Making Ophthalmologists Crazy or Maintenance of Certification?

The worth of this process.

By Steven L. Mansberger, MD, MPH

Maintenance of Certification (MOC) in ophthalmology is a hot, controversial topic. Since January 2016 on the American Glaucoma Society’s Listserv, members of the organization have written the highest number of posts on this topic (n = 26), beating surgical privileges (n = 19), and flushing the tube of an Ahmed Glaucoma Valve (n = 16; New World Medical). I therefore understood why GT wanted an article on MOC, but I am not quite sure why I agreed to write it! Maybe I wanted to investigate whether MOC is “worth it.” The process’ value may be related to the evidence (or lack thereof) and the perception of stakeholders.


• Maintenance of Certification (MOC) in ophthalmology is a hot, controversial topic.

• One may consider MOC a formal method of sustaining and improving ophthalmic performance and knowledge.

• There is no certification that guarantees performance or positive outcomes. That said, the author believes that a formal system of continuous learning (eg, MOC) is beneficial.


Society considers physicians—like accountants, lawyers, and tradesman such as electricians—to be professionals.1 Professionals master a complex set of knowledge, exhibit exceptionalism, and govern themselves. In the medical profession, self-governance includes standards of care, licensure, education, training, and recently MOC. According to Levin and Spaeth, innovation (improvement) is ethical to medical care with decreased risks, increased benefits, and lower cost.2 One may consider MOC a formal method of sustaining and improving ophthalmic performance and knowledge.

The American Board of Medical Specialties and Accreditation Council of Graduate Medical Education codeveloped the MOC core competencies, which include

1. practice-based learning and improvement

2. patients’ care and procedural skills

3. medical knowledge

4. systems-based practice

5. interpersonal and communication skills

6. professionalism

Although most glaucoma subspecialists will agree that these topics are important to physicians, patients, and the public, most ophthalmologists will also agree that MOC may have difficulty measuring all of these competencies accurately and reliably. For example, professionalism may require direct observation of a physician communicating with a difficult patient, and the ability to perform surgical procedures may require direct observation as well. The public may not need MOC for some of these competencies; ophthalmologists inherently strive for the highest level of performance, because angry patients and surgical complications lead to emotional stress, a loss of patients, and lawsuits. Finally, some practices already include patients’ satisfaction (Press Ganey scores) in compensation, and some states and secondary payers measure, report, and create action plans regarding surgical complications.3 Overall, ophthalmologists may not need MOC for all of these competencies.


What is the evidence for MOC? Surveys suggest that the public values MOC as a way to protect patients, but the public may not recognize that quality of care does not mean patients’ satisfaction. A recent study by my group suggests that patients’ satisfaction is rarely affected by physician factors but is more commonly related to office factors such as the cost of care, waiting time, and the performance of the front and back office staff.4

Studies indicate that MOC participation is associated with a low number of disciplinary events, an urban (rather than rural) location, younger (rather than older) age, and specialty training (when compared to generalist training).5 It is easy to imagine that an older clinician has a higher risk of disciplinary events simply because he or she has been in practice longer, and the other associations could be similarly related to bias.

The American Board of Medical Specialties recognizes that, regardless of the profession—be it health care, law enforcement, education, or accounting—there is no certification that guarantees performance or positive outcomes.6 An ophthalmologist who successfully completes MOC does not necessarily provide higher-quality health care, satisfy patients to a greater extent, or perform well on other important public health measures such as cost-effectiveness. An ophthalmologist who fails MOC, however, may have undiagnosed dementia or poor ophthalmic knowledge. Either would be useful to detect.


Some doctors argue that the cost of MOC is too high. In 2016, MOC fees were $2,000 over a 10-year period. The American Board of Ophthalmology’s (ABO’s) website states that the value of the MOC outweighs its cost, because a diplomat will earn 49 continuing medical education (CME) credits that are worth $2,450 ($50 average cost of 1 CME credit). MOC costs do not include the diplomat’s time devoted to study, cancelled clinic, and other costs. The ABO has decreased the time of MOC by streamlining the time-consuming uploading of CME credits, and it has made the practice-improvement modules simpler to complete.7


Why do I participate in MOC? My research, teaching, and emergency call responsibilities expose me to all subspecialties of ophthalmology, including cornea, retina, anterior segment, neuro-ophthalmology, and pediatric ophthalmology (strabismus after glaucoma surgery). MOC helps me understand the core knowledge that my ABO colleagues feel should be universal to ophthalmologists. I believe that a formal system of continuous learning (eg, MOC) is beneficial to the public perception of ophthalmology. For me, MOC does not mean “making ophthalmologists crazy” but rather “making ophthalmologists current.” Then again, maybe I am crazy about learning.

1. Professional. BusinessDictionary. Accessed December 19, 2016.

2. Levin and Spaeth. The ethics of innovation. In: Shaarawy TM, Sherwood MB, Grehn F, eds. Guidelines on Design and Reporting of Glaucoma Surgical Trials. Amsterdam, The Netherlands: Kugler; 2009.

3. Coronary artery bypass graft (CABG) surgery in California. Office of Statewide Health Planning and Development. Accessed December 19, 2016.

4. Kinast RM, Barker GT, Day SH, et al. Factors related to online patient satisfaction with ophthalmologists. Ophthalmology. 2014;121(9):1843-1845.

5. Lipner RS, Hess BJ, Phillips RL Jr. Specialty board certification in the United States: issues and evidence. J Contin Educ Health Prof. 2013 Fall;33 suppl 1:S20-35.

6. Kempen PM. Maintenance of certification – important and to whom? J Community Hosp Intern Med Perspect. 2013;3(1):20326.

7. Foundation. American Board of Ophthalmology website. Accessed December 19, 2016.

Steven L. Mansberger, MD, MPH
• senior scientist, vice-chair, and the director of glaucoma services, Legacy Devers Eye Institute, Portland, Oregon
• (503) 413-8202;
• conflict of interest: volunteers several nights and weekends with the ABO to write MOC questions and examine oral board candidates


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