With the first few administrations of the neuroradiology maintenance of certification (MOC) examinations now complete, here are a few thoughts on the program. The concept of maintenance of competence is unassailable and critical to the credibility of physicians’ commitment to lifelong learning. Because it is new, we may expect the examinations to require us to do things, and to document activity, that we have not done before. Reports that many eligible neuroradiologists have declined to participate in the MOC process are troubling, and an examination of the details suggests some possible reasons. The initial implementation has had startup problems in 4 major areas: communication, cost, convenience, and content. There is a risk of failure of compliance by radiologists, which may lead to loss of public confidence.
Communication
Few radiologists understand what the MOC process does or how they should participate. This formal need to demonstrate ongoing learning is new, and we need much more information on what is happening and why. The structure of the programs, the methods by which we document our expertise, the testing requirements, the reasons for the exorbitant cost and inconvenience, and the regularity with which these activities must take place are opaque to most radiologists. The American Board of Radiology (ABR) should undertake an educational initiative to raise the general level of awareness and understanding within the profession. The information posted on the ABR site leaves many important questions unanswered.
Cost
The $1400 “reduced” fee and the $270 annual ongoing expense appear excessive. If they truly reflect necessary expenses to support recordkeeping and generating the examination, this must be explained to radiologists. The computer-based examination does not require a large cadre of examiners to come to a central location, eliminating one large component of expense compared to the diagnostic radiology oral board examination. Neuroradiologists submit the cases themselves on-line or on CD at little or no expense, further reducing the cost of creating this examination. The ABR requires that “You must remain current with your payments throughout the MOC cycle.” Why? During the 10-year periods between examinations, radiologists are required to participate in lifelong learning activities, including traditional continuing medical education and self-assessment modules (SAMs). Each of these involves its own costs, beyond the annual fee to the ABR. What are we getting for our $270 per year? These fees do not cover the educational activities, because radiologists pay these directly to the entities that provide them. What if one does not remain current with these payments to the ABR? Does this reflect on professional competence or participation in SAMs? The ABR should carefully review its costs, and provide explanations for the high price of recordkeeping. I discuss below another element of cost, the need to travel to distant test centers.
Convenience
Although those practicing neuroradiology continuously for the past 10 years are unlikely to fail the examination on multiple repeat attempts, for those who do, the ABR includes the following provision: “If you have not passed the exam 3 years after the expiration of your certificate, you will be required to repeat the primary oral exam to regain your certification.” Similarly, those who elect to permit their certification to lapse, then wish to recertify (perhaps in response to state or local requirements for a recent certification) also will be required to repeat the primary oral examination.“ Why? Is the oral examination a better assessment of competence than the computerized examination? If so, is the computerized examination valid? If the computerized examination is valid, is the requirement of repeating the oral examination simply a device to coerce radiologists into ongoing participation?
Traveling to one of 3 test sites to take a computerized examination is unnecessary and perhaps the most irritating aspect of the MOC process as it is currently configured. Current ABR guidelines require that the MOC examination be “proctored and secure,” but this does not require offering the examination only at limited sites and times. Test centers across the nation routinely administer other examinations with fees a tiny fraction of that charged for the MOC examination. These test centers provide security at least equivalent to the requirements of presenting an admission ticket and displaying some form of identification, as currently employed for the MOC. Elaborate identification and biometric schemes are not employed and are not necessary. Although the need for high-quality images exists in principle, the images presented at the MOC examination were of limited quality, on conventional computer monitors, without the ability to adjust windows or levels. These demands are within the capabilities of widely available desktop computers. If higher-quality image chains really are necessary, these are available throughout the nation in hospitals and radiology practices. These sites could provide the examinations with local proctors. Either solution would eliminate the expense of dedicated computers for this examination. The costs of travel, hotel, and time away from practice are prohibitive for most radiologists, and many will forgo MOC for these reasons. The ABR should establish a high priority on offering the examination in as many sites as possible across the nation. At a minimum, it should articulate a near-term goal of offering the examination in every state and in every major city. Longer term, it should anticipate that all neuroradiologists will be able to take the examination in their home communities. A stopgap measure might include offering the exam in conjunction with major medical meetings. I am sure the ASNR would work with the ABR to offer the examination at its annual meeting. This would save extra costs of travel and hotel at the expense of requiring the radiologists to miss several hours of the meeting.
Content
The ABR should revise the examination to emphasize study interpretation and consultation. In its current form, there are many hypothetical questions with ambiguous wording. The examination could benefit from proofreading by an English-major copyeditor. The examination was overly simplistic and narrow in content. The test ignored many important areas, such as trauma, and required only superficial knowledge of critical pathologies such as stroke and neoplasia. There was very little advanced imaging, with nearly no diffusion studies, nearly no spectroscopy, and no perfusion imaging. Far from requiring ongoing education, this examination could have been passed by someone who, competent 10 years ago, had ignored all subsequent progress in neuroradiology. These omissions challenge the sincerity of the stated goal of ensuring that neuroradiologists remain current in their field.
Compliance
Many eligible neuroradiologists have failed to sign up for the MOC examination or the ongoing MOC process. Are they wrong? These physicians have time-unlimited ABR certificates in radiology or diagnostic radiology. Do they need to participate in MOC? From an altruistic point of view, it is important to radiology that the lay and medical publics see radiologists engaging in the formal MOC process. Although other physicians will realize that these formalities cannot actually ensure ongoing competence, they will appreciate the noble intent. The public probably will attribute failure of the MOC process to lack of commitment to lifelong learning on the part of neuroradiologists. This could encourage unqualified physicians to practice radiology to an even greater extent than they already do. This would be unequivocally bad for patient care. We may not like being in this position, but as neuroradiologists we have a collective responsibility to endorse appropriate standards of care. We now confront a logic-of-collective-action problem. All neuroradiologists recognize the need for successful MOC, but few individuals will benefit directly from their own participation. Few of us face state licensing requirements for MOC. Third-party payors compensate neurologists for interpreting imaging studies and cardiologists for stenting carotid arteries. Obviously, the payors are not concerned with evidence of high-level expertise. Hospitals vary widely in their credentials requirements and some may require MOC specifically or other ongoing evidence of competence. Because this is a moving target, it may be difficult to predict whether more hospitals and health care entities will impose such requirements or, if MOC fails, whether those with these requirements may drop them. Those who passed their neuroradiology CAQ 10 years ago, and have unlimited certificates in diagnostic radiology, may simply decide that they do not need a current neuroradiology subspecialty certification. If rising trainees see their faculty mentors or senior colleagues in practice abandoning MOC, the fellows may decide to accept jobs practicing neuroradiology, but without obtaining subspecialty certification. Under this doomsday scenario, both MOC and subspecialty certification could fade away if neuroradiologists decide they are more trouble than they are worth. Such an extreme outcome would be unfortunate, but it could arise if the MOC process remains too opaque, expensive, and time-consuming.
Conclusion
To preserve this important initiative, the ABR should: (1) establish better communication and more transparent goals, (2) reduce the cost of MOC, (3) make test centers widely available, and (4) make the content more closely related to modern clinical study interpretation and consultation.
Editor’s note: The trustees of the American Board of Radiology were offered an opportunity to respond and chose not to.
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