I recently took the American Board of Surgery MOC exam. This will make the third time in my career that I have recertified in General Surgery and I am more convinced than ever that there must be a better way. Taking a three-hour exam every 10 years is a poor way to assess my competence as a surgeon, and given the type of questions I saw on the exam, it doesn’t even seem a good way to evaluate my basic knowledge of my craft. To be fair, most of the questions had some basic clinical relevance. All too often the wording of the question seemed designed to trip the examinee up, or mislead one into a false assumption. Then there were the questions that had little or no relevance to my actual practice. It is necessary that I know the appropriate chemotherapy regimen for a premenopausal woman with a triple negative breast cancer? Yes, it is somewhat relevant, but it seems enough to know that she needs aggressive treatment without knowing the exact combination of agents the Oncologist should use. Even if that were useful to me, my DEA license does not extend to giving antineoplastic drugs. It would be illegal and malpractice for me to do so.
“Several professional boards have already done away with the traditional recertification exams in favor of more continuous and nuanced evaluations. It is time for Surgery to do the same.”
All too many of the questions on the exam were on material just as irrelevant or obscure. Why? I took time from my practice to study material that I will not retain and that I can easily look up if the need arises. I spent several thousand dollars on this exercise in abuse, considering the preparatory course I took, materials I purchased, not to mention the exorbitant fee charged to take the exam. In the end, I did not feel that I had learned very much, and felt drained and exhausted once it was all over.
Several professional boards have already done away with the traditional recertification exams in favor of more continuous and nuanced evaluations. It is time for Surgery to do the same.
What is the purpose of recertification in the first place? Is it to provide some measure of how well a surgeon has kept up with advances in the profession? Is it to ensure some basic knowledge of the state of the art, or to test one’s ability to regurgitate esoterica?
If we are truly interested in ensuring that surgeons keep up with advances in the field, I would offer a modest proposal as an alternative. The ABS or the American College or some other agency should poll recognized authorities about the most significant changes in practice in recent years. Then put those lessons together every 2 years as a course for practicing surgeons. In order to recertify, a surgeon should participate in the basic MOC activities and would need to show that he had taken the most recent update course, either online or in a conference setting.
Such a course would cover the basic knowledge base surgeons should command, but there is still the disconnect between book knowledge and surgical competence. Knowing what to do does not ensure the ability to do it.
If our aim is to evaluate surgical competence, there is no substitute for direct observation. What about a core group of retired surgeons who would function as professional evaluators for the certifying Boards? A surgeon seeking recertification would pay a modest fee to have one of these evaluators shadow him for a few days, observing his practice both in the operating room and on the wards. Most experienced surgeons can tell from a few basic observations – how does the subject handle tissue, how does he/she talk to patients and staff, how well does the subject observe and comply with basic precautions and patient safety measures, etc – if a surgeon under evaluation is safe and competent. The idea would not be to rate anyone relative to some arbitrary scale, but simply to ensure basic competence and safety. Even if the only surgery observed is a simple biopsy or hernia repair, an experienced surgeon can assess another’s basic skill and competence.
Such a system might be a bit more expensive, (although given the price tag of the recent MOC exam, I don’t think so) but it would give a much more complete picture of the ability of a surgeon than the examination system now in use.
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Bruce Davis, MD, is a Mesa AZ based general and trauma surgeon. He finished medical school at the University of Illinois College of Medicine in Chicago way back in the 1970’s and did his surgical residency at Bethesda Naval Hospital. After 14 years on active duty that included overseas duty with the Seabees, time on large grey boats and a tour with the Marines during the First Gulf War, he went into private practice near Phoenix. He is part of that dying breed of dinosaurs, the solo general surgeon. He also is a writer of science fiction novels. His works include the YA novel Queen Mab Courtesy, published by CWG press (and recently reissued by AKW Books as the e-book Blanktown). Also published through AKW Books are his military science fiction novel That Which Is Human and the Profit Logbook series, including Glowgems For Profit and Thieves Profit.