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Is Maintenance of Physician Board Certification a Sham?

Author Information (click to view)

Skeptical Scalpel

Skeptical Scalpel is a recently retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last two years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog has had more than 340,000 page views, and he has over 4200 followers on Twitter.

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Skeptical Scalpel (click to view)

Skeptical Scalpel

Skeptical Scalpel is a recently retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last two years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog has had more than 340,000 page views, and he has over 4200 followers on Twitter.

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To answer my own question, it is.
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Over the last few years, medical specialty boards have begun to compel physicians to maintain board certification by a number of means. This is an extension of recertification requirements that have been in existence since the mid-1970s.

Here is what the American Board of Surgery (ABS) mandates for Maintenance of Certification (MOC) every 3 years (except where noted):

1. You must have an unrestricted medical license, hospital privileges in surgery, and references from the chief of surgery and the chair of the credentials committee of your hospital. It’s hard to argue with the need to have a license and practice in a hospital. However, if a surgeon had real quality issues, shouldn’t they have come to light before the end of a 3-year cycle of MOC?

2. You must document 90 hours of CME credit, 60 of which must include some sort of Q & A testing that must be passed with an average score of at least 75%. I have previously blogged about the inadequacy of most CME programs. Even CMEs that require testing are often laughably simple. The American Board of Internal Medicine offers (for a price) open-book and internet-based courses. Regarding self-assessed CMEs, the ABS website states: “…there is no required minimum number of questions and repeated attempts are permitted.”

3. You must successfully complete a written recertification exam every 10 years. Surely that must be an effective measure? Maybe not. For the last 5 years, the pass rate for recertification in general surgery is 94% or greater. The American Board of Internal Medicine (ABIM) recert exams must be a little tougher, or those who take it may not be as smart as surgeons. The pass rates for the ABIM recert exams have been 88% to 92% for the last 4 years, with similar rates for all medical subspecialties.

4. You must participate in a national, regional, or local outcomes registry or quality assessment program. Participation in a national outcomes registry sounds great, but none of the available registries have policing powers and many rely on individual surgeon input to track outcomes. As mentioned in the critique of the first requirement, quality issues are far more likely to be discovered at the local level than by a registry that collects data submitted by the surgeon herself.

I’ve known a few physicians well under the age of 65 who could have used a checkup from the neck up.

As if all the above issues are not enough, how about this for a hot potato from the ABS:  “Periodic communication skills assessment based on patient feedback may also be required in the future.” I can’t wait to see how that information is going to be collected. By what criteria will communication skills be judged? And what will happen to someone deemed a poor communicator?

I suppose the boards are doing all of this to forestall government or other regulatory bodies stepping in. Meanwhile, let’s everyone play along.

None of the MOC requirements address another issue, which is fitness for practice. A recent article in the Washington Post on aging physicians notes that some hospitals are setting age limits at which doctors are required to undergo physical and mental evaluations in order to maintain staff privileges. That’s great but not for just the elderly; every doctor needs to have periodic fitness testing.

Right now, all you have to do to stay on the staff of most hospitals is to have a colleague attest to the fact that you are in good health — hardly a rigorous standard.

I’ve known a few physicians well under the age of 65 who could have used a checkup from the neck up.

To answer my own question, maintenance of certification is a sham.

Skeptical Scalpel is a recently retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last two years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog has had more than 340,000 page views, and he has over 4,200 followers on Twitter.

 

4 Comments

  1. The criteria for board certification have escalated regularly since certification was no longer “permanent.” The costs in time and money have risen as well. CME and other supporting activities are a major cottage industry now. An hour of CME now reaches $60.
    The frustration is that there is no evidence that MOC has improved patient care. I have asked the Board of Pediatrics (no reply) as well as the Neonatal Resuscitation Program (no studies.) I have searched the literature. Only in Canada and overseas has the process been studied and all do re-certification and education differently.
    MOC is a power and money grab by the Boards. What we want should be driven by outcome, not process.

    Reply
    • Good comments. Space considerations kept me from including my opinion about the costs of all this. I agree with you completely and that CME has become a cottage industry. I have used that term myself.

      I also agree that there is not a shred of evidence that any of the MOC components is of value in protecting the public or identifying bad doctors.

      Reply
  2. These are interesting criticisms. What I would be curious to read is how you would design a better system. It sounds like someone with your background could offer some helpful suggestions.

    Also, a high pass rate for the written exam is not too surprising. You can imagine that many doctors who felt themselves slipping during the past 10 years choose to forgo the test and just quit. Furthermore, if a new doctor has passed his or her step exams, it is doubtful that they would fail a recertification exam just 10 years later. These early pass rates would drive the average pass rate upwards.

    Reply
    • Sorry for the delayed response. You may be right about the high pass rate being unsurprising, but I can tell you that I didn’t study for the recert general surgery boards and passed it 3 times with ease.

      There must be a better way. I understand the the ABIM is going toward more clinical scenarios and away from simple questions of fact.

      Reply

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