Physicians are struggling to adapt to a sea change in the health care 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, and re-examination by specialty boards to renew 10-year time-limited certification.
Unfortunately, these external pressures aren’t lessening. Despite recent changes made to maintenance of certification (MOC) by the American Board of Internal Medicine (ABIM), a continuous process of MOC is still required by many boards in order to maintain 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) when MOC was initially debated and approved, I support the concept of MOC. However, I believe this burden can and must be made less onerous while still meeting the goals of MOC.
I believe that the MOC 10-year 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 their recall of memorized facts.
I suggest that MOC examinations 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 that 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 health care 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.
David Troxel is medical director, The Doctors Company.
