INTRODUCTION
A physician certified by the American Board of Medical Specialties (ABMS) typically has a time-limited certificate (usually ten years).(1) Although a fully trained specialty physician, one of the tenets of medical professionalism demands that a physician commits himself to lifelong improvements in knowledge and clinical practice.(2,3) This is normally achieved through participation in programmes that document ongoing medical competence, such as the American Board of Internal Medicine (ABIM) and Maintenance of Certification (MOC) programme. Many organisations recognise that such programmes are an important aspect of professional responsibility and fulfilling our part of the contract with society.(3,4) However, the methods of recertification should be relevant to a variety of practice settings, consider cost and time, and accommodate different learning styles. Some doctors have elected not to undergo MOC programmes for reasons of costs, both in terms of time and finances, irrelevance to practice and other factors.(5) In a survey conducted by the New England Journal of Medicine, it was shown that about 64% of American physicians would choose not to participate in MOC programmes.(6) Conversely, a similar poll with the public conducted by MSNBC showed that 80% believe that physicians should renew their certifications.(7) Despite the inherent public and professional belief in the need for maintenance of professional competence, MOC programmes are controversial due to time, cost, and the lack of public and institutional support for funding and apportioning of other resources. Some have expressed concerns about the hypocrisy, and ethical and financial conflicts of interest in physician-supporters and professional drivers of MOC programmes.(8) Moreover, evidence of MOC programmes in improving the quality of patient care has been challenged.(9)
The regulatory climate in Singapore currently does not require recertification through participation in an MOC programme or sitting for an examination – yet.(10) However, similar to the requirements of most state medical boards, documentation of participation in accredited continuing medical education sessions is required for renewal of practice certificates (licensure) by the Singapore Medical Council (
MY RECERTIFICATION JOURNEY
My certification in internal medicine by ABIM was to have lapsed in 2013. Sometime in 2012, I discussed recertification with a colleague, Dr Srinivas Subramanian, and we made a pact to be recertified in 2013. Let me recount my journey and the price of professionalism (see
Table I
Breakdown of the costs of recertification.
Realising that I could not fit time in to study for the Boards while in Singapore, I did what most doctors in institutional practice do – go away for a conference. In April 2013, I scheduled myself to attend the American College of Physicians (ACP) Annual Internal Medicine Meeting held in San Francisco, CA, USA. Since the meeting had pre-conference courses on MOC questions review, I took two of the courses that fitted my time schedule and spent two days doing multiple choice questions. A few hundred doctors commiserated with me, all presumably also due for recertification. I attended what I thought was an excellent conference, focusing on the track with updates in the various subspecialties and also timing my conference participation with attendance of the Convocation Ceremony of the College where I had been elected to Fellowship.
To recertify, the ABIM MOC programme (see endnote) requires adequate completion of a series of multiple choice questions (by modules according to subspecialty branches of internal medicine) in order to achieve a requisite number of points. Some of these points are achieved through participation in a Practice Improvement Module (PIM). I enrolled in the chronic kidney disease PIM and had to track at least 25 patients whom I see in clinic. This was painfully tedious and I had to stay after-hours to enter the data on the website. Moreover, follow-up data, including proposed improvements to be implemented, was also required. However, the PIM report reinforced points of management in patients with chronic kidney disease stage 4 and helped me identify weaknesses in my clinical care processes. Furthermore, interventions had to be developed and follow-up on these measures taken to determine their effectiveness. Honestly, even though it was painstaking, the well-designed module was educational and eye-opening – I learnt that we can always do better.
Going over the online MOC programme question modules was also time-consuming. The questions are related to more recent clinical trials and scientific findings. Some physicians have commented that the questions are more difficult than the actual recertification examination. As the modules are done online, they can be completed at one’s own pace. However, access to study materials, including journals, is often required – I am thankful for the Internet and ready access to the well-stocked electronic library of the medical school. Nonetheless, I could not determine the answers to many questions and had to consult colleagues in other specialties, who were also occasionally stumped.
Besides the questions in the MOC programme, I also reviewed key topics in internal medicine using ACP’s Medical Knowledge Self-Assessment Program (MKSAP) and practised answering multiple choice questions. I had scheduled myself for the fall recertification examination in Singapore (computer-based examination in a test centre). Due to a heavy work schedule, I took one week of vacation time to put in more practice. Despite this, I managed to complete all the MKSAP questions (about 1,000) only once, achieving scores of 60%–70% on average. It would usually be better to randomly repeat the questions to determine if the learning points have been assimilated. If you perform well, you would most certainly pass. Being less prepared, I had a week of situational anxiety and dysthymia after taking the examination.
While sitting in a cafe on the day of the examination, I reviewed some of the topics that I had less contact with in my daily work as a nephrologist, and wondered which private practice group I would join if I failed recertification. At the test centre, I met a cardiologist who had moved to Hong Kong. He was also recertifying in internal medicine, and like me, he had returned to Asia for the sake of his spouse. We registered our presence at the test centre and were guided into our seats in the highly secure facility. I felt like I was entering a biosafety-level 3 laboratory and certainly hoped that the examination was not an extinction-level event. At lunch with my new friend, I mentioned that the examination was quite difficult. By early afternoon, my MOC journey for internal medicine was completed.
Returning to work, I discussed my experience with Srinivas, who felt that I should not have any problem with the examination. But of course, I felt otherwise, as I alluded to the feeling of incomplete preparation. Several months later, I received an email – I passed. Subsequently, I received a detailed performance report, which showed that I had attained an average score. As each subject area, with the exception of cardiology (20 questions), had only ten questions, it is clear that depth and breadth of clinical knowledge and practice could not conceivably be assessed in one examination. I obtained my best score for rheumatology, all thanks to a colleague who had gone over some questions with me one afternoon, and also met me in the office pantry to confer.
CONCLUSION
It is inevitable that continuous professional competence assessment, recertification, re-licensure or revalidation will come to Singapore. While we continue to debate the relative merits, I think it is more important to determine the methodology of doing so, without duplication of efforts. Singapore is a small country and the professional community is small in number, even smaller when considering specialties and subspecialties. It is clear that the professional societies and regulatory agencies will not be able to implement credible and non-controversial programmes. To increase efficiency and productivity, and reduce costs to the Singapore society, it would be better to outsource this process or work with larger professional bodies. Physicians should be able to choose a programme that best fits their scope of practice. However, it is likely that, besides the efforts put in by physicians themselves as a commitment to professionalism, the economic price will be borne by patients in the name of public assurance of medical competence and safety. If the burden becomes too onerous, one can always become a banker.(3)