Maintenance of Certification, or MOC, has been discussed quite a bit recently in the American College of Surgeons General Surgery Community, was the topic for a JAMA Tweetchat earlier today (which I unfortunately couldn’t attend due to other obligations), and was the topic of a NY Times opinion piece on Monday. For those who aren’t familiar with the concept, the idea of MOC is that the knowledge base in medicine is expanding exponentially, making the idea of time-unlimited specialty certification a bit of an albatross. We all take our certification exams near the time when we finish our residency training; I’ve been out of my general surgery training a “mere” 10 years, I don’t practice true general surgery, and I assure you there were plenty of things I had to brush up on (and learn de novo) when I took my general surgery MOC exam last year. When I took my MOC exam in critical care a couple of months ago, it required less preparation since much of it involved things I do every day. Nevertheless, I found myself a bit put-off when I was asked to hand calculate a value for a patient; in the real world, I pull out my iPhone, drop in the appropriate numbers in my medical calculator app, and voila!- free water deficit calculated.
While MOC has been mandated by the American Board of Medical Specialties (ABMS), the component specialty boards of the ABMS have been given a great deal of latitude in what implementation of MOC looks like. Done well, MOC will provide a foundation for us to provide better patient care in our day-to-day practice. Done poorly, MOC turns into nothing short of an onerous and irrelevant box-checking exercise. A common complaint lodged against the certification process, and MOC in particular, is that the system is being developed and delivered by individuals who are not in active practice; while this may be true for some specialties, I am grateful that surgery seems to be a marked exception. Not only are those who have developed and implemented MOC at the American Board of Surgery (ABS) still in active practice and themselves participate in MOC, there is also a commitment to refining the process to best serve surgeons and our patients (see D. Mahvi’s “Report from the Chair” on Page 2). Based upon Dr. Ofri’s Times editorial and this blog post describing shadowy financial practices by the American Board of Internal Medicine, my gratitude for the work of the American Board of Surgery’s work in this area is perhaps even greater.
Here are the basic struggles we are still faced with:
- One of our junior surgeons informally polled recent graduates of her residency program recently. They rated keeping up with the literature at an 8-9 level of difficulty on a 1-10 scale. How can we facilitate this process?
- We need to keep up, or we’re not capable of providing best care for our patients. But how do we best keep up in a way that enhances those patient outcomes? Can an MOC system be designed that results in improved outcomes?
- The system we have isn’t yet meeting us where we are in terms of the day-to-day delivery of clinical care. For example, in surgery there are aspects of MOC that relate to practice assessment. A closed-book MCQ exam? That’s nothing like the real-world. I commented the week after my critical care MOC exam that while I took the written at a testing center the week before, my ICU was giving me the practical exam on a daily basis.
- In a feature unique to surgery, how do we know that an individual’s technical skills are safe, both at the time of their initial certification, much less when they apply for recertification? How do we know that they are keeping up not just with the cognitive base, but also the technical base, to deliver quality surgical care?
Do I have a brilliant solution? Honestly, I don’t. I’m hopeful that the ABS will keep listening to those of us here in the trenches, and will keep refining the process. I’m also hopeful that someone in surgery will find a way to replicate the two studies cited in Ofri’s opinion piece, allowing us to see if MOC done differently can be done “better.” And most importantly, I’m hopeful that preparing for my general surgery MOC again in 9 years won’t be too onerous, especially if I remain committed to not taking out gallbladders.
Great post, great questions, Amalia.
Addressing your bullets, off the top of my head:
1) The greatest barrier to keeping up with literature is our closed-access publishing model, in my opinion. Move to an open-access model and the 8-9 level difficulty of keeping up with the lit will drop to 1-2. Our publishing model no longer serves to distribute science, but to impede it.
2) MOC and outcomes: EHR-based learning (earning CME while learning about the patients we actually see) is a good start. Archemedx and other learning architecture can link our practice, learning, and documentation. Proving outcome difference would take an experiment we haven’t designed or committed to, but Dr. Price Kerfoot talks about some related research here: https://www.youtube.com/watch?v=hnR5hmCtRR8
To improve outcomes, besides access to lit, we need access to best practices. Surgery needs a comprehensive, vetted, point-of-care resource (its own entire UpToDate) and it’s not under way as far as I know.
3 and 4) Practice assessment? Technical competence over the long haul? I have no idea, but agree that MCQ (I’d add oral exams) are poor proxies. Clearly we lack the resources to measure all we’d need to prove every surgeon is competent, even if we agreed on how to measure.
Till the resources and assessment techniques are available, I suspect we depend a great deal on the professionalism we learn in training and thereafter – on a culture which values competency, self-improvement, honesty, collegiality, and dedication to high standards for our patients. If we can’t prove to a certifying body that we’re all competent, we can at least foster a culture that strives forever for excellence.
Chris
[Musing on my MOC exam: http://onsurg.com/safe-surgeon/%5D
Chris, I’m so glad that you found this post- and that you put time into such a thoughtful reply.
I really believe that the ABS wants to make the process best for our life-long learning, and best for our patients. The challenge is in what that actually means. Your answers are some great beginnings!
I have been in practice for more than 30 years and I’m still working but less than before and I have to keep up with all the MOC requirements to keep up with the old and new surgical knowledge. I also have learned that SESAP is a great tool for all surgeon to take since it has helped me in my clinical practice and keeps my confidence going. I have taken the ABS recertification exam at least three times and in three more years I expect to take another exam. I wish the ABS would give a break to surgeons who are willing to take the fourth examination for seniors surgeons.
Moises, that is a really interesting idea. I know that one thought under consideration is for them to have the MOC exam more targeted to people’s actual practices, which I think would help all of us; I found preparation so hard last year for the General Surgery MOC since I haven’t taken general surgery call in 6 years!