The Doctor’s Advocate | Fourth Quarter 2014
Editorial Comment on Maintenance of Certification
Physicians are struggling to adapt to a sea change in the healthcare delivery system. Solo physician practices are disappearing, small group practices are merging to become larger, and large group practices are being acquired by hospitals and integrated delivery systems. All of this is occurring in a milieu of decreased fee-for service reimbursement from government and private insurers, bundled payments and pay for performance, increased levels of student loan debt, pressure to increase productivity (five patients per hour instead of “just” four), an increasingly difficult regulatory environment, frustration with electronic health records, re-examination by specialty boards to renew 10-year time-limited certification, and now, maintenance of certification (MoC) with two- and five-year milestones to achieve. Furthermore, many physicians in full-time practice face additional pressures as they try to balance family and career.
Unfortunately, none of these external pressures will lessen or go away, and they may actually intensify as the Affordable Care Act is fully implemented and medicine becomes increasingly commoditized.
As a profession, there is little we can do to significantly alter these societal trends, most of which are being imposed by external forces, such as pressures from legislative and regulatory bodies, an increasingly powerful health insurance industry, complex hospital systems that are growing in size and influence, and the need to control the costs of a healthcare system that consumes almost 20 percent of the gross domestic product.
However, there is one thing we can do as a profession—and that is to mollify the pressures that we impose upon ourselves! One of those pressures is the MoC program, with its episodic medical knowledge and practice assessment modules/milestones and its 10-year examination. These requirements are all deemed necessary in order to maintain our specialty board certification—which has become ever more important because it is often required for hospital privileges and membership in provider networks.
As a former trustee of the American Board of Pathology and a delegate to the American Board of Medical Specialties (ABMS), I support the concept of ongoing MoC. In fact, I was a voting member of the ABMS when MoC was initially debated and approved, and I chaired my board’s first MoC planning committee. However, I believe this burden can and must be made less onerous while still meeting the goals of MoC.
Each board’s MoC program has unique features, making generalizations difficult, so I will limit my comments to the episodic and 10-year examination processes and not comment on the specialty-specific practice assessment and knowledge milestones.
I believe that the MoC examination process should be tailored to accommodate the growing time and reimbursement pressures of medical practice, and it should reflect the ways that today’s physicians maintain their medical knowledge and keep up with its rapid growth.
The time-honored methods of reading medical journals, attending national and state medical society meetings, and fulfilling state medical board continuing medical education licensure requirements will doubtless continue. However, attending meetings that require travel and hotel expenses and time spent out of the office has become increasingly difficult and may be a factor contributing to membership declines for many national medical specialty societies.
Physicians who have grown up in the information age acquire much of their medical information via the Internet, through online courses, and from resources like UptoDate and Google searches. Today, the emphasis in medical education is more on how to acquire and keep up with medical knowledge, given its short half-life, than on the rote memorization of medical facts. Relying on a recent edition of a textbook has become less prevalent, because the information might not be current by the time the book is published, and texts are expensive. In truth, the ability to incorporate state-of-the-art medical information directly into clinical decision making has never been better.
For these reasons, board examinations should incorporate the learning techniques that doctors actually use to acquire information, answer patient questions, and keep up to date—rather than focus on testing them to recall memorized facts.
I suggest that MoC examinations should be structured as follows:
- Make them Internet-accessible, open-book/open-journal exams that test the physician’s ability to access information in a timely fashion, thereby simulating the office or hospital practice environment where this skill is essential to the delivery of high-quality patient care.
- Focus the exams on medical information that is relevant to the individual physician’s medical practice—rather than retesting the specialty’s comprehensive broad database of medical knowledge that has already been appropriately tested during the initial certification exam.
- Give the exam in the environment where the physician is most accustomed to accessing the information in daily practice—ideally in the office or home. After all, the purpose of MoC should be to simulate the physician’s practice environment and test for the ability to access and use the knowledge required to provide patients with safe, high-quality medical care. Of course, this means that the exam cannot be proctored, but it shouldn’t be necessary when testing board certified professionals on their ability to access need-to-know information used daily in their medical practice—rather than testing their ability to recall knowledge, which requires restricting access to information sources. This approach will also eliminate travel and hotel expenses as well as the practice disruption of being out of the office.
Medicine has always held itself to high standards of professionalism, and we are all proud of this differentiating tradition. The changes under way in our healthcare system are profoundly affecting the practice of medicine and require us to revise the processes we employ to maintain and monitor our continuous goal of professional excellence. The processes must not become so onerous that they are unsustainable.