Stop Debating Competence and Foster A Culture of Excellence

Before the news gets too cold, I’d like to point out two excellent articles on Maintenance of Certification (MOC) for the trainees. One of them is a cross-specialty national survey of physician attitudes toward MOC recently published in the October issue of Mayo Clinic Proceedings. The video below encapsulates the findings.

Along with that is a first person article by a doctor undergoing the board recertification examination. You really need to read both to get a clear idea of the history of MOC and the positions taken on it by the boards and rank and file doctors. The real issue for me is whether our profession chooses to settle for “competence” or pursues building a culture of excellence.

I take issue with Cook, et al when they claim “…evidence confirms that physicians cannot self-assess their learning needs.” I think I know pretty well when I need to check the medical literature when I encounter an issue in my field I need to know more about. My opinion about this is well known to all who know me and read my blog. I’ve even been pretty frank about with the American Board of Psychiatry and Neurology (ABPN). I think Part IV of MOC should be rescinded altogether although the ABPN recently notified me and one of the residents that our Delirium Clinical Module was finally approved for MOC credit. However, you’d have a pretty challenging time finding the link by trying to navigate from the ABPN home page URL.

Go ahead, I double dog dare you.

That’s why I’ve put a link to it on my own blog home page. And I suspect that the incentive for using it might be lukewarm now that the ABPN has changed the rules about the clinical module requirement. While they haven’t actually gotten rid of Part IV, they almost have. No one who doesn’t want to work on the PIP Clinical Module actually has to because they can substitute a Feedback Module. Most front line doctors don’t have time to fiddle with the PIP Clinical Modules on the ABPN MOC web site because so many of us are subspecialized it’s virtually impossible to find one which would be meaningful and worth taking time away from our practice for. That’s why we call the PIP Clinical Modules “busywork.” The Delirium Clinical Module is pertinent but why would anyone bother now?

The ABPN technically doesn’t violate the American Board of Medical Specialties (ABMS) insistence on retaining Part IV because Part IV itself remains intact. On the other hand, psychiatrists are probably getting a break from the burdensome and wasteful PIP Clinical Module because, while Part IV is not optional–the PIP Clinical Module is.

Furthermore, I think that our own Clinical Problems in Consultation Psychiatry (CPCP) and our new Psychosomatic Medicine Interest Group (PMIG) case conferences are better ways to implement the principle of lifelong learning than the MOC Part IV or so-called clinical modules. The trainees do excellent work in both. In my opinion, fostering the pursuit of excellence is far more important than settling for competence, which the MOC does a poor job of supporting in any case.

The Cook, et al paper and Dr. Ofri’s piece send fundamentally the same message, which is that the MOC processes are too flawed to accomplish what the boards claim they do–support the principle of lifelong learning. I agree that rank and file physicians and boards would do well to stop the endless debate about the pros and cons of the present form of MOC, agree to scrap the low bar of “competence” and start earnest and honest collaboration on how to support the efforts of doctors in their worthwhile though unsung search for a culture of clinical excellence.


Cook, D. A., et al. (2016). “Physician Attitudes About Maintenance of Certification: A Cross-Specialty National Survey.” Mayo Clin Proc 91(10): 1336-1345.
OBJECTIVES: To determine physicians’ perceptions of current maintenance of certification (MOC) activities and to explore how perceptions vary across specialties, practice characteristics, and physician characteristics, including burnout. PATIENTS AND METHODS: We conducted an Internet and paper survey among a national cross-specialty random sample of licensed US physicians from September 23, 2015, through April 18, 2016. The questionnaire included 13 MOC items, 2 burnout items, and demographic variables. RESULTS: Of 4583 potential respondents, we received 988 responses (response rate 21.6%) closely reflecting the distribution of US physician specialties. Twenty-four percent of physicians (200 of 842) agreed that MOC activities are relevant to their patients, and 15% (122 of 824) felt they are worth the time and effort. Although 27% (223 of 834) perceived adequate support for MOC activities, only 12% (101 of 832) perceived that they are well-integrated in their daily routine and 81% (673 of 835) believed they are a burden. Nine percent (76 of 834) believed that patients care about their MOC status. Forty percent or fewer agreed that various MOC activities contribute to their professional development. Attitudes varied statistically significantly (P<.001) across specialties, but reflected low perceived relevance and value in nearly all specialties. Thirty-eight percent of respondents met criteria for being burned out. We found no association of attitudes toward MOC with burnout, certification status, practice size, rural or urban practice location, compensation model, or time since completion of training. CONCLUSION: Dissatisfaction with current MOC programs is pervasive and not localized to specific sectors or specialties. Unresolved negative perceptions will impede optimal physician engagement in MOC.

4 thoughts on “Stop Debating Competence and Foster A Culture of Excellence

  1. Jim,

    Agree completely.

    Any of us around from “back in the day” can attest to high quality medical care and teaching. It was focused on academics and not appeasing case managers and billing and coding experts. The guidance came from experienced expert physicians and not business managers.

    The highest quality of medicine in teaching that I ever experienced was right up to the day I graduated from Medical School. I did two consults on the service and finished up at 10 PM.

    That was a Nephrology service in Froedert Hospital in Milwaukee in 1982.

    All of the testing and “standards” since are like Trivial Pursuit” by comparison.


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