The alarming decline of internal medicine recertification pass rates

Let’s talk internal medicine maintenance of certification (MOC).

I recertified back in 2011, and it was an onerous process capped off with a challenging exam.  Thankfully I passed, and I’m good until 2022.

Since then, the American Board of Internal Medicine has made maintenance of certification a more “continuous” process, and is sparking some outcry among physicians.  Wes Fisher has multiple posts on his site critiquing the entire endeavor.

But what I find more interesting is the first time pass rates of those who took the internal medicine maintenance of certification exam.

In 2009, it was 90%.

In 2013, it had dropped to 78%.

No matter how it’s framed, that’s an alarming drop.  Especially considering that maintaining certification is a condition of staying employed by many hospitals and health systems.  And while physicians can retake the exam, it’s a time consuming and stressful process.  Especially when their jobs are on the line.

What’s going on here? I see a couple of reasons.

The first is the continuing stratification of internal medicine.  With hospitalists becoming more prevalent, it’s uncommon for general internists to see both hospitalized patients and outpatients.  When I recertify in 2022, it will be more than 15 years since I last took care of patient in the hospital.

The second is the increasing bureaucratic demands that internists already face on the job.  And I’m not just talking burdensome pre-authorizations and paperwork, but also shifts to electronic records, and data gathering to meet pay for performance requirements.  These mandates require significant resources and time, which doctors in the past didn’t have to deal with.

Combine this with MOC’s time-consuming practice assessment component, and it’s no wonder that internists have less time than ever to prepare for the exam.

How do we fix this?  Board exams need to be modified to fit current practice paradigms.

First, they should be open book.  With the advent of mobile apps, UptoDate and IBM’s Watson, more medical information than ever is available on demand. Relying on memory, as board exams do, reinforces an antiquated model of care.  I as I wrote back in 2011:

Why, then, are we still relying on  a “memory-based curriculum,” where doctors still need to recall endless amount of facts on closed board exams?

If I don’t know the answer when I’m with a patient in the exam room, I look it up, or ask someone who does.  In this era of patient safety and emphasis on reducing medical errors, it doesn’t make much sense to rely on rote memory to practice medicine.

Watson antiquates closed board exams.  Instead of sitting in a testing room, doctors should be evaluated on how well they can find the necessary information — not how well they can recall something they memorized.  Board certification tests should be open-book, or, at least, provide the resources ready for physicians if they can’t recall an obscure medical fact.  Just like real life.

Second, it’s time to stratify the internal medicine board exam to fit current practice trends.  That means a separate exam for both primary care internists and hospitalists.  It’s unlikely that I will ever care for a ventilated patient in the intensive care unit, and the same can be said for the hospitalists and primary care topics.

These changes will make maintenance of certification not only less onerous to internists today, but also more relevant to the medicine they practice every day.

The alarming decline of internal medicine recertification pass ratesKevin Pho is an internal medicine physician and co-author of Establishing, Managing, and Protecting Your Online Reputation: A Social Media Guide for Physicians and Medical Practices. He is on the editorial board of contributors, USA Today, and is founder and editor,, also on FacebookTwitterGoogle+, and LinkedIn.

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  • Dr. Drake Ramoray

    I disagree whole heartedly in your remedy. Open book? Seriously? How about we get rid of MoC as well as the beuracrartic meaningful use, hassles, prior authorizations, and actually let doctors focus on you know medicine and taking care of patients.

    • rbthe4th2

      I have to respectfully disagree with you there Dr. Ramoray. I have no problem with people who can’t remember a boatload of facts, as long as they can look it up. After a while, you’re going to remember things and won’t need to look up as much. That’s where I think it could be looked at. Those who are newer and younger, I’d like to look up. Those older, I would hope that they didn’t need it as much.

      I do want to know they’re current and the ability to fly thru UpToDate is actually something that I wrote a note about to one of my doctors on, thanking them for doing so, as I felt that it showed they really cared about my health and wellbeing to do that. Having been on the receiving end of some major ego trips, a doctor who says I’m going to check something in front of a patient, made me very comfortable with them. No one nowadays can know everything, and that’s fine. They also need to know how to recover from a fumble. :) A lookup is better than a fumble. :)


      • Dr. Drake Ramoray

        My point is not that doctors can’t look things up, or that they shouldn’t. My point is the exam questions should test things that physicians should know, and thus not have to look up. Asking me on what chromosome the gene defect for a rare disorder is located in the genome is not relevant to my practice of medicine. Recognizing the disorder on the other hand should be something I know. The questions should not be so isoteric that they need to be looked up in the first place.

        • rbthe4th2

          True both on getting you for things you should know and I am one of those who thinks we need something other than bloated, useless exams for MOL.

        • SteveCaley

          One of the reason Mr. Flexner’s report revolutionized American medical education in 1910 was that he called for elimination of the vast majority of medical schools. Most schools based the entirety of their physician training on didactics and bookwork. Mr. Flexner was instrumental in the standardization of the third and fourth clinical years, and the increase of postgraduate training. Flexner had his misunderstandings, but the point on bookwork was spot-on.

  • drwes

    Kevin -
    Thanks for bringing this issue to light. As you know, I too have recently “recertified” thinking my testing would be good until 2023, but alas, this is not the case. We now must “pay to play” a fee every two years to be considered “meeting MOC standards” by the ABIM beginning 1 May 2014. Physicians should realize that the plight of physicians who don’t pass their MOC exam has not been studied (or even considered important) by the ABIM’s non-elected leadership. The stress, the potential loss of hospital credentials, and even the ultimate end-game of losing one’s license to practice medicine is being tied (according to the AMA’s projected goals) to the ABIM’s MOC process – all at a time when the need for internists is greater than ever.

    Which leads me to wonder why. Might it be that the leadership of the ABIM are more concerned about corporate interests and the business of medicine than they are about the very doctors they pretend to represent? Might they be promoting the global arbitrage of physician manpower to cut costs or to line their own pockets when their organization keeps 48.6% of their revenues from physicians for their own salaries? How do they get to decide what makes a good physician? Where are the data to support the effectiveness of their assessment? Might their so-called quality assessment experiment violate every statute of the 1979 Belmont Report requirements for testing unproven assessments on doctors? The whole process, needless to say, is a mess and those in charge need to be held responsible.

    I would advocate boycotting the MOC process until physicians’ well-founded concerns are addressed head-on by the ABIM and their motherships, the AMA and the American Board of Medical Specialists. After all, these folks at least seem to understand their pocketbooks.

    • LeoHolmMD

      It might be difficult to have an organized boycott. But perhaps individual physicians can negotiate directly with the hospitals/organizations. I can easily make the case that Board Certification does nothing for my skills as a practitioner. I can demonstrate that my drive to stay up to date does not need provocation from an illegitimate group of desk surfers. If some daylight hit the MOC, I think the public would see how absurd it is and wonder why physicians are having their time wasted and their wallets raided.

      • Dr. Drake Ramoray

        As more doctors move to being employed by hospitals, and then hospitals require board certification (or even MoC for that matter) the likelihood of there being a grassroots change is highly unlikely. The AMA is a failure (has been since before I was a physician).

        I just say make us all public employees and be done with it. Fat pension, make it like the VA where I can’t be sued, spend sometime in diversity training, attend a bunch of government mandated meeting on requirements (oh wait I already do that).

        Just make me a government employee so when there is question in reducing my pay like with the sequester I can get that as back pay later. Why have government mandates, public service requirements, and be paid by the government without the benefits of being a government employee. Might as while unionize while we are at it. Then we can be like the teachers unions. “It’s for the children.”

        I say its for the patients.

    • SteveCaley

      Now, there is extensive pressure being placed to link MOL (maintenance of licensure) to MOC, in many State medical boards.

  • LeoHolmMD

    Great post. To question further: Where exactly does the legitimacy of the Certifying Board come from? It does not appear to be from those who are governed by it. The public could care less as long as doctors are doing the right thing for them. Their increasing distance from relevancy is likely of little concern to a body whose main function is racketeering.

    • Dr. Drake Ramoray

      Your post sounds disturbingly like our federal government. How far the profession of medicine and this country has fallen.

  • doc99

    “An interesting game – the only winning move is not to play.” Joshua aka WOPR, “WarGames”

  • Dr. Drake Ramoray

    I should have gone to nursing school, then I wouldn’t have to take these boards to practice medicine independently in the first place.

    *Grabs some popcorn.

    • Kristy Sokoloski

      The questions for the NCLEX that Nursing Students have to take in order to become a licensed nurse is pretty tough for a lot of Nursing Students. And because of the toughness of it that’s why they get drilled in tons of NCLEX questions throughout their program so that when they take the actual test questions like it will be very similar so that they can pass on the very first try hopefully. And yes, NPs have to take boards as well as Nurses that choose to get specialty Nursing certificates of their chosen specialty. I am working toward getting back in to Nursing School. I hope to start again in May.

  • NewMexicoRam

    I’ve said this for years about the ABFM examination process.
    The MoC procedure is costly and cumbersome, and essentially useless.
    The exam itself takes too long, is also expensive, and, as you say, tests memory, not real life work.
    If they are going to keep the exam, change it to the type of exam that many nursing boards use: once a testor reaches a certain number of correct answers, and the statistical probability of a passing score is reached, the test ends there. Many can pass in less than an hour. A 4-5 hour test is ridiculous.

  • Kristy Sokoloski

    That’s about what the number is for the number of questions for NCLEX. I know when I got my certification for Medical Assisting that for the certifying organization that we were going through in order to pass the exam you had to get a 70 or higher. I passed with a score of 74.

  • SteveCaley

    The MOC process is prejudiced towards clinicians who follow a “familiar” pathway to the particular boards, usually an academic clinical pathway. It is possible to assess certain types of practices quickly and easily; and in other conditions, it’s virtually impossible. This is truly a counfounding of the intent of the process of “MOC.”

  • SteveCaley

    No. Emphatically wrong. A low pass rate does nothing to validate the intrinsic effectiveness of the process. That’s a VERY serious cultural myth that’s ingrained itself in American business and gone metastatic. “Fire the lowest 25%” is the Jack Welsh Mantra – it’s horrific management.
    Recitation of more abstract, and clinically irrelevant, material in a multiple-choice examination is the HEIGHT of the insanity of industrialism. “suggesting an open-book, to camouflage the weaknesses of the current system and doctors” means that memorization is all that is needed to be a doctor.
    The quality of test is reflected only in the quality of test. Testing is itself a statistical process that is an INCREDIBLY poorly understood in society, extensively abused, and completely invalid in most applications.

    If you wish to help the process, let’s just put a firm 10 year deadline on practice for all physicians, and then assure the citizenry that the knowledge of the older doctors is irretrievably obsolete. Given the current turnover rate, it’s probably not going to matter, anyhow.

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