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Approximately 2 years ago, I overheard several of my colleagues talking in the hallway regarding their status with the American Board of Internal Medicine (ABIM). They had just completed the process of recertification and were sharing stories of their experiences. Remembering that my certification was becoming long in the tooth, I wandered into their conversation territory. The tales of their recertification experience, and the knowledge that I could no longer avoid the process myself, increased my gastric acid levels. The conversation also prompted me to log onto the ABIM Web site. After scanning the site, I realized that recertifying in medical oncology would be a somewhat daunting task, particularly given my busy work schedule, harried family life, and baseline fatigue of the middle-age oncologist.
The first task, which lasted more than an hour, was trying to figure out exactly what it was I had to do and how to get signed up. Once enrolled, I noted that this would be a three-step process. First, my credentials had to be verified. I was able then to move to step two, the self-evaluation modules. At the time I started, the completion of five modules was required. Since the first of 2006, the modules now have a point value. Rather than the requirement of completing five modules, 100 points are now required for self-evaluation. Point values vary, depending on module length. When I did it, the applicant would have 90 days to complete the 60 questions in each module and return them to the ABIM. The modules are basically an open-book test, and they come with the suggestion that the questions can be answered with help from textbooks, Web sites, or conferring with colleagues. The choice of booklet or CD/computer modules was offered. At some point along the way, I would also have to sit for the secure examination, which is the third step in the process of maintaining certification. Once these tasks were completed, I would have my medical oncology sheepskin renewed for another 10 years. The onetime fee of around $1,000 included the cost of all the modules, as well as the secure examination, which was offered twice a year in multiple locations.
Having successfully enrolled, I decided to sit down and formulate a strategy that would complete the recertification process by the end of 2005, at which time my original certificate expired. I realized that the whole process would take a lot of time, as considerable study would be necessary for me to pass the secure exam. I looked over the list of self-examination modules from which I could choose and saw that only three medical oncology modules were available. One of those was “recent advances” in oncology. There were also two general oncology modules. I ordered the first of these general oncology modules, opting for the paper booklet. I thought that if I got stuck on some of the questions, I could carry the booklet around with me and ambush unsuspecting colleagues for help.
With the first run-through of the booklet, I decided to use the Oncology MKSAP1 to help me answer the questions that I was not sure of; I would use my trusty DeVita2 as a backup. Surely 10 years of oncology experience, and 8 years of general internal medicine before that, would give me an edge in getting through this quickly. The going was slow initially, as my confidence in answering questions on leukemia, sarcoma, and so on, had waned over the past 8 years of my caring for primarily breast cancer patients. I vowed to cut out television on weekday nights and to read the Oncology MKSAP cover to cover. The overall goal was to take the certification examination May 2005. This would give me another shot at the exam before the expiration of my certificate, should the board invite me to take the test again after scoring was complete. By May, I wanted to have the three oncology modules completed, and the Oncology MKSAP read. This would be my study strategy for the secure exam.
The secure examination is now only offered by computer at a designated test site; thus making the search for two No. 2 lead pencils a thing of the past. The security measures at the site reminded me of entering the Pentagon; government-issued IDs and fingerprint scanning were required. Once seated at the computer screen, I was able to quickly overcome the butterflies and move through the questions at a fairly rapid pace. The exam consisted of all single best-answer questions. There was a break after the first timed section. The examination center allows you to work at your own pace, and the length of the break is up to the person taking the test. I opted for an energy bar, a short walk, and then was right back to work on the next section. This was a far cry from my original internal medicine and oncology board exams. There was no having to sit and wait until everyone finished a section. Also avoided was lunch discussion on whether you answered “C” on the malaria question or what was pictured in the smudgy figure that resembled the Andromeda galaxy.
My real-world experience, as well as the studying, paid off, and I received notification from the ABIM within a few weeks of my passing score. This left two modules to complete. One of them was easy and was based on patient and peer review. A booklet with tear-out pages was issued. The pages contained questions for patients regarding my performance as a physician. These were answered by instructing the chosen patients to call a 1-800 number and use the touch-tone phone to make responses. Twenty-five of these had to be tallied by the ABIM. As I proceeded through the clinic day, I not so randomly handed these out to patients that I was pretty sure liked me. There were also 10 forms for review by physician colleagues. Once again, I admit that I asked for evaluations from my friends. As I handed the evaluation requests out, I wondered what the point of the whole thing was, as I already knew that a good evaluation was forthcoming. At this point, I just wanted to be finished with the whole thing.
The last self-evaluation module that I chose was on general internal medicine topics. At this point I felt little pressure, having cleared the hurdle of the secure exam. All I had to do was have the answers to this last module turned into the board by the last day of 2005. By this time, I had moved away from the paper-based module to the CD version. I printed the questions, so I could continue to fold them up in my pocket and ask my internist friends how they would answer some of the more difficult questions. The review of internal medicine was useful, particularly on what to do with such clinical problems as hypertension, diabetes, and mild renal insufficiency. The CD modules also have the advantage of giving instant feedback once the answers are sent to the ABIM through the computer. After receiving confirmation of successful completion of this last module, I was done. Several months later, I received my new certificate, which I dropped off at the frame shop on the way home. Several days after getting it back from the frame shop, a number of requests arrived for copies of the new certificate. As I took some digital photos that I hoped would satisfy the bureaucratic hunger of the organizations that wanted the copies, I reflected that some things are just learned the hard way.
How can this process be improved for oncologists? ASCO has already convened a Maintenance of Certification Task Force to evaluate this issue. More self-evaluation modules for medical oncology would be helpful. These could include site-specific reviews of the common cancers, pharmacology/new drugs, and so on. ASCO has a new study source in the works (ASCO, manuscript in preparation), which will replace the most recent edition of the Oncology MKSAP.
The Quality Oncology Practice Initiative (QOPI) is now up and running, and it is designed to give the oncologist knowledge of practice strengths and weaknesses. Access to tools and strategies to improve care are part of this. The data collected for QOPI can be used to complete ABIM's Self-Directed Practice Improvement Module as credit toward MOC. To have your practice participate in this ASCO initiative, e-mail email@example.com or call (703) 519-1449.
Does this process add up to being a better oncologist? Was the whole thing worth the effort? My answer to both is absolutely yes. I would like to think that I learned some things during the journey. In his book, A Guidebook to Learning, Mortimer Adler stated that reading is not enough in the quest for lifelong learning. Successful lifetime learning requires discussion. Most of us have access to tumor boards, which provide this key ingredient of successful lifelong learning. Dialogue with colleagues regarding new knowledge learned in the maintenance of certification is readily available at tumor boards, small meetings, and the ASCO annual meeting. This discourse will help us reach the goal we all want, which is true lifelong learning.
Challenges remain in the Maintenance of Certification process. Should everyone be required to go through this process, despite being “grandfathered” in medical oncology? Rather than creating such a requirement, it is my hope that with continued improvement in Maintenance of Certification, all oncologists will consider doing this voluntarily, whether or not it is required. With continued hard work by the ASCO staff and membership, coupled with continued feedback to the ABIM, Maintenance of Certification will become attractive to everyone. It is also my hope that ASCO will continue to lead in improving the process, and set an example to all of the other subspecialties in internal medicine.