Having served on the Continuing Board Certification: Vision for the Future Commission, I am well aware of the criticism surrounding Maintenance of Certification (MOC)—it's not relevant, costly, duplicative, to name a few. But the commission, as well as the multiple individuals and organizations (eg, professional and state societies, state licensing boards, Federation of State Medical Boards) that presented data and opinions to the commission, uniformly endorsed initial certification as valuable and necessary. The public members on the commission were particularly adamant about the necessity for initial certification.
In this issue of the Journal of Graduate Medical Education, Reisdorff and colleagues report the results of a survey administered to American Board of Emergency Medicine (ABEM) applicants at some point during the Oral Certifying Exam (OCE).1 The survey is open to several methodologic criticisms, particularly the influence of test anxiety and test result uncertainty. It is of interest that in recent years medical students have questioned the validity and value of components of the licensing process, particularly the United States Medical Licensing Examination (USMLE) Clinical Skills Examination and the use of USMLE Part 1 scores in the selection process for internship interviews. How do we address the questions and criticisms about uniform examinations that all medical students and residency/fellowship graduates must take? Is opposition to such examinations a result of an effort to minimize the stress of medical school and residency?
I think that key discussions about such examinations revolve around professional responsibility and self-regulation. It is incumbent upon the medical community to acknowledge that we assume the responsibility for assuring the competence of physicians; we also celebrate what we uniquely bring to health care and patient well-being. Without scope and rigor, how do we distinguish ourselves from our physician assistant and nurse practitioner colleagues? It is important that we do not dilute the rigor of our training and assessment in an effort to minimize stress and burnout. How can we achieve meaningful assessment in a way that fosters both learning and self-improvement?
While considering the question of initial certification, I also viewed this article through the lens of a reviewer, and additional queries and observations came to mind. In the introduction, the authors mention discontent with continuing certification, but it is critical that the issues of initial certification and continuing certification not be confused. Even with continuing certification, satisfaction and dissatisfaction vary significantly between different disciplines; it would be inaccurate to suggest universal discontent. In fact, ABEM diplomates have a very high level of satisfaction with their board's continuing certification process and comment that the process reinforces or augments knowledge and provides career benefits.2,3
As I noted above, giving a survey during a very high-stakes exam (before one knows its results) is problematic. There was a high rate of participation (78%) in the survey. How long did the survey take? Despite reassurance, could the test takers have had concerns that ABEM could know who had or had not completed the survey?
Was there a difference between the May and October respondents? Why do some applicants take the May exam and others the October exam? Presumably, everyone would have already taken and passed the written exam to be eligible for the OCE. What was the time interval between the oral and written exams? Were all respondents first-time examinees? What are the pass rates for US medical school graduates on these exams?
An OCE is very stressful. As the liaison for the American Board of Pediatrics, I served on the ABEM Board of Directors when there were still liaisons between ABEM and other certifying boards. The ABEM OCE made an effort to recreate the atmosphere of a busy emergency department, itself a high-stress environment. I even felt stressed as an observer! The value of the certification process may be diminished by the stress of the exam. It would be valuable to do a similar survey for the written exam. It's possible that applicants had completed their studying before the written exam, thus, studying for the OCE was duplicative. This might explain the comments from some respondents of not deriving any benefit from preparing for and taking the OCE. Could the amount of preparation for either the written or oral exam have been influenced by the performance on the In-Training Examination (ITE)? Is it possible that those who spent more money preparing for the exam had been advised by their program directors that they might not pass the boards, based on their ITE scores, or that they didn't pass the written exam the first time and had spent more time and money preparing for the second go around?
In their conclusion, the authors note, “Initial certification requires a considerable investment of time and money.” Most importantly, initial certification requires the successful completion of an Accreditation Council for Graduate Medical Education accredited residency. The certification process is the final step in the educational experience, not only for the diplomate's learning, but also for evaluating their educational experiences.
The authors note that the value of initial certification remains undetermined. To whom? And what is meant by “value?” Most medical and public organizations firmly believe that the health of the nation is influenced by having well-trained and well-prepared physicians, and that the certification process assures the public that competence has been achieved.
The public has become a more active and vocal voice in expecting initial certification and continuing certification of all physicians. There is strong evidence that physicians are not good at self-assessing their knowledge and skills.4 The public is also cynical about physicians complaining about the cost of the process. Most physician salaries are substantial, although medical student debt is also substantial. The role of medical student debt in resident dissatisfaction with certification might be a fruitful area for future research.
I am surprised by how underinformed residents are about board certification, in regard to public expectations and insurers and hospital credentialing committee requirements. It would seem appropriate for program directors (and maybe the boards) to educate residents more effectively on the role of certification in their professional lives and as part of their professional obligations.
On the other hand, there certainly are opposing views in the medical community about requiring MOC. In fact, some states have developed legislation restricting medical licensing boards (15 states), insurers (7 states), and hospitals (6 states) from requiring physicians to participate in continuing certification. There has been discontent among physicians with lifetime certificates about participation in MOC.
What are the next steps to address the survey findings while acknowledging its limitations? First, residents appear underinformed about the importance of board certification for their professional futures. In my experience, it is not uncommon for residents to confuse their certifying board with their professional society. Residents need to know that the public has access to information about their board status. Maybe emergency medicine physicians do not need to woo the public, since patients coming to an emergency department do not get to choose their physician. But it is quite different for many specialties in which health plans proudly announce that their physicians are all board certified. Residents also need to know about the relationship between medical liability and certification status.
Despite the survey findings, I doubt that few residents would opt not to take their initial certifying exams. Emergency medicine has become a highly competitive field, and it is hard to imagine that such a competitive group of individuals would choose not to continue to prove their competence.
