Over the past decade and a half, there has been considerable attention given to the utility of Maintenance of Certification (MOC) examinations in order to remain board-certified for many specialties.  As a de novo approach, the impetus was to serve as a better means to keep physicians current with the rapidity of changes occurring in any given specialty.  Ongoing scrutiny regarding the correlation between the MOC, as well as other requisite lifelong learning curricula to support the 10-year re-examination cycle, remain under the magnifying glass as to how efficacious they really are. 

The most recent JAMA articles JAMA. 2014; 312(22):2348-2357. doi:10.1001/jama.2014.12716; JAMA. 2014; 312(22):2358-2363. doi:10.1001/jama.2014.13992 acknowledge that there is no definitive data correlating MOC to improving physician core competencies or to assure that procedural skills are up to snuff.  The advice of the authors does call for a collective effort in supporting the ongoing development of the examination and better means to measure its success.  Interestingly, other than peer review processes and category I & II CME, board certification is the essential mandate for many credentialing committees to grant physicians staff privileges.  With board certification in place and without any notable time gaps from active practice, staff privileges often get rubber-stamped.  However, it is not uncommon for certain credentialed procedures to remain on a provider’s list that may not have been performed in years. 

Circumstances can go unaddressed for multiple credentialing cycles and span board recertification as well.  There is really no other methodology to support current competencies, technical skills or current funds of knowledge associated with those skills other than self-governance or peer review processes, which do not necessarily account for current competencies any better than written recertification exams.  There really should be insight as to how to incorporate a more proactive, hands-on, tailored role-playing methodology to help the MOC evolve.  The practice of medicine today and seemingly even more so in the future will be heavily reliant on team integration, refinement of procedural skills, clinical decision processes and techniques with the need to bring it all together efficiently and safely.

Case-based learning introduced in medical schools over the years was an early attempt to address the awareness that didactics and exams alone did not serve well enough when transitioning to third- and fourth-year clinical rotations.  Certainly, entirely swapping out traditional basic medical science didactics for hands-on or group sharing is not the answer.  However, in medical school and residency, the combination of both, when done well, makes a real difference for most of us.  As the years go by, we may see ourselves regressing back to a similar position as a med student or resident physician, where licensing exams and board certifications must be passed in order to have a career. 

It does not make sense that essentially the exact same or parallel process would be the expectation every decade in order to avoid our careers from ending.  There are several other means to test and assure that essential competencies are in place and specific to the provider taking the test.  The MOC exam might benefit from being right sized to the scope of practice not just to the specialty itself and the ocean of knowledge attached to it.  Just because you can’t make the throw from shortstop to first anymore doesn’t mean you can’t play second base.

There are and will be even more physicians with years of experience and thousands of clinical encounters who should be able to practice medicine without being excluded solely based on a written MOC exam.  To not make necessary changes to the process, but most importantly realistic changes, is terribly myopic.  It completely negates the value of years in practice and diligence to clinical excellence that so many physicians have incorporated into their careers and can continue to offer to their patients.  As there is a call for ideas and direction of how to make the MOC process more relevant there seems to be a few possible areas that might be considered and integrated during the 10-year recertification cycle.  The JAMA article “Certifying the Good Physician: A  Work in Progress” states that, “The findings in this study provide a reminder that health care today has become team-based. Many clinicians are involved in delivering routine care, and how well those clinicians integrate their efforts is the dominant determinant of patient outcomes, safety, and efficiency.” 

Most emergency physicians, given the option of taking a written MOC exam vs. an oral exam, choose the former.  There may be something to this, where practically all comers, if given the choice, elect to sit for a written exam.  Nevertheless, oral boards are more in keeping with the practice of medicine, which today is well supported by the rapid development of simulation training in multiple medical specialties, as well as in other unrelated professions, including aviation, engineering, business and finance.  Furthermore, there is also a limited amount of MOC-CME and testing on bad outcomes.  Considering a greater, but not a predominant focus on testing on potential pitfalls of key malpractice cases, may seem counter intuitive in recertification, but it may be a nugget to drill down on and that, too, can be incorporated into MOC simulation training - oral examinations.  The aviation industry utilizes this as a key focus in remaining competent. Years of experience in practice are invaluable and are true intangibles that are challenging to measure from a written MOC exam.

The JAMA articles noted there to be no support that the quality of care was any different from those who were grandfathered from taking the MOC, in comparison to those who have to recertify.  It is current fact that many graduate physician training programs do not provide enough cases for those completing their programs.  Their practices thereafter are not likely going to make up for this, nor should they be expected to.  Recognizing that simulation training is of value in medical residencies may also be considered for the evolution of MOC exams as a more relevant and directly measurable piece of the testing process.  Simulation training can incorporate clinical decision process, use of resources and team integration.  It is not and does not have to be exclusively procedure focused.

Therefore, the MOC process, if it were to implement simulation with an oral board or interactive component, may be better aligned to help keep all of us in scope and competent in more measurable ways.

Physicians with opinions and experience should offer them as a proactive way to grow the MOC process. The recertification process should evolve from physicians for physicians.


Lukas Kolm, MD, MPH

Please send your comments or questions to president@nhms.org or post a comment below.


Time limited certification must be reinstated. The use of time limits is extortion by the ABMS to conscript physicians into there COMPLETELY unproven corporate income program. It is time to openly REJECT ABMS programming. Physicians are adults able to choose on the open market the educational programs that meet THEIR needs. Everyone should read on www.changeboardrecert.com or other articles demonstrating the nonsense of MOC: Maintenance of certification and licensure: regulatory capture of medicine. Kempen PM. Anesth Analg. 2014 Jun;118(6):1378-86. doi: 10.1213/ANE.0000000000000061. PMID: 24842183 MOC must go: one physician's viewpoint. A critic of Maintenance of Certification explains why the costly program burdens physicians. Kempen PM. Med Econ. 2014 Jan 25;91(2):49-50, 52, 55. No abstract available. PMID: 25211958 Corporate interests necessitate conflict of interest declarations by all authors. Kempen PM. Anesthesiology. 2014 Aug;121(2):431-2. doi: 10.1097/ALN.0000000000000326. PMID: 25050506

just started my second "MOC experience" in ophthalmology. I just re-certified in 2010. It is a useless exercise in busy work with NO ADDED VALUE to me, my board and the patients that I serve. It does, however, generate $2000 for the ABO and all they provide is a computer program and computer generated PORT exams and then a proctored DOCK exam. There is a 1% failure rate. This is a fabulous cash cow for the ABO that provides, again, NO ADDED VALUE to anyone other than the ABO. I complain a lot about the "noise" in medicine and the waste and the endless committees of futility but I DO have an answer to the MOC. I recently participated in the New Hampshire Marine Boating Course and test to be able to operate a motor boat in New Hampshire. I got access to a well conceived, well thought out, well constructed interactive computer course in boater education. I took and passed section exams online before continuing the instruction. I sat for and passed a well constructed proctored written exam and did it for I believe about $35. To my mind, this is the best model I have seen. The difference is that there WAS VALUE ADDED in this boating course! This MOC "junk" (edited by NHMS staff) needs to be simplified, made relevant and made cheaper or made extinct and be shown for what it really is, extortion perpetrated on doctors by their own boards for a near meaningless sheet of paper demonstrating Board Maintenance. Follow the money.