Maintenance of Certification

The last few posts were a set-up for this one. For a while, there has been a big debate within the medical community over this process of "maintenance of certification," also called MOC. Recently though, there have been some opinions and editorials published about it in the lay media, so I figured I should write about it.

Each specialty has a board that determines the criteria for granting certification to physicians in that field. Several generations ago, board certification was like a diploma, awarded when one passed all the exams and met all the requirements. However, as we began to recognize that medicine changes drastically over time, we realized that it makes more sense to limit the length of certifications and require recertification. That way, we could continually ensure that board-certified physicians practiced up-to-date cutting-edge medicine. For most specialties, recertification occurred every ten years.

However, along with changes in medical education, specialty boards moved towards requiring a continuous process for recertification. This received a lot of criticism as it is quite onerous and costly. Research has never shown that requiring board recertification improves patient outcomes. As a result, many physicians find its burdens significant and relevance questionable.

We are starting to ask whether test performance reflects a physician's competence. Tests must be written so the answers are black-and-white, but the true difficulties in being a physician are all about handling the gray zone. Tests are designed to be comprehensive, but physicians may only want to practice in a limited scope. A commonly cited example is that anesthesiology boards will test knowledge of pediatric anesthesia whether or not the physician has a job that involves pediatric patients. Many find that they are being tested on things that are not relevant with their actual job. Test questions take years to validate so they are never really fully up-to-date.

I believe most physicians don't like MOC because of the economic consequences. These programs are expensive. Recertification can cost up to tens of thousands of dollars, particularly in specialties (like mine) which require in-person oral examinations across the country. Furthermore, there is a lot of murkiness about whether boards have a monopoly (since it is very hard to find a job without board certification) and how much its executives make from this enterprise.

I believe there are a lot of unspoken consequences of requiring all this bureaucratic paperwork. Each day I take off in order to participate in continuing medical education is a day where I am not taking care of patients, not contributing to society. I am completely happy doing so if I believe what I'm doing will help my practice and my patients. But a lot of MOC activities aren't what I'd choose to improve my practice. I am extraordinarily driven to learn more, improve my skills, and engage in learning, however, MOC recognizes and requires only a very specific and narrow set of activities. While I agree physicians need to govern ourselves and ensure professionalism and lifelong learning, I don't think the system in place is set up to do so effectively or efficiently.