How to fix maintenance of certification: Here's what I'd do

There’s a lot of angst when it comes to board recertification. The general consensus is that doctors find the requirements onerous, while a more cynical segment calls the whole process a money-making operation for our professional societies and those that profit from recertification courses and materials.

Cardiologist Wes Fisher has articulated the many criticisms against board recertification: “Does board recertification do more harm than good?“, and “Maintaining board certification: Stop with the patient surveys.”

A major argument in favor of board certification is that it maintains and improves the quality of care for patients. However, as internist Danielle Ofri writes in the New York Times, recent studies have repudiated that notion:

Two recent studies in The Journal of the American Medical Association are the first to seriously evaluate the role of M.O.C. in physician quality and medical costs. They compared doctors certified just before the 1990 change (who were grandfathered in for life and not required to recertify) and their colleagues who certified just after 1990. One study looked at costs and the other at quality (as measured by patients’ glucose levels, blood pressure, colon cancer screening rates and the use of medication for heart disease). The studies differed in methodology but the upshot was that patients’ medical outcomes were no better and overall costs were only marginally lower in the recertifying group (2.5 percent).

So, to summarize, maintenance of certification is expensive, time-consuming, and doesn’t improve quality of care.

It’s time to change the process, as internist Robert Centor says to a formative (which helps a learner grow) rather than a summative (which tests what the learner knows) process.

How do we do this? Open-book testing. As Dr. Ofri writes,

Let’s strip away the archaic exam and the paperwork-heavy practice assessments. A periodic, modest-size, open-book test that incorporates relevant knowledge and updates would be more reasonable.

There is much more to the science, art and practice of medicine than medical knowledge. But it is the one aspect we can easily assess on a profession-wide scale. Open-book, self-paced tests are the best way to keep knowledge current. The act of searching for answers — whether from journals, textbooks, databases or colleagues — is itself the knowledge. All the rest is busy work and red tape.

I suggested something similar to this back in 2011: Why Watson makes board certification exams obsolete in medicine. Doctors are no longer encouraged to treat patients purely by memory: There’s simply too much information to know. Patient safety is at the forefront of everyone’s minds, and that means looking stuff up.

So here’s what I propose, as it relates to internal medicine maintenance of certification.

1. Eliminate the practice management requirement. More doctors are practicing in integrated health systems where quality metrics are already being measured as part of their jobs. Duplicating this process is time-consuming busywork that doesn’t improve patient care.

2. Make the examination open book, with access to an UpToDate-like resource. Doctors today have mobile phones and tablets in their pockets to look up information that they don’t know. If patient safety is truly valued, the ability to find the correct information supercedes how well a doctor can memorize it.

3. Make certification more frequent. I agree that recertification should be a more continuous process, rather than one test a decade. A lower-stakes, open-book test every, say, 7 to 8 years serves that purpose. And to address the elephant in the room: Yes, it will also maintain — if not increase — the revenue stream that feeds our professional societies.

A win-win, as they say.

The furor over maintenance of certification is a self-inflicted distraction by our medical leaders. We are wasting time, resources (and valuable New York Times op-ed space) fighting among ourselves when we should be advocating together to improve our health system.

It’s time to move on.