Regarding the board examinations, I was honored by and remember well my stints with the ABIM from 1990 to 1998, writing and evaluating questions for the rheumatology and then internal medicine certification examinations. It was well understood that a written examination was no substitute for practical performance. Members still sitting on the committees when I began my service described how graduation from a “good program” (i.e., one that is well established and with a respected mentor who would vouch for the candidate) would carry substantial weight. Still, there was always concern about objectivity and fairness. For example, the nature of the “curve” then used was of concern: A candidate might fail in a year when all the others were exceptional, but pass in another year when the competition was not so great. We, therefore, proceeded to subject each question on the existing exam, as well as every new question that was proposed, to an analysis to determine a fair pass–fail grade on its own merit.
The early discussions about and planning for maintenance of certification (MOC) occurred in the 1990s. The intention at the time was simply to document that the board-certified rheumatologist had been paying attention to and understood advances in the field and how to apply them. Allowance was to be made for those primarily engaged in research and those in clinical practice. It was assumed that the vast majority would easily pass the knowledge part and that only a few outliers and the few who exhibited a significant deficiency in the practical practice questions would fail. An example of a critical question might be one that included the possibility of choosing a dangerous combination of drugs. The exam would require evidence of ongoing study over the years between certifications, but would not be so demanding that it would be distractive.
The Evolution
Obviously, the recertification examinations have undergone an unfortunate and counterproductive evolution. I was at dinner recently with two excellent practitioners who had recently been subjected to (that is had taken) the examination. They described just how stressful it had been.
One stated that it was going to be her last examination; she would retire in 10 years rather than go through the recertification process once again. What a loss that would be!
The other added how demeaning and pejorative it felt just to enter the exam room: “It was more difficult than to go through airport screening; I almost thought I was going to have to be strip-searched!”