Maintenance of Certification: Comment

We read with great interest the editorial “Maintenance of Certification: Has MOC Gone Amok?” by Nelson and Butterworth, which was published in the October 2018 issue of Anesthesiology, commenting on our recent publication examining the relationship between participation and performance in the Maintenance of Certification in Anesthesiology program and medical license actions against anesthesiologists.¹  As evidenced by this and several other publications,^2–6  the American Board of Anesthesiology (Raleigh, North Carolina) is committed to a rigorous and transparent evaluation of Maintenance of Certification in Anesthesiology.

The carefully crafted title asks a rhetorical question using the hyperbolic word “amok,” effectively calling into question the purpose and vision of Maintenance of Certification in Anesthesiology. We take seriously and welcome this conversation within the anesthesiology community. Although a full discussion on the purpose and vision of Maintenance of Certification in Anesthesiology is beyond the scope of a letter to the editor, we will address this issue succinctly at the conclusion of this letter.

We first comment on two general areas addressed by the editorial. The authors view the publication as “research to determine whether Maintenance of Certification in Anesthesiology 2.0 is fulfilling its promise.” However, our research included only diplomates certified between 1994 and 2005 and followed them through their first 10 yr of certification, which was between 2004 and 2015, depending on the year in which the diplomates were initially certified. Maintenance of Certification in Anesthesiology 2.0 did not launch until 2016, so the results and conclusions of our study reflect diplomates’ participation (or nonparticipation) in the original Maintenance of Certification in Anesthesiology program not the redesigned program (Maintenance of Certification in Anesthesiology 2.0). Thus, the premise of the editorial is not valid; the publication does not at all evaluate Maintenance of Certification in Anesthesiology 2.0, but rather the original Maintenance of Certification in Anesthesiology program (“Maintenance of Certification in Anesthesiology 1.0”).

The authors also argue that mandating any type of learning experience violates tenets of adult learning theory, and that certifying boards should consider reverting to a recertification approach in which only a periodic high-stakes examination is administered. Their argument implies that Maintenance of Certification in Anesthesiology or its equivalent should serve solely as a credential, rather than a learning opportunity. Our findings provide support for the utility of the original Maintenance of Certification in Anesthesiology program (“Maintenance of Certification in Anesthesiology 1.0”) as a credential, as those who completed their requirements in a timely manner were at lower risk for license actions.²  However, adult learning theory supports the concept that, if properly designed, Maintenance of Certification in Anesthesiology can also serve as a learning experience. As noted by the authors, adult learners want choices and “possess a deep need to be treated as capable of self-direction.” This concept underlies the requirement by state medical boards (and Maintenance of Certification in Anesthesiology) for continuing medical education—with specific learning opportunities chosen by the learner. A core element of the Maintenance of Certification in Anesthesiology 2.0 program is the Maintenance of Certification in Anesthesiology Minute longitudinal assessment, a web-based, lifelong learning platform that promotes and supports personalized knowledge acquisition, assessment, and demonstration of proficiencies. Based on concepts of adult learning theory, Maintenance of Certification in Anesthesiology Minute replaced the once-every-10-yr examination, and delivers questions that are mapped to the diplomate’s self-identified practice profiles. Before its introduction in 2016, we conducted a pilot study demonstrating that participation in the Maintenance of Certification in Anesthesiology Minute does in fact improve medical knowledge.³  This would support the fundamental concept that Maintenance of Certification in Anesthesiology activities can also serve as effective learning experiences for adult learners.

We believe that anesthesiologists are aligned with the purpose of Maintenance of Certification in Anesthesiology “to improve health and enhance outcomes,” although the strategies and tactics are, and should be, the subject of a community-wide discussion. Indeed, we recognized that to improve its value, Maintenance of Certification in Anesthesiology 1.0 needed to evolve based on principles of adult learning theory. Such concepts are at the heart of Maintenance of Certification in Anesthesiology 2.0, which assumes that learners are self-directed, internally motivated, and have a legacy of experiences that makes them different from the candidates applying for initial certification. Learning material must be relevant to their needs, which should be respected in all aspects of program design. Consideration of these needs is exemplified by our Maintenance of Certification in Anesthesiology Users Group, which is leading in the recalibration of Maintenance of Certification in Anesthesiology to a program that has even greater value to the diplomate.

We respectfully disagree that Maintenance of Certification in Anesthesiology has “gone amok,” and it is difficult to discern how any of the data presented in the editorialized paper can be used to support this contention. Nonetheless, we seek perspectives and feedback from our community regarding how certification can serve not just as a credential, but more importantly as a vehicle to help us as physicians continually improve our knowledge and the practice of our specialty.

Support for this study was provided by the American Board of Anesthesiology, Raleigh, North Carolina.

Dr. Cole has served as a director and president of the American Board of Anesthesiology (Raleigh, North Carolina), president of ABA-International, LLC (Raleigh, North Carolina), and director of the American Board of Medical Specialties (Chicago, Illinois). Dr. Culley has served as a director and secretary of the American Board of Anesthesiology, secretary of ABA-International, LLC, member of the Continuing Certification Committee of the American Board of Medical Specialties, ex officio member of the Anesthesiology RC at the Accreditation Council for Graduate Medical Education (Chicago, Illinois), and as an executive editor of Anesthesiology (Schaumburg, Illinois). Dr. Fahy has served as a directory and vice president of the American Board of Anesthesiology and vice president of ABA-International, LLC. Dr. Warner has served as a director of the American Board of Anesthesiology.