Maintenance of Certification: One Size Should Not Fit All

After a conference call and having returned several phone calls, I again opened my ASCO Medical Oncology Self Evaluation Program (SEP) book hoping to steal an hour to reread the chapter on multiple myeloma, and begin digging deeper into head and neck cancer. It was March 2011, and my Maintenance of Certification examination was looming a mere 6 weeks away. While trying to parse the relative roles of thalidomide (Thalomid), lenalidomide (Revlimid), and bortezomib (Velcade), I was interrupted by a call from my research study assistant asking for assistance in screening a patient for a breast cancer clinical trial.

Somewhat ironically, as one who has enjoyed being immersed in breast cancer care and research for 2 decades, I was annoyed to have to tear myself away from the study hour I had hoped to sneak in. I felt compelled to bone up on “everything but breast cancer” in anticipation of taking this recertification examination. But there it was; I had to get back to my day job. Knowing that I could sneak in an hour at Starbucks before a planned lecture the next day, I tucked the board review materials away and began screening the potential clinical trial candidate.

Less and Less about More and More

I am far from unique in this professional dilemma. In an era of rapidly changing diagnostic and therapeutic interventions for the wide spectrum of malignancies, many oncologists are increasingly challenged to maintain sufficient expertise in managing many diseases. The “jack of all trades” who does not keep up with the dynamic landscape of lung, breast, colon, prostate, and many other cancers runs the proverbial risk of knowing less and less about more and more until he/she knows nothing about everything.

Many medical oncologists in academic centers—but also increasingly in community cancer centers and practices—have a much narrower focus. Like myself, these super-specialists spend all or the vast majority of their time treating one or two types of cancer. In effect, one could argue that this phenotype runs the risk of knowing more and more about less and less until they may know everything about nothing. Of course, this is an exaggeration, but it underscores an important dichotomous reality of contemporary medical oncology practice. By extension, there is a disconnect in how the American Board of Internal Medicine (ABIM) approaches recertification. Despite the heterogeneity that exists in clinical medical oncology practice, the ABIM’s recertification process has not evolved substantially—it remains a “one size fits all” proposition.

Ensuring Quality Care?

Presumably, maintenance of board certification is desirable to ensure quality care of patients with cancer. Whether recertification truly results in ensuring quality care is a critical issue beyond the scope of this commentary; certainly this should be assessed with validated tools and metrics. The ABIM Medical Oncology Maintenance of Certification Examination Blueprint states, “The exam is designed to evaluate the extent of the candidate’s knowledge and clinical judgment in the areas in which a Medical Oncologist should demonstrate a high level of competence. Expertise in the broad domain of Medical Oncology and the diagnosis and treatment of both common and rare conditions that have important consequences for patients will be assessed.”¹

Really? This statement reflects the faulty notion that my specific professional activity requires broad expertise in diagnosing and treating both common and rare conditions. My patients scratch their heads when I mention that I spent innumerable hours in the early months of 2011 learning about the molecular basis of resistance to imatinib (Gleevec) for chronic myelogenous leukemia, or the role of temozolomide, bevacizumab (Avastin), and radiotherapy in treating glioblastoma multiforme.

I try to convince myself, poring over the latest management of cutaneous T-cell lymphoma while sipping my second doppio espresso macchiato, that somehow this knowledge will cross-fertilize and make me a better breast cancer doc. Unfortunately, despite my hypercaffeinated state, I struggle to make that leap. I am distracted by all of the other clinical and academic work that I’ve pushed aside to carve out time to prepare for this examination (which happily I did pass).

A More Relevant Recertification Process

Shouldn’t the ABIM and the medical community feel more secure in knowing that my competence was assessed by an examination that focused on the care of the disease that I indeed treat—an examination that would actually dig even deeper into the nuances of breast cancer prevention, diagnosis, and treatment, and demand that the super-subspecialist demonstrate proficiency and knowledge in the unique area of purported expertise and clinical practice? Should the male patients of my colleague Dr. Michael Morris, a renowned prostate cancer specialist, take comfort in knowing that he got all the gynecologic oncology questions right on his recertification exam?

It is time for the ABIM to develop and implement a more nimble, relevant, and flexible recertification process, one that at least would tailor the written examination to the narrower patient profiles of the many practitioners who are “masters of one.” The rationale seems clear, and the tools are available.^2,3

I am certain that there would be many super-specialists in all disease types who would support this effort by volunteering to draft tailored examination questions relevant to their area of expertise. In the current era of informatics, the machinery is readily available to provide a regularly updated, dynamic library of examination questions tailored to address the unique realities of contemporary oncology practices—to meaningfully assess the jacks of all trades as well as the masters of one.

I’m just not sure I have it in me to go through this exercise again in 2021, as it is currently designed. I am hoping that by then there will be increasing sensitivity and responsiveness to my widely shared concerns. ■

Disclosure: Dr. Seidman reported no potential conflicts of interest.

References

1. Available at http://www.abim.org/pdf/blueprint/medon_moc.pdf. Accessed May 3, 2012.

2. Madewell JE: Lifelong learning and the maintenance of certification. J Am Coll Radiol 1:199-203, 2004.

3. Epstein RM, Hundert EM: Defining and assessing professional competence. JAMA 287:226-235, 2002.