Another concern voiced by opponents of MOC is a requirement that a secure, written examination be completed without access to outside sources of information. This condition contradicts what most medical educators stress to trainees: When practicing their craft, they should take advantage of the best sources of information rather than rely entirely on their memory. Is there any benefit to writing these exams at this stage of a physician’s career? Will it make me a better doctor? Some authors have questioned whether examination scores serve as surrogate markers rather than measures that define true clinical competency. Medicine is replete with surrogate markers that may correlate well with a particular outcome, but may not be truly causal.5
The logical belief that the current MOC process will improve a physician’s knowledge &, hence, performance, has yet to be confirmed in randomized trials.
Perhaps the most annoying aspect of the MOC is the need for a “secure” test environment. Frankly, this policy is insulting and demeaning to applicants whose identity must be confirmed by digital fingerprinting or by palm-vein recognition technology. We can board airplanes or tour the White House with far less scrutiny. Watches, wallets, pens, pencils are verboten, and only “essential medical items (e.g., nitroglycerin, asthma inhalers, diabetic supplies) may be brought into the testing room with prior approval of the ABIM.”6
The National Board of Medical Examiners (NBME) went even further. In 2007, it denied extra time breaks to a medical student, Sophie Currier, who was breastfeeding her 4-month-old daughter, stating that lactation was not covered under the Americans with Disabilities Act.7 What were they thinking? Did this exam happen to include a section on ethics and professionalism? Although the NBME initially prevailed, five years later, the Supreme Judicial Court of Massachusetts overruled the lower court decision and sided with Dr. Currier, enshrining the right of future test takers to be allotted extra time to breastfeed.
The most striking aspect in the debate over the MOC is the lack of evidence to support its current iteration. Although nonrandomized data suggest an association between initial board certification and improved clinical performance, little or no data exist demonstrating improved outcomes of care related to recertification. The logical belief that the current MOC process will improve a physician’s knowledge and, hence, performance, has yet to be confirmed in randomized trials.5
However, this has not prevented the various boards from assuming that this statement is correct. It is puzzling that this hypothesis has not been studied more vigorously. There are currently several hundred thousand participants who have completed MOC, and with an estimated 50,000 new participants each year, it would not be hard to analyze the effect of recertification on physician performance. Surely, funding to support large, randomized trials should be readily available. After all, in 2012, ABIM revenue totaled $49 million, with 62% of this income derived from certification fees and 36% from MOC fees.4
The Illusion of Validity
Psychologist Daniel Kahneman, PhD, spent much of his career rooting out characteristic flaws in human thinking. For example, he coined the term, the illusion of validity, to describe how we often reach conclusions based on false assumptions. His first recollection of this error occurred decades earlier in his life, when he served as a young Israeli Army officer. In an effort to identify recruits who demonstrated exceptional leadership skills, he served on a team of observers whose task was to witness a series of team-building exercises performed by soldiers. As Dr. Kahneman recalled:
