In this Letter to the Editor, Morie Gertz, MD, MACP, chair of the American Board of Internal Medicine’s (ABIM) Hematology Board, chair emeritus of the Department of Medicine at Mayo Clinic, and a member of the American Society of Hematology (ASH), responds to a letter written by Robert Brodsky, MD, 2023 ASH president and director of hematology at Johns Hopkins University.
Dr. Brodsky’s letter, written in September 2023, was addressed to Richard Baron, MD, MACP, president and chief executive officer of ABIM, and urged ABIM to significantly reform its Maintenance of Certification (MOC) program and Longitudinal Knowledge Assessment (LKA). The letter cited concerns raised by ASH members that the LKA doesn’t reflect real-life clinical practice or target an individual’s scope of practice and creates high levels of stress for the test-taker. Here, Dr. Gertz continues the conversation, directly addressing the assertions made by Dr. Brodsky and others in recent months.
Over the past year, there has been a high level of activity in social and print media criticizing the concept of the ABIM MOC program, with some in the hematology community calling for a return to lifetime certification, whereby a physician would only need to demonstrate their knowledge at the beginning of their career, with no objective way of knowing that they are keeping it current throughout their career. Some of the criticisms are pointed, particularly on social media channels, containing inaccuracies about the intent and structure of MOC and categorically rejecting all counterarguments. Last year, a letter from the president of ASH to its membership called for the elimination of high-stakes assessments and substituting mandatory reporting of continuing medical education (CME) activities. I would like to clarify my position on this issue by addressing the following points:
Self-Assessment, CME, and the Evidence for MOC
Many diplomates believe it is in their best interest to eliminate all forms of assessment and rely on self-directed CME. Of course, CME is not completely without value. There are many high-quality CME activities out there, but CME alone isn’t enough to assure we know what we need to know to deliver the most up-to-date medicine to our patients. As the Dunning-Kruger effect has shown, we are all unaware of our own blind spots; through ongoing standardized assessments they can be revealed, and the results can help guide our studies and address gaps in our knowledge. Some have also wondered — and rightfully so — whether there is evidence supporting programs like MOC. They suggest that physicians who maintain certification do not provide better care than those who do not. However, a substantial body of literature demonstrates superior outcomes for physicians who maintain certification.1
Physicians who are already skeptical of MOC tend to reject this research because it is sponsored by ABIM, so they consider it inherently biased. This occurs even when discordance between some of the questions and relevance to clinical practice is identified.2 I encourage any researchers to help us better understand the evidence supporting MOC or ways in which it could be improved. Yet, other than those at ABIM or supported by them, no one has taken on this kind of work. Moreover, we have no high-quality evidence that participation in CME as an alternative realizes better patient outcomes.
The Importance of Certification to Patients
As a certifying organization, ABIM is obligated to create a high standard for all physicians, with the understanding that not all will meet this bar. This is done in service to patients, who rely on board certification when choosing a physician, giving them confidence that the person they are trusting with their care is practicing medicine based on the latest research and evidence.
With the demonstrated improved outcomes in physicians who are board certified, we can do no less for our patients than to ensure that lifelong learning is occurring in physicians who carry certification. I suspect that most patients have some level of expectation that their providers are being tested on a regular basis from the time they complete training through retirement, which can span 35 to 40 years. Since my initial certification, nearly two-thirds of the information I initially learned is out of date.3 Patients are aware of the rapid growth of knowledge and expect that those of us who hold their lives in our hands be as thoroughly tested as an airline pilot. If my pilot boarded the plane and told me that he had never flown in that plane and had never been tested on a simulator but had read the airplane manual, I would be less than satisfied.
The Time Commitment to MOC
Much criticism has been made of the time commitment required to stay certified. In 2022, ABIM introduced the LKA, which was developed based on physician feedback. Each quarter, physicians participating in the LKA receive 30 questions, and data show that on average it takes about an hour to answer all of them, resulting in about four hours a year. I would argue this is the equivalent of two pre-certifications for a PET scan from an insurance company or three days of managing Epic InBasket notes. I believe that physician frustration at the lack of autonomy is being directed at ABIM because other external factors cannot be influenced.
The Time Limit on Assessment Questions
Others have raised concerns regarding the four-minute time limit for each LKA question. Because full access to internet searching is permitted, the time limit was added to be more reflective of a daily practice where 20 patients can be seen a day, and it would not be practical to look up every single question on the internet in the absence of significant basic knowledge. The time limit was also informed by analyzing the average amount of time needed to answer questions on similar exams, and extra time was added as a buffer. As previously noted, most questions are answered in about half the amount of time allotted, and physicians can also draw from an annual 30-minute time bank if they need extra time on a question.
Specialization Within the Discipline
Some have argued that they are single-disease specialists, whether in lymphoma or transplant or coagulation. While this is true, this does not represent most diplomates, who are largely community-based4 and are therefore responsible for consulting on any problem that is remotely hematologic and consequently need a broad knowledge base. Many societies and medical organizations are predominantly led by physicians from academic medical centers rather than community-based primary care systems. This gives an outsized voice to academicians whose practice does not reflect the community at large.4 Even single-disease specialists who frequently monitor fellows with general clinics do hospital rotations where they have no control over the nature of a hematologic patient admission or do a hematology consulting service, which requires a broad base of knowledge. Excepting a few ultra-specialists would negate the value that examinations produce for the entire community. Data suggest that examinations can be produced with appropriate content relevant for the practice.5
In addition to this, ABIM recently announced plans to launch tailored versions of the LKA in hematology in 2026, with a higher percentage of questions focused on malignant and classical hematology.6 This is in direct response to feedback and surveys within the discipline asking for assessments that more closely align with the practice of specialized physicians. ABIM is listening and working on solutions that benefit its diplomates.
The Cost of MOC
The cost of certification has also been questioned. However, the creation of a fair question requires management of hundreds of volunteer item-writers, medical editors, statisticians, and experienced clinicians to ensure that the questions are fair, unambiguous, and cover a relevant teaching point. This infrastructure has a cost, and I feel that $220 a year for a certificate (and $120 a year for each additional certificate) is reasonable, especially in comparison to many of the other things physicians are expected to pay for.
Additionally, physicians need to maintain certification only in the areas they are practicing. So if you’re primarily seeing patients with cancer, you should keep your Medical Oncology certificate. If you find value in keeping your Hematology certificate, I encourage you to maintain it as well.
Conclusion
It has been suggested that knowledge gained in preparation for assessments is promptly lost, but the data suggest otherwise.7 Peter Drucker, a pioneer in the field of quality improvement, has been quoted as saying, “If you cannot measure it, you cannot improve it.” Our assessments can always be improved and remain a work in progress. However, to suggest that they should be abandoned because of deficiencies serves neither physicians nor the patients we are pledged to protect.
References
- Gray B, Vandergrift J, Landon B, et al. Associations between American Board of Internal Medicine Maintenance of Certification status and performance on a set of healthcare effectiveness data and information set (HEDIS) process measures. Ann Intern Med. 2018;169(2):97-105.
- Gray B, Vandergrift J, Lipner RS, et al. Comparison of content on the American Board of Internal Medicine Maintenance of Certification examination with conditions seen in practice by general internists. JAMA. 2017;317(22):2317-2324.
- Hawkins RE, Welcher CM, Stagg Elliott V, et al. Ensuring competent care by senior physicians. J Contin Educ Health Prof. 2016;36(3):226-231.
- Jones AT, Barnhart BJ, Durning SJ, et al. The association of changing practice settings on Maintenance of Certification exam outcomes: a comparative study of general internists over time. Acad Med. 2018;93(5):756-762.
- Dai M, Hagen M, Eden AR, et al. Physician opinions about American Board of Family Medicine self-assessment modules (2006-2016). J Am Board Fam Med. 2019;32(1):79-88.
- Gertz M. ABIM Blog. ABIM to develop malignant and classical (nonmalignant) versions of hematology assessments. March 14, 2024. Accessed May 21, 2024. https://blog.abim.org/abim-to-develop-malignant-and-classical-nonmalignant-versions-of-hematology-assessments/.
- Chesluk B, Gray B, Eden A, et al. “That was pretty powerful”: a qualitative study of what physicians learn when preparing for their Maintenance-of-Certification exams. J Gen Intern Med. 2019;34(9):1790-1796.
For over two decades, ASH has worked with ABIM on the MOC program. ASH advocates for lifelong learning via a program that is evidence-based, transparent, and relevant to one’s practice. ASH supports education and formative tests to identify gaps in knowledge. ASH’s advocacy has brought changes to MOC, but more work is needed, as stated in ASH’s letter to ABIM in September 2023. Read the letter and learn what else ASH has been doing at hematology.org/moc.
The content of the Letter to the Editor is the opinion of the author and does not represent the official position of the American Society of Hematology unless so stated.
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