Ensuring physicians' competence--is maintenance of certification the answer?

Pressed by their leaders, external stakeholders, and a public troubled by lapses in the quality of care and unsustainable cost increases, physicians are facing stiffer challenges in initiatives designed to link more closely the goals of learning with the delivery of better care and measures of greater accountability. The initiatives are works in progress being implemented by national accrediting organizations, state medical licensing boards, the federal government, and others,1-5 but the most contentious among them (and the focus of this article) is the maintenance of certification (MOC) program sponsored by the American Board of Medical Specialties (ABMS) and its 24 member boards, which promote continuous professional development.6 MOC requires most certified specialists to seek recertification on a periodic basis — typically every 10 years — by successfully completing a four-part assessment designed to test their medical knowledge, clinical competence, and skills in communicating with patients. The MOC program was initiated in 2000, but the pace of recertification has accelerated since 2009. Approximately 375,000 boardcertified specialists and subspecialists (about half the number that the 24 boards certified initially) meet MOC requirements, according to the ABMS. Although the number of specialists engaged in the process grows by about 50,000 diplomates a year, the exercise also draws strong criticism from physicians who assert that MOC is too expensive and the process is too time-consuming. Another concern is a requirement that a secure examination (one of MOC’s four parts) be completed without access to outside sources of information. This condition contradicts what medical students and residents are currently taught: they should take advantage of the best sources of information rather than rely entirely on their memory. Younger physicians also suggest that so-called grandfathers7 (generally specialists who were certified before 1990 and received timeunlimited credentials) should also face the rigors of recertification (Eggen M: personal communication). Among 66,689 diplomates of the American Board of Internal Medicine (ABIM) who hold only time-unlimited certificates, only 1% have chosen to become recertified through MOC. The ABIM also certifies physicians who practice in 19 subspecialties. Since 1990, all certificates issued by the ABIM have required diplomates to complete MOC to remain certified. Two ABIM areas of specialty actually were established before 1990 without ever having issued time-unlimited certificates — critical care medicine in 1987 and geriatrics in 1988. Like ABIM, other specialties also report low recertification rates among their diplomates with time-unlimited certificates, including dermatology (8%), nuclear medicine (12%), plastic surgery (5%), and urology (1%). One of us holds a time-unlimited certificate and is enrolled in MOC. More than 75 years ago, the ABMS and its predecessor organization began to build a national system of standards for educating medical specialists.8 As originally conceived, securing board certification was considered a once-in-alifetime challenge designed to show a doctor’s competence after completion of residency training. Until 1969, all the ABMS-member boards issued lifetime specialty certificates, but as the skills necessary to practice medicine grew exponentially and research showed that, on average, the clinical skills of physicians decline over time,9 time-unlimited certification was called into question. Since its founding in 1969, the American Board of Family Medicine (ABFM) issued only time-limited certificates. Initially these certificates were valid for 7 years, but now they remain valid as long as a diplomate meets MOC requirements.10,11 As of 2000, the ABMS adopted MOC as a policy with general standards for all of its