In recent years, many orthopaedic surgeons have expressed strong dissatisfaction with the Maintenance of Certification (MOC) process of the American Board of Orthopaedic Surgery (ABOS), and in particular its onerous high stakes exam process. The AAOS Board of Directors has heard these complaints and understands your concerns regarding the time and costs required to complete the ABOS MOC requirements, the relevance of the subject matter to your practice, and the lack of evidence to support the benefit of current MOC exam requirements.

At the recent National Orthopaedic Leadership Conference (NOLC) meeting in April, the Board of Councilors (BOC) and Board of Specialty Societies (BOS) adopted by wide margins an Advisory Opinion that provides the following:

RESOLVED, that the AAOS Board of Directors and the Maintenance of Certification Alternative Pathway Project Team should continue to explore the feasibility of easing the recertification process by eliminating the requirement of a high stakes recertifying examination, either through collaboration with ABOS or by the development of an alternative MOC pathway.

The BOC and BOS adopted similar Advisory Opinions in 2015 and 2016, including a call for the AAOS to develop and implement an alternative process of MOC and board recertification. In my travels around the states, I've also repeatedly heard your urgent concerns. And, in fact, at least 17 states are now considering legislation to limit health plans and hospitals and/or state licensing bodies from requiring physicians to be board certified and/or participate in MOC programs operated by specialty medical boards.

As I shared with you at the "My Academy" meeting in San Diego, we hear your frustration with MOC and recognize that the burdensome ABOS MOC process is not reflective of your practices.  We know that the requirement of high stakes exams every 10 years is especially unpopular, unproven, and costly. In September 2016, the AAOS Board of Directors, after detailed discussion, established a Project Team to explore alternative pathways to MOC. This group will make a formal report to the AAOS Board of Directors at our meeting this month, and we will share those findings with you later this summer.

The AAOS Board Project Team has explored the MOC process by studying other medical boards such as internal medicine and anesthesiology. Not surprisingly, many other organizations, including the American Medical Association, are also struggling with MOC. All medical boards are overseen by the American Board of Medical Specialties (ABMS), the likely 10,000-pound gorilla in the room. The unchecked power of the ABMS to impact physicians' lives and livelihood will likely continue to escalate if the physician community doesn't make itself heard loud and clear.

A recent study conducted by the University of California, San Francisco (UCSF) and Stanford University published in the Annals of Internal Medicine at http://annals.org/aim/article/2398911/cost-analysis-american-board-internal-medicine-s-maintenance-certification-program concludes that the cost of implementing most recertification requirements in internal medicine will skyrocket to an estimated $5.7 billion over the next 10 years. The 10-year cost to an internal medicine physician currently is more than $23,000. The researchers indicate the high costs of the MOC programs in internal medicine demonstrate the need for higher-quality evidence that will actually lead to improved clinical outcomes for patients.

Whether the costs of MOC will be passed on to employers, payers, or patients is not clear.

"We want to know whether these requirements offer a good return on investment for society," noted one of the study authors, Dhruv Kazi, MD, MSc, MS, of the UCSF Department of Medicine, Department of Epidemiology and Biostatistics, and Center for Healthcare Value.

In response to the concerns and frustration of orthopaedic surgeons regarding the challenges and relevancy of the MOC process, the ABOS has indicated some initial willingness to experiment and pilot new models designed to meet the MOC guidelines identified by the ABMS, while at the same time making the process more relevant and less burdensome. The results of these pilots have yet to be determined, but we are encouraged by this early effort, and expect to see more progress as your voices are heard. But this alone is not sufficient.

We hear you and we will persist
AAOS leadership expects to meet with the ABOS this month to continue discussions we have initiated. As you will see in the article on p. 14 ("MOC: What's New and What You Need to Know"), the ABOS is also listening to your concerns and considering several changes to the process. I can assure you, we will not back down from our commitment to provide you with new, less burdensome alternative pathways for MOC in the near future.

MOC will also be an important topic at the AAOS Board of Directors meeting this month. As the process unfolds with ABOS, we in the Academy leadership want you to know the AAOS will continue to strongly advocate for and firmly voice the concerns of our members to the ABOS to ensure that the MOC process is restructured to be fair and meaningful. If the ABOS cannot provide such options for MOC, then the AAOS will pursue our own MOC alternatives.

MOC Changes for Internal Medicine and Anesthesiology
MOC for other specialties is also undergoing more rapid changes than what has transpired up to this point in orthopaedics. Physicians from all areas of internal medicine have complained the MOC requirements are not relevant and out of step with the realities of their work. As evidenced by a recent announcement from the American Board of Internal Medicine (ABIM)—which, like the ABOS, is a member board of the American Board of Medical Specialties—the ABIM is replacing the 10-year MOC requirements with more meaningful, less burdensome assessments that focus on cognitive and technical skills. As noted by the ABIM, physicians certified in internal medicine and in nephrology will soon have a new MOC assessment option. Although the 10-year exam will remain an option, beginning in 2018, these physicians will have the option of taking a shorter assessment every two years. These shorter examinations, dubbed "knowledge check-ins," can be completed in the physician's home or office, or in a testing center. The ABIM noted that "those who meet a performance standard on shorter assessments will not need to take the 10-year exam again to remain recertified." The ABIM is still under scrutiny to demonstrate how its efforts lead to improved quality or efficiency of patient care.

The American Board of Anesthesiology (ABA) established Maintenance of Certification in Anesthesiology (MOCA 2.0®) for diplomates with subspecialty certificates. MOCA 2.0 is delivered in a web-based learning platform designed to promote personalized lifelong learning by allowing their diplomates to demonstrate their proficiency and enhance their knowledge. The pilot that the ABA is running allows participants to answer 30 questions per calendar quarter, thereby alerting the ABA to identify diplomates who may not be keeping their knowledge current.

For more information
To learn more about the ABOS MOC process, visit www.abos.org or call the ABOS at (919) 929-7103.

For more about MOC preparation courses offered by the AAOS, visit www.aaos.org/courses

For more MOC resources from the AAOS, visit www.aaos.org/moc

MOC Prep Courses
The AAOS will offer 1-day courses to coincide with all four of the practice-profiled recertification exams that will be offered by the ABOS in 2018. Thus, in addition to the AAOS Board Maintenance of Certification Course to be held Nov. 2–4 in Boston, the Academy is presenting the following four MOC specialty review courses:

• Trauma, Nov. 2–3
• Foot and Ankle, Nov. 2
• Adult Reconstruction, Nov. 3
• Spine, Nov. 4

Additionally, an MOC Pediatric Review Course, "One-Day Fundamentals in Pediatric Orthopaedics Review Course," will be presented by the Pediatric Orthopaedic Society of North America (POSNA) and the AAOS Nov. 28–Dec. 2, in Orlando, in conjunction with the International Pediatric Orthopaedic Symposium (IPOS) for those who take the pediatrics recertification examination in 2018.