Challenges in Mounting Examinations Used for Maintenance of Certification

• In Event: Maintaining Certification: Issues, Challenges, and Potential Solutions

Abstract

In the 1970s, a small number of member boards in the American Board of Medical Specialties (ABMS) began to issue certificates that expired in six to ten years duration. As of 2006, all 24 ABMS member boards had switched from issuing lifetime certificates to time-limited certificates, requiring their diplomates to pass periodic (typically every 10 years) secure examinations to maintain certification. In the past few years, dissatisfaction with maintenance of certification (MOC) programs has grown, and increasing numbers of diplomates have called for another approach to MOC examinations (Hawkins et al, 2016)
There are a number of reasons behind the dissatisfaction, reflecting the challenges in mounting effective written examinations for MOC. First, the purpose of examinations used for MOC may not be entirely clear. While initial certifying examinations are intended to ensure that those taking it possess the requisite knowledge and skills for certification, some have argued that, once initial certification has been achieved, the purpose should shift from a summative assessment intended to identify those meriting certification to a formative assessment designed to assist certified doctors in staying up to date (Hawkins et al, 2017) – a shift from “assessment of learning” to “assessment for learning” (Schuwirth & van der Vleuten, 2011)
Second, it can be difficult to determine the knowledge and skills that should be assessed on an MOC exam. At the time of initial certification, candidates are “undifferentiated” – they have not yet determined the areas of specialty that they will emphasize in their practice. Over time, however, practices evolve, typically narrowing over the course of a career (Melnick et al, 200?). It is not clear if MOC exams should encompass the full breadth of the specialty assessed in the initial certifying exam or focus on kinds of patients on which that a diplomate encounters in their practice (Handfield-Jones et al, 2002). The former is logical from the standpoint of maintaining the “meaning” of the specialty certificate, but the latter may be more effective in improving patient care and protecting the public.
Third, ensuring the relevance of the test material to diplomates’ practice is difficult. Too often, test questions assess diplomates’ ability to recall isolated facts, rather than challenging them to apply their knowledge to realistically described patient care situations. The latter is more effective, both because it signals the relevance of the material to practice and because it should facilitate retention and transfer of the tested information to patient care.
Finally, a high-stakes examination taken every six to ten years may lack credibility for the credentialing community and the public. This is particularly true toward the end of career when cognitive declines are more likely to occur.
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Author

• David B. Swanson, American Board for Medical Specialities