Everyone hates exams. Most of us hate regulations. But, exams and regulations in medicine came about because of abuses in the past that led to the public distrusting doctors. It’s a fascinating, and somewhat terrifying history that starts with changing “medical schools” from for profit (and horrible!) businesses into what we know today. As general doctors started doing ophthalmology, surgery, or obstetrics full time, it was became clear that defining what constituted a specialty, and demonstrating that practitioners were competent was important.
What does it mean to be “board certified”?
Being “board certified” means that one of the 24 specialty boards in the United States attests that you have met all the requirements and have passed rigorous exams to show that you are qualified to practice in that specialty.
Does the board certification last forever?
Short answer, no. Family Medicine was the first specialty (in 1970) to realize that initial certification was not enough. As the public continued to ask for evidence that physicians remained up to date, Surgery (1976), Emergency Medicine (1980) and Ob/Gyn (1986) added a recertification examination. As of 1990, the remaining boards became “time-limited” which means board certification expires after 6-10 years, unless physicians take and pass the recertification examination. So, many internists who are now in their 60s and 70s didn’t have to do anything other than pass the initial examinations. (This is referred to as being “grandfathered”).
Who makes up “the board” for the specialties?
The members of most boards are volunteer physicians in the specialty. In surgery, which I know the best, the board members are called “directors”. There are 41 directors of the American Board of Surgery who represent a variety of organizations and specialties in surgery. These volunteer surgeons spend 20+ days a year away from their practices with no pay (although their expenses are paid) to give the oral examinations in surgery, and to design and validate the written examinations. They also have a variety of committees and projects which focused on one critical question: “What do we need to do to make sure we maintain the public trust in surgeons?”
How do the specialty boards decide if specialists are up to date?
Since 1990, boards have to be “maintained”. If you don’t maintain your board, you lose it. Hence the term, Maintenance of Certification (MOC). So what do you have to do for “MOC”? In addition to having a license, most boards have requirements to document hospital privileges and provide letters of reference. Here’s a summary of the other requirements for four of the largest boards:
| Continuing Medical Education (CME) | Recertification examination | Practice Assessment | Cost | |
| Internal Medicine | Must do some CME every 2 years.
Must get 100 MOC points every 5 yrs. (roughly 20-25 hrs/yr) |
Recertification examination every 10 years (counts as 20 hrs MOC points) | Nothing required.
Can earn MOC points by QI or by teaching. |
$1940 ($194/yr) for General Medicine.
$2560 ($256/yr) for specialties. |
| Ob/Gyn | Read at least 30 of the 45 articles provided by the board annually and answer four questions/article (=25hrs CME credit) | Exam every 6 years but may be exempt if excellence demonstrated by answers to articles. (pilot program) | Completion of ABOG practice improvement modules
QI projects Presentations/publications |
$265/year.
Additional fee of $175 if exam is required. |
| Pediatrics | 100 MOC points/5yrs. At least 40 in CME, 40 in practice assessment
“Question of the week” delivered by email. 20 questions = 10 MOC pts. |
Recertification examination every 10 years (counts as 60 hrs of CME) | Institutional or practice QI projects | $1300/5yrs ($260/yr) |
| Surgery | 90 hrs in 3 yrs. (30 hrs/yr) of CME (lectures or online)
60 hrs (20/yr) have to be Level 1(test questions involved) |
Recertification examination every 10 years (counts as 60 hrs of CME) | Participation in an outcome or quality improvement program | $1600 ($160/yr) |
What happens if doctors decide to not do MOC?
Being board certified is voluntary and so is maintaining a board. But, if doctors choose not to do MOC, they will lose their board certification.
Here’s some of the possible implications if a doctor loses board certification:
- Hospital bylaws almost universally require staff members to be board certified. These bylaws will have to be rewritten for doctors who have lost their boards in order for them to work in these institutions.
- The ACGME requires that faculty that teach residents are board certified.
- The American College of Surgeons requires that all doctors are board certified who work in ACS accredited Trauma Centers or Children’s Surgery Centers. .
- The American Academy of Pediatrics requires that all doctors in the NICU are board certified in order for the NICU to be verified prior to accreditation.
My bottom line on MOC
Since the new MOC requirements went into place I have increased both the quantity and quality of the materials I use to stay up to date, which I strongly feel has made me a better surgeon. I still don’t like taking exams, but every time I do (I have three boards, so I take a lot of them!) I learn so much that I find the experience invaluable. (Yes, that’s after the exam, not before or during… that hasn’t changed since medical school.)
MOC isn’t perfect, but it’s evolving, and the reason it exists is a good one. Passing laws state by state to make MOC “optional” has the risk of hurting the public’s trust in physicians – and the risk of creating quite a bit of chaos for hospitals, training programs, and others. For what? Saving $200 a year? Not having to take the test every 10 years? Not having to log the CME that is required by almost all state medical boards?
“Here’s what’s at stake: we physicians are granted an extraordinary amount of autonomy by the public and the government. We ask people to disrobe in our presence; we prescribe medications that can kill; we perform procedures that would be labeled as assault if done by the non-credentialed. If we prove ourselves incapable of self-governance, we are violating this trust, and society will – and should – step into the breach with standards and regulations that will be more onerous, more politically driven, and less informed by science. That is the road we may be headed down. It is why this fight matters.” Robert Wachter, MD