diplomates who choose the oral examination must submit a six-month case list.

Evidence of life-long learning

The ABOS agrees that degradation of knowledge is a recognized occurrence if a physician does not actively try to keep up as the specialty moves forward.

Continuing medical education (CME) is an ongoing part of MOC. The ABOS will require documentation of CME and self-assessment on an ongoing basis.

When MOC is fully implemented, two three-year cycles of CME and self-assessment will be required prior to application for the cognitive examination.

Diplomates whose certificates expire in 2010 through 2016 will be participating in a transitional MOC process. Prior to application for the cognitive examination, a minimum of 120 Category 1 CME credits are required.

Included in the 120 credits must be a minimum of 20 Category 1 credits from a scored self-assessment examination (SAE). The SAE must be a formal test of 10 credits or more, such as the SAEs in general or subspecialty orthopaedic topics (for example, SAEs that are currently available from the Academy or the specialty societies). These must be returned and formally scored by the issuing CME provider.

CME should be topically related to orthopaedic surgery, but may include those credits required by state medical boards for licensure.

CME and SAE must be reported directly to the ABOS by the Diplomate.

Evidence of cognitive knowledge

The position of the ABOS, as well as that of the ABMS, is that knowledge does not guarantee competence, but without knowledge there can be no competence.

A secure cognitive examination, either written, computer-based or oral, is required to fulfill this component of MOC.

Practice-profiled examinations in spine surgery, sports medicine and adult reconstruction are available for orthopaedic surgeons who have sub-specialty interests in these areas. These tests will include 80 core orthopaedic questions and approximately 120 questions in the respective specialty area.

The Hand Certificate of Added Qualification examination, with the 80 core orthopaedic questions, is also a valid means to fulfill this requirement.

Evidence of performance in practice

This is the most difficult component to evaluate. An evaluation of performance in practice is intended to serve as a quality improvement model. It is meant to allow the diplomate to compare his/her own practice with other orthopaedic surgeons regionally and nationally.

Peer review will also serve to confirm performance in practice.

The orthopaedic surgeon who chooses the oral recertification pathway will fulfill this component by participating in the oral examination process.

Case list submission will ask the diplomate to review documentation of best practices appropriate to the practice of orthopaedic surgery. Items to review in personal case audits will vary with type of practice and as best practices are better defined.

Patient surveys are being developed by the ABMS and others and may be required as a means to fulfill this component at some time in the future.

Methods are also in the development phase to allow a non-operative orthopaedic surgeon to fulfill this component.

Wherever possible, the ABOS will incorporate instruments that are required by other agencies and give credit for MOC part IV.

Note: Additional requirements for MOC will be implemented as programs and data management systems are developed to support them.

How will MOC benefit orthopaedic surgeons and their profession?

As members of a profession, we have an unwritten contract with society to regulate ourselves. As stated by Richard L. Cruess, MD, et al, “Society expects that the traditional obligation of medicine to self-regulate will reflect the morality of the profession and will be met in a fair, open and stringent fashion.”

Most of us would agree that it is better for physicians to set the rules and standards by which we are measured. If, as a profession, we fail to set such standards, we may find ourselves subject to rules and regulations set by outside organizations or govern-mental bodies. We must not lose our status as a profession lest we be relegated to that of a mere trade. The MOC program, as currently instituted and as it will develop in the future, can help prevent that.

When will this affect us?

MOC is here. If you have a time limit on your board certification, you will be part of the MOC program—if you choose to maintain your board certification through MOC.

The ABOS is working with ABMS and other parties with a stake in physician certification. State medical boards are already looking at programs for Maintenance of Licensure. A carefully maintained board certificate may be able to satisfy your state board’s requirements for licensure renewal. Hospitals are receiving instructions from the Joint Commission on Accreditation of Healthcare Organizations for evaluating physicians with respect to the six core competencies.

MOC will begin with ABOS diplomates whose board certification expires in 2010. These diplomates have already been notified by the ABOS. Diplomates whose certificates expire in 2011 will receive notification from the ABOS soon. The ABMS member boards have collectively agreed that the start date for full implementation of the MOC process will be no later than 2016. Programs will be in place and the process will be moving forward at that time.

How is the Academy working with the ABOS to facilitate the transition to MOC?

The Academy and the ABOS have established a Joint ABOS/AAOS MOC Task Force, which includes representatives from both organizations. Task force goals are to communicate the rationale for MOC and its goals and to find solutions for orthopaedic surgeons seeking to meet MOC requirements. The Academy provided input to the ABOS on the MOC program throughout its development.

How should I stay informed of the latest updates to the MOC program?

Many details regarding MOC are still being developed, so be sure to check regularly for updates from the ABOS. As soon as you can register for the MOC tracking on www.abos.org, you should provide information about yourself and your certification status, and keep checking for updates about the requirements to maintain your certification.

At the AAOS Annual Meeting, visit the MOC information booth sponsored by the ABOS (see box for details). For more information about the ABOS’ MOC program, visit www.abos.org or contact the ABOS at (919) 929-7103.

Marybeth Ezaki, MD, chairs the MOC Committee of the ABOS and serves as the ABOS chair of the Joint ABOS/AAOS MOC task force. She can be reached at MarybethEzaki@tsrh.org G. Paul DeRosa, MD, executive director of the ABOS, is a member of the Joint ABOS/AAOS MOC task force.


  1. Cruess, RL, Cruess, SR, and Johnston, SE. Professionalism and Medicine’ Social Contract. J Bone Joint Surg Am 2000;82:1189.