MAINTENANCE OF
Can We Improve a Good Idea?
Tom James, MD
L
et’s start by separating out the concept
of maintenance of certification from
the current processes employed by
the Boards within the American Boards of
Medical Specialties. I believe that it is the requirements which are causing physicians the
greatest consternation rather than the belief
that maintenance of certification is not necessary. As physicians we strive to provide our
patients with optimal medical care. I doubt that there are many
doctors who have resigned themselves to provide only marginal or
ineffective care. But how do we know whether the care we provide
years after completion of residency is up to date and appropriate?
Much of the informal learning that once occurred in Doctors’
Lounge conversations has disappeared with the decline in numbers
of physicians providing hospital rounds.
tification is associated with improved outcomes. This is clear in a
variety of specialties and settings. Hanson et al. showed that board
certified pediatricians and family physicians in private practice
achieved higher levels of childhood immunizations with Medicaid
children than did those who were not board certified. Chen et al.
had similar findings for those general internists and family physicians in the care and the outcomes of elderly patients with acute
myocardial infarction. The large Comprehensive Care Project that
measured physician performance in ambulatory settings also found
that board certification was one of several parameters associated
with improved patient outcomes.
PRO
Having standards of care by which physicians’ contemporary
practice of medicine is tested seems only appropriate. We certainly
expect that individuals providing other technical services are kept
up to date and have their skills tested. Who would want to step on
board a plane if the pilot did not have to undergo periodic simulation testing? Other fields from electricians to teachers go through
competency or knowledge-based testing.
The public and the media are raising the question of physician
competency. While most of us began clinical practice at a time when
a physician was assumed to be “the good doctor,” unless proven
otherwise, such is not the case today. With the rise of consumerism,
and the media extensively reporting on physician medical misadventures, there is much more skepticism than in the past. Laura Landro
has a Wall Street Journal column entitled “The Informed Patient.”
She reports on medical consumerism. Last year one of her more
popular columns was entitled “How Qualified is Your Doctor.” This
article focused on board certification and for seasoned physicians,
on maintenance of certification. Other consumer-focused articles
appear in print or in blogs indicating that the physician resistance
to maintenance of certification amounts to finding the easy road
rather than on patient care. In other words, our own antipathy
toward MOC based upon the nature of the requirements is being
misinterpreted by the public as apathy toward ensuring appropriate
care. As a profession, we must redirect the discussion toward finding
better ways to assure the competency and qualifications of ourselves.
There certainly have been studies demonstrating that board cer20
LOUISVILLE MEDICINE
These studies looked only at board certification. Maintenance
of certification as a marker is still young so that similar studies,
admittedly, have not been performed. But it is reasonable to assume
that when such studies are performed that the results will be similar.
One would expect that physicians, who maintain education and
monitor their practice for clinical outcomes and patient response
will be better able to provide appropriate care.
The maintenance of certification programs have included areas
that are essential areas of residency training programs including:
•
•
•
•
•
•
Professionalism
Patient Care and Procedural Skills
Medical Knowledge
Practice-based Learning and Improvement
Interpersonal and Communications Skills
Systems-based Practice
These seem to be laudable and basic attributes in principle. But
because of the vocal responses from its membership, Dr. Richard
Baron of the American Board of Internal Medicine released a letter
in February indicating that the ABIM had listened and was suspending the “Practice Assessment, Patient Voice, and Patient Safety
requirements for at least two years.” Additionally he announced that
the examination was to be changed, ostensibly to improve the pass
rate, a reduction in fees, and greater flexibility in demonstration of
medical knowledge. He closed his letter saying: “It remains important for physicians to have publicly recognizable ways—designed
by internists—to demonstrate their knowledge of medicine and
its practice.” With that statement Dr. Baron recognized both the
obligation to demonstrate competencies to the public/our patients
and to have a process driven by physicians.
The question now before us should not be whether maintenance
(continued on page 22)