Certification in Pediatric Hematology/Oncology
Maintenance of Certification Q&A
Questions Submitted to:
James A. Stockman, III, MD
President and CEO
American Board of Pediatrics (in 2008)
From: The American Society of Pediatric Hematology/Oncology
A: The design of the Maintenance of Certification (MOC) programs of all Member Boards of the American Board of Medical Specialties (ABMS) are intended, to the extent reasonable and possible, to reflect "real world" issues. There is increasing public demand to ensure that physicians maintain up-to-date medical expertise. The American Board of Internal Medicine Foundation, in their publication entitled: Medical Professionalism in the New Millennium, indicates that physicians’ professional responsibilities do include a lifelong commitment to maintaining expertise in clinical medical treatment. The Institute of Medicine (IOM) in its publication, To Err Is Human, challenges all medical professionals to make the healthcare system safer by periodically re-examining and relicensing providers “based on both competence and knowledge of safety practices.” The IOM report recommends that medical regulatory boards, such as state licensing boards, as well as the certifying boards, take a more proactive and involved approach to assessing practitioner competence. In responding to these challenges, the certifying boards have all drafted their MOC programs to reflect what these external forces are demanding. The method of doing this is the four-part MOC program that assesses six general competencies.
Q: If correct, can you elaborate on the four components and how they are intended to demonstrate "real world" expertise or competence?
A: Again, to the extent possible, the four components of the maintenance of certification program are structured to periodically assess the six general competencies that have been agreed upon across the "house of medicine" (medical knowledge, patient care, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice). These six competencies are assessed at the undergraduate level, during residency and fellowship training, and now at the postgraduate/practice level. A variety of specific assessment instruments have been elucidated for use at each of these levels in order to allow proper credentialing for these general
Q: Can you give us a brief history of how we have arrived at the four-component MOC?
A: The structure of MOC has a framework of four components:
- Part 1 – Professional standing
- Part 2 – Commitment to lifelong learning and involvement in periodic self assessment
- Part 3 – Cognitive expertise
- Part 4 – Evaluation of performance in practice
Embodied within these four components of MOC are various assessment instruments geared to provide an understanding of the six general competencies. Discussions about the design of a four-component maintenance of certification and the assessment instruments contained therein began more than 10 years ago at the ABMS level. All 24 boards of the ABMS now have virtually identical overall designs to their MOC programs, although the assessment instruments used do vary somewhat.
A: This query addresses whether the cognitive assessment (the closed-book examination, MOC Part 3) is more relevant than an open-book, proctored examination. It should be noted that Part 2 of MOC does include an open-book, non-proctored, series of self-assessments that do allow, in fact encourage, the use of books, articles, and on-line searches. The Part 3 component is a closed-book examination largely because of the requirement of testing centers that no resource materials be available for security reasons. To complicate matters, allowing ready access to resource materials would also make difficult the completion of the examination within a specified timeframe in a testing center. As is true of the initial certifying examination, the Subboard of Pediatric Hematology-Oncology is asked, when preparing test questions, to prepare these in a manner that is consistent with the examinee being able to answer the question without the use of resource materials. The type of questions utilized on the MOC examination reflect this same approach and scoring of the examination is adjusted to reflect the perceived difficulty of the questions that are included on the examination. Again, if one looks at the totality of the cognitive assessment (Parts 2 and 3 of MOC), the overall process does reflect the real world in the way one accesses and tests for knowledge. The reason why a secure examination is a requirement of MOC is discussed in response to the next question.
Q: Who makes decisions regarding issues such as the closed-book exam? Is it the ABP or a higher authority?
A: The requirement for a closed-book examination is one that is required by the ABMS of its 24 Member Boards. This is
in response to public comment and input and the reasonable expectation on the latter’s part that physicians should
periodically demonstrate their knowledge of a discipline by taking such an examination. Although many providers do
not perceive this public interest in the assessment of physician competence, including that related to the passage
of a secure examination, there are many examples of this, including recent discussions that have occurred within the
Federation of State Medical Boards (FSMB). The FSMB has recently received a report from its Maintenance of
Licensure Committee that outlines the competencies that should be expected of all licensed physicians here in the
United States. The report outlines clear definitions of what these competencies and included are the six general
competencies mentioned above. The report indicates that as part of relicensing, all physicians should be held to a
periodic assessment of these competencies, including the passage of a secure written examination every 10 years.
This report is likely to be forwarded soon to the individual state licensing bodies for potential implementation.
Here in North Carolina, the North Carolina Medical Board has already received clearance from the state legislature
to enact a much more rigorous relicensing set of policies consistent with the report of the FSMB. The FSMB report
unequivocally states that physicians who are actively engaged in MOC programs of their respective boards will have
these requirements waived at the time of relicensing. Attached is the final report of the Maintenance of Licensure
Committee of the FSMB as well as the most recent news bulletin of the NC Medical Board. These are well worth
everyone’s reading since it is clear that the certifying boards are not the only entity pursuing a comprehensive
assessment of physician competency including the expectation that physicians should have their medical knowledge
assessed with a secure examination.
Q: Recertification is a very expensive process. Please inform us as to the reasons for such costs.
A: The recertification process is a detailed and comprehensive one, but when one considers the annualized cost versus
the potential benefits of being certified, the cost seems reasonable in light of the value of the certificate and
its contemporary relevance. Creating a valid certification and recertification process requires a rigorous approach
with methodologic and psychometric challenges. The initial certifying examination and the recertifying examinations
administered by the ABP are the third least expensive among the 24 certifying boards of the ABMS. The certifying
examinations of the ABP have risen at significantly less than inflation over the past 35 years, unlike all but two
other boards of the ABMS. The ABP remains committed to creating added value to the certificate holder in its
discussions with the state medical licensing boards, insurers, the Joint Commission and other credentialing bodies.
Q: Do the certifying bodies such as the ABP have an open dialogue about idealizing an MOC process with the physicians
they represent?
A: The mission of the ABP is directed to the public interest. The ABP certainly encourages open dialogue with its
diplomates about continuously improving our maintenance of certification programs. Currently, approximately 250
non-staff physicians serve on various committees of the ABP, many of these individuals on maintenance of
certification committees. These physicians come from highly diverse backgrounds. The ABP does include in its
policy and decision-making, public representatives as well. We encourage our subspecialty subboard members to
actively interact with societies around our MOC programs and encourage feedback to the ABP.
Q: There have been informal discussions among our members about whether Part 3 could be more focused on the
individual’s sub-subspecialty practice such as hematology versus oncology; although the vast majority of members
continue to desire combined H/O boards. Can you please comment on this possible approach?
A: This question addresses a very important topic. It is likely that over time, our MOC programs will increasingly
reflect, in their design, areas of focus within a particular subspecialty. Aspects of Part 2 and Part 4 of MOC
already do this to some extent. With respect to the cognitive assessment (the secure examination) thus far the
question mix reflects a comprehensive overview of each of the subspecialists, consistent with the name of the
certificate. Thus far, there has been no consistent view on the desirability of modifying the recertification
examination to differentiate hematologists and oncologists.
A: Individual physicians are encouraged to share their views with members of the Pediatric Hematology-Oncology Subboard, our Board of Directors, staff, and anyone else with respect to the MOC program, its design, and its current assessment instruments. It is only through such dialogue and interaction can we improve what we are doing and maximize the relevance of the process.