Neel Sharma: Medical certification—too many tests?

In May this year, Paul Teirstein and Eric Topol authored a viewpoint on the role of maintenance of certification (MOC) in the States. Their article highlighted the shift from a ten yearly to two yearly MOC approach pointing towards concerns of the value of such frequent retesting. These included the lack of evidence for such a shift, the fact that a written test can never truly translate to what is done in actual practice (“clinical decisions are often not black and white, yet test questions must have one best answer”), the limitation of the test itself in an environment of super specialisation (“adult anesthesiologists who never treat children must take a test that includes questions about pediatric anesthesiology. General surgeons must review trauma surgery for the recertification examination even though they do not treat patients who sustain trauma. A cardiologist who spends four days per week in a basic science laboratory and one day caring for patients in a clinic is tested on reading cardiac echocardiograms and exercise stress tests, yet never performs these services”) as well as the significant costs involved. In keeping with the first point, they detailed that evidence supporting physician certification and MOC was written by ABIM employees.

Unlike the States, the UK does not have a two yearly maintenance of certification programme (MOC). After doing specialist exams (royal college membership and speciality certificates in the case of the physician route) we undergo revalidation as required by the General Medical Council. Revalidation is an initiative where all doctors are required to demonstrate evidence of the following, typically on a five yearly basis:

1. Continuing professional development (CPD).
2. Quality improvement activity.
3. Significant events.
4. Feedback from colleagues.
5. Feedback from patients.
6. Review of complaints and compliments.

Unlike MOC, revalidation does not include written testing. I agree that as a trainee prerequisite specialist exam completion is required to exit as a specialist. But the value of retesting as clinicians become super specialised is contestable. Drawing on my own progression as a gastroenterology trainee with an interest in upper GI pathology, I would question the value of a retest on general gastroenterology if all I see in the future is upper GI based disease, for example.

Paul and Eric went on to highlight their preference for CME based programmes over written testing as a worthwhile one. There is certainly truth in this. After all as clinicians we have an inner desire to enhance our expertise for the betterment of our patients and after years of training it is an automatic phenomenon to keep up to date through journal readings and conference attendance.

On the subject of testing, it now seems that clinical knowledge alone is not only what matters. In the UK there has been a move towards situational judgement assessment for exiting students to determine whether they possess the professional attributes of a newly qualified doctor. The concept of situational judgement has also been piloted for trainee selection. Personally speaking, such over testing antagonises the value of on the job performance. I note the AAMC have cemented the concept of entrustable professional activities for new starters and there is merit in extending this platform for specialists. Furthermore, for those specialists who perform specific procedural based skills, a written test, either clinical or attribute based, will provide no added value. Drawing parallels to the aviation industry, pilots undergo regular simulation exercises as a method of licence maintenance. Unfortunately such a luxury is not common place in medicine.

Assessment drives learning, but as specialists the method of assessment matters. Day to day workings cannot be assessed in written form and we should ensure that if testing continues it needs to be more real.

Neel Sharma graduated from the University of Manchester and did his internal medicine training at The Royal London Hospital and Guy’s and St Thomas’ NHS Foundation Trust. Currently he is a gastroenterology trainee based in Singapore.

Competing interests: None declared.