Maintenance of Certification (MOC) presents a challenge for me and others trained in my time frame. Before my class, physicians took exams after their post-graduate training and obtained life-long certification in their specialty. My class was the first to be issued time-limited certificates in Pediatrics. What has this meant over time as I have sub specialized and grown older?
A lot of money and pain. MOC has proved so tedious that The New England Journal of Medicine featured articles about the practice in its January 8 issue. One, Boarded to Death, was contributed by Paul S. Teirstein, MD, a physician whose petition to change the process has been signed by 19,000 doctors.
Since I was in the first wave of time-limited physicians, I have a “historical” perspective on this issue. My initial exams in general pediatrics and pediatric nephrology both occurred in hotel ballrooms. Each cost about $1,000 plus time off of work and travel costs.
General Pediatrics Recertification (Early 1990s)
In my first job I supervised residents on the inpatient pediatrics service each year. When I had to renew my certification, the process cost about $1,000 (similar to the original exam), but otherwise proved pleasing. The exam came on disks that I ran in my own computer. I had a time limit (in weeks) to complete it once I loaded it, but otherwise I could do as much research as I liked. The questions generally dealt with important clinical topics, and I received immediate feedback about the results. There were several things I learned through this process. Stuff not relevant to my life as a nephrologist had been published, and I had completely missed it! I pulled papers and looked stuff up! I learned a lot, and it was easy to fit into my life as an academic clinician-scientist starting up a lab.
This format cost money and time, but overall I felt the process was rewarding and useful. If they had stuck with this, I might still be certified in general pediatrics. Yup, it was that good.
First Pediatric Nephrology Recertification (2003)
By this point, the powers that be had decided that an open-source exam was not appropriate. No, we doctors needed a “high-stakes” exam. I had to find a testing center and take a supervised exam. This meant studying and taking off a day of work; lucky for us, most cities with an academic medical center will have a testing center. A few weeks after the exam, I received my score (passing!) and a summary of the question areas and my score for each category. My weakest area was transplantation; not exactly surprising, since other areas of nephrology have always interested me more.
This format cost money and time. The proctored exam annoyed me; I could not take my jacket or purse into the exam room. Let’s face it, no doctor knows every fact that they need to know. However, the questions dealt with reasonable topics. Any competent nephrologist should be able to pass this exam.
General Pediatrics Recertification (Late 1990s)
The general exam now required a secure test center. As my new employer no longer required this certification, I opted out. I simply could not justify the cost of the exam, the cost and time off to take a review course (my only hope to pass), and the other annoyance of something not required.
Next Pediatric Nephrology Recertification (2013)
By this time, recertification has grown into full-blown MOC. Once again, the cost was around $1,000 for a ten-year period. Requirements over that time included:
Maintaining valid, unrestricted state medical license (with its own requirements for continuing medical education hours)
Educational and quality improvement modules approved by the Board; these could also count for continuing medical education hours, but might conflict or duplicate other activities required elsewhere
Another exam at the testing center
The medical license is pretty easy; if I don’t have that, being board certified is pretty useless. The educational module could be fulfilled by subscribing to a monthly Question and Answer publication sold by the Board (can you say more money). I enjoy this piece of the effort; I learn stuff. The quality improvement modules proved annoying. The ones relevant to my job duplicated efforts my employer had in place (prescription writing, hand washing, weight control). I got through the two required, but the process was generally useless. The cry about this part resulted in the Board agreeing to certify centers (more money) to produce their own modules. Finally, my exam this time included scanning with a metal detector. The questions seemed more esoteric than before, and when I got my letter, it told me I passed. No feedback on areas that might need improvement. Just a score and the cut-off.
The Future of MOC
Compared to Dr. Teirstein, my lot seems light. He is trying to maintain certification in several subspecialties. The time away from my other duties is less problematic for me, and the educational efforts supplement my other academic activities. When we arrange things so institutional quality projects can count for MOC, that part will also be less problematic.
The point many physicians have made regards the secure exam. Physicians simply do not have to remember information the way they once did. I can pull up drug information and other references on my smart phone in the exam room. If I did need to know which interleukin was secreted by a lymphocyte expressing certain markers (an actual question from my last exam; clinically relevant my ass), I can have the answer in about a minute. I am sure the person who wrote that one (a) studies the immune system and (b) considers it relevant, but I still do not know the answer. No one has yet died from this knowledge gap.
In addition to MOC, our institutions have placed further training burdens on physicians. Time here and there, even at no formal cost, adds up. I especially love reviewing fire safety on an annual basis. RACE never changes, you know.
Some form of ongoing education and certification requirements seem reasonable. I have seen some doctors who have not kept up, and it did affect patient care. However, the current system seems as much about income for the Board as it is about quality of care. We have to be able to make it less of a burden, or physicians will just go without it. And then it serves no purpose.