does maintenance of certification (board recertification) really have any value?

I was originally board-certified in ob/gyn in 1996. It was tough; besides a written exam, I had to compile a list of every patient I saw in the office, operated upon in the OR, etc. for an entire year. Back then, software for this was pretty horrible and painful to use, and everything had to be done to the American Board of Obstetrics and Gynecology’s strict specifications in terms of page layout, printing, etc. But I did it, and then had to fly to Chicago and sit in a room in the Westin Hotel while three pairs of examiners came in and grilled me for an hour each on gynecology, obstetrics and office practice. I had to defend why I treated specific patients the way I did, and left absolutely convinced that I had failed miserably. Everyone was made to feel that way. But I did pass and had a 10-year certification. While grueling and akin to mental torture, I felt that it was an accomplishment, especially given that many people were failed by the examiners that year.

Beginning in 2006, I had to undergo recertification. One had the option of taking a live written exam that gave you recertification for a few years, or completing 120 open-book, multiple-guess questions about various papers in the clinical literature; taking the clinical questions route (“ABC” for “annual board certification”) gave one recertification that lasted one year. Nearly all of us diplomates opted for the ABC route. It was easy, albeit pricey, but we all knew it was somewhat ludicrous. The hardest part wasn’t answering the questions, but obtaining the articles. It spawned a small industry of companies that would help provide the abstracts of the various papers needed, which I hope didn’t dupe too many gynecologists out there since the abstracts can be had for free online very easily. We all realized that one really didn’t learn much from reading the articles and answering the questions, and it was also clear that people didn’t remember any of what they had read afterwards; ask any gynecologist if he or she remembers any of the papers used for the ABC exam even a year ago and you’ll likely get blank stares.

Things got worse around 7-8 years ago, when under pressure from other professional boards to get tougher, ABOG opted into what has been termed “Maintenance of Certification” or MOC. In addition to the usual list of multiple-guess questions about various clinical papers, one had to complete other requirements, including annual case-base testing (which didn’t officially cause one to fail, and I was nevertheless exempt as I am no longer in full-time clinical practice), and a written exam every six years. I took the written exam (really a computerized exam) last year and passed, although I was surprised I never received the questions with answers as was promised at the end of my taking the exam. Without such feedback, how can someone truly learn and know what he or she answered incorrectly and why?

I recently registered again for the 2014 MOC process, dutifully paid my annual fee, and submitted my active medical license. All routine. But today I received an email from ABOG telling me that my application is incomplete because I never submitted a signed form from another ABOG diplomate to attest to my character. That was something that we all used to do every year, but for the past two years was not apparently required, so I was a bit surprised to see it return. Does ABOG think I became an axe murderer in the past year? Given that I’ve been board-certified (technically, a “diplomate of the American Board of Obstetrics and Gynecology”) since 1996, has my “moral character” somehow drastically declined now that I’m in my 50’s? No worries; I already have a friend who is happy to attest that I have “demonstrated good moral and ethical character, and have voluntarily elected to have limited or no OB/GYN Admitting Privileges,” but the Board has received the same attestation over a number of years, and I’d be curious if they’ve ever had anyone who couldn’t produce at least one other gynecologist who would sign such a form for him or her. Honestly, it’s silly.

So every year, all of us board-certified gynecologists must pay several hundred dollars for the privilege of taking an open-book multiple-choice test about articles that are largely forgettable and that probably teach little or nothing. Asking questions like “What was the sample size in the study by Yifnif and colleagues?” has no lasting value whatsoever. Most of us can, and should, be able to read basic clinical papers and understand how to find the information when asked for it. My kids could do the same thing. None of this means anything.

Maintenance of Certification programs in several specialties have never, ever, been demonstrated to improve clinical outcomes. Not one bit. People aren’t practicing better medicine because of MOC. Patients are not doing better because of MOC. All it appears to amount to is a way for medical specialty boards to feel like they’re doing something to make sure that their board-certified physicians are still up to par, and generate some revenue while doing it. It’s quality monitoring theater.

Why do I still maintain my board certification status? Two reasons; in my specialty, I could no longer be a Fellow of The American College of Obstetricians and Gynecologists without it, as it is required for continued membership in what is the main professional society for ob/gyns. Second, I worked really hard to become board-certified in the first place, and that board certification itself does mean something, at least to me. So I don’t have any interest in giving it up.

There was a good paper on MOC not too long ago in NEJM. It makes many good points about the problems with MOC as currently implemented. In fact, i can’t really find many physicians who truly like MOC. We all think it’s silly and don’t like taking the time and money to deal with it. The only people who I can find to really defend MOC are associated with professional medical societies.

So yes, i’ll go through the same motions again this year. I paid my fee, I’ll answer the questions (which, incidentally, can be re-answered online if incorrect until one gets it right) and print out the automatically-generated certificate attesting to my board certification status for this year. But I won’t have any delusions that it made me a better clinician. Even continuing medical education doesn’t usually produce improved clinical outcomes, so why would making physicians read through a few dozen clinical papers in an open-book format work any better?