The mission creep of maintenance of certification

The mission creep of maintenance of certification

Up until 1988, being board certified in pediatrics was a voluntary process of passing the board exam once in a career. The American Board of Pediatrics (ABP) apparently realized this process didn’t make them much money, so in 1989, they abruptly ended “lifetime certification” and required an open book test and the associated fee every seven years.  I was in pediatric residency during this maintenance of certification (MOC) stage, the mandate was an annoying and costly change from lifetime certification, but an open book test seemed manageable for a busy pediatrician to complete.  I watched my attendings work on their open book tests over the lunch hour.  It was collegial and almost fun.

The ABP apparently realized this process didn’t make them enough money either, because in 2003, they abruptly required a secure exam every seven years. This was a bigger deal, requiring participation in expensive $1,000 board review courses, offered conveniently by the same academic doctors who established this new requirement. Secure exams, in addition to costing more to administer and prepare for, also require taking time away from the office and patient care for the actual test.

Then out of the blue, just seven years later, the rules changed yet again.  Passing the boards once in a career wasn’t enough, an open book exam every seven years wasn’t enough, a secure exam every seven years wasn’t enough: Pediatricians needed to remit $990 and enroll in a continuous MOC program.  Because pediatricians are a compliant lot, I did as I was told.

So what is continuous MOC? In addition to now costing $1,200, it’s an incredibly convoluted, continual process of complying with the boards and financially supporting their friends.  It requires a secure examination every 10 years, an utterly humiliating process where practicing physicians are treated like criminals. I was subjected to a body scan, I had to lift my pants above my knees and show my bare arms to the proctor. For administering this humiliation, Prometric received $1.7 million from the ABP in 2013.  Every 5 years it also requires 40 points of “approved part 2 activities” and 40 points of “approved part 4 activities” and then another 20 points of either part 2 or part 4 Activities.  But the 10 year test may not coincide with the 5-year MOC requirements. Confused yet?

Approved part 2 activities are incredibly difficult online questions that are largely designed for pediatric subspecialists.  Approved Part 4 activities” are purportedly practice improvement modules that take 2-4 months to complete. Part 4 activities involve pulling charts, enrolling patients into study groups without their consent, doing the study and reporting the data to the boards.  Currently, there are nearly 400 research projects being done on children through part 4 MOC. Not only is performing research on children without consent immoral, it is costly in both time and money for the patient.

In an effort to show improved care, the physician is compelled to order testing that may not be necessary for the individual child and ask for more frequent office visits than is necessary. One has to question the validity of any practice improvement module that a physician is participating in upon threat of losing their hospital privileges or insurance participation.

So when will this end? What will the next iteration of MOC bring? It’s my aim to never find out, because I’m no longer part of the compliant lot. I look at ABP president James Stockman’s $1.3 million salary and realize they will not voluntarily stop forcing us to participate in their testing and their research projects.  The outrage against MOC and this clear overstep and monopoly by our boards is rising. State medical societies are passing resolutions to end MOC, it’s only a matter of time before the American Medical Association has to listen to us. State legislatures are taking steps to protect physicians from these unaccountable outside corporations. A federal lawsuit against the AMBS by the Association of American Physicians and Surgeons is moving forward. Physicians are connecting together nationally through the work of Change Board Recertification.

History shows mission creep and the hubris it reflects invariably results in catastrophic failure and retreat by the offending force. December 17, 2015 is the day the American Board of Pediatrics will finally retreat from my career and my care of patients.  My next cycle of MOC starts on that day, and my answer is “I will not comply.”

Meg Edison is a pediatrician and can be reached on Twitter @megedison.  This article originally appeared on Rebel.MD.

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  • Dr. Drake Ramoray

    Join AAPS. Stop paying dues to societies that foist these burdens upon you. No AMA, AAFP, ACP, and for me no Endocrine Society.

    The only thing these people understand is dollars so take them somewhere else.

    The lead article on the website. AAPS takes MOC to court.

    • James O’Brien, M.D.

      Exactly. Starve them out and it will cease to be a problem.

      But most of you won’t.

      • DeceasedMD

        Good point. Actually I am not entirely sure why more of that is not happening. it is not entirely impossible to practice without board certification and at this point might be something to be proud of. LOL.

        • SteveCaley

          The brachiators who run the hospital HR departments require board certification. They seem to see it as a component of State Licensure. Within a few years, it will be.
          The same brachiators will not let you admit patients to the hospital unless you have been admitting within the last 24 months. I’m not aware that a relapse of chronic pancreatitis has changed all that much since 2010. But that shows how sadly out-of-the-loop I have been, I fear.

          • James O’Brien, M.D.

            Which means this will be another battle we lose if we give into that.

            What would Tyler Durden do? Stay the course?

  • SteveCaley

    Medicine is turning swiftly towards branded, subscriptive mediocrity. We prefer to eat at A_______’s Restaurant, which is a franchise chain serving identical food on a colorful menu, identical between Duluth and Topeka. We stay at the H_____ hotel and rent our cars from H_____ Rental agency. Our purchases are guided by our class and subclass images and goals. What is a Mercedes? A Taurus? A Kia?
    Thus, we are guaranteed of a comfortable, interchangeable mediocrity – and we like it that way.
    In several years, the Endocrine Society will come closer to the old Kelly Temp Agency as a certification-and-referral service. You will maintain a subscription to their assurance of competence, and inspectors will review the Product to make sure it fits within Corporate standards.
    People crave McMedicine – biggie size.
    The principle of having as professionals, the individuals capable of efficient and accurate reasoning is gone by the boards, literally, along with the un-branded motel and the un-listed restaurant. Incompetence and harm are cast as the nature of the Unapproved Physician. How can someone remain a good surgeon all her life, without Control and Command?
    Best Practices assures that you will get amoxicillin for your child’s ear pain, and narcotics for your sprained ankle. Customer satisfaction is designed to measure nonconformity by the uninformed customer. Look no further than your local fast-food restaurant for the future of drive-thru McMedicine.

    • Patient Kit

      I don’t think I’ll ever really understand the mass attraction to chain everything. I’ve lived my life mostly avoiding chain restaurants, chain hotels, chain pizza (I’m amazed that’s even allowed in Brooklyn!). I’m definitely not looking forward to chain McMedicine. It’s hard to believe that people actually crave the mediocre. I’m more inclined to believe that people tend to choose the relative comfort of the known over the discomfort of the unknown.

  • DeceasedMD

    Wow this is really getting uglier by the minute. “Currently, there are nearly 400 research projects being done on children through part 4 MOC (and the data goes to the boards).” My question is how is this data lucrative to the boards and how does this serve them?

    Submitting to a body scan and body search seems unconstitutional frankly for a doctor taking a test. So far, pediatrics, surgery and cardiology are all sounding pretty ugly with similar complaints. My guess is every board is pretty corrupted by now. I do think this is a good sign that so many physicians are pushing back and not complying. Perhaps the same can happen elsewhere.

    • RenegadeRN

      This is happening in other areas of healthcare as well. I remember when passing the NCLEX and becoming an RN was enough… Now board certification creep has exploded into nursing worlds too. I called BS and refused to play. No issues being able to work-yet.

      Now I am shifting gears and careers into nutrition and low and behold- a stupidly expensive board exam with recert every 5 years, with REQUIREMENT to attend out of state conference 3 out of 5 years to qualify for recert exam. What?? It’s cheaper and less hassle to maintain BC in nursing than nutrition!

      Totally ridiculous and a blatant money grab. Ticks me off to no end.

      • DeceasedMD

        wow thanks for sharing. I don’t think anyone really understands the depths of our MIC (medical Industrial complex). There are niches for these parasites everywhere, more than I could ever imagine. And yours is yet another example that would have never occurred to me. I have never heard of such BS in my life from reading about all the corporations in business that collaborate with medical clinicians and make things more ‘efficeint”. Makes me sick Renegade. And are you getting out of nursing because of how the nursing field itself has detiorated? Like Steve Caley said about the nursing field, “The last one to leave please turn out the lights.”

        • RenegadeRN

          Parasite is a perfect description!
          In a word- Yes! I am keeping my RN license intact, but not working directly as an RN. It is just not worth the jeopardy placed on my license every darn time I showed up for work.

          I am not whining, really. I know it basically sucks for most of us in the healthcare field these days. I have just Lost my desire to stand for 12-16 hrs with a 30″ break only if I’m lucky. Never figured out just how that is even legal.

          Younger nurses just have no idea what they are walking into. They are also leaving in droves after the first year. Turnover is sky high, with most new RNs saying they don’t make near enough to put up with the personal dangers and hassle.

          • RenegadeRN

            Oh-and no, it won’t be me turning out the light…I’m already gone baby gone!

          • DeceasedMD

            And loving it!

          • RenegadeRN


  • James O’Brien, M.D.

    Forget the AMA or anything they think. They are part of the problem.

  • Eric Strong

    I know that for many physicians, being forced to use an undesirable EMR, or the Affordable Care Act, or any one of a dozen other external forces are a primary reason for diminished career satisfaction. But nothing frustrates and angers me as much as the ABIM and this MOC garbage. How did a private organization with zero oversight and with patient wellbeing clearly not their primary focus ever get so much control over who’s allowed to practice medicine? And how did physicians ever let this happen? There must be some way to fight back besides sending money to AAPS (not that this is a bad idea, but it feels drastically insufficient).

    • Dr. Drake Ramoray

      The key in my area would be to change the hospital by laws. As it stands board certification is required (by at least 2 years after you become board eligible) to maintain hospital privileges. Of course since the overwhelming majority of physicians who have privileges at the hospital are employed by the hospital that is a tough sell. These are the same people who have been convinced that they must use the EMR.

      This is one of the lesser reasons I plan to develop an outpatient only practice. If it ever gets to the point that I choose not to continue board certification it will be up to the patients to decide if that matters. It should be noted that some insurance companies require specialists to have hospital privileges as part of their contracts.

      • James O’Brien, M.D.

        What’s even more insane is that doctors (especially internists) are beating themselves up with tougher MOC and lower pass rates as the speciality withers away to be replaced by less qualified non MD practitioners. The way internal medicine is going it will be the most brilliant unemployed specialty of all.

        • Dr. Drake Ramoray

          Agreed. They just don’t see the big picture. Fortunately for me very few people understand Endocrinology, and even less want to do it. My job is secure, assuming I continue to want to do it.

      • Eric Strong

        As a hospitalist, an outpatient only practice isn’t exactly an option for me…

        • Dr. Drake Ramoray

          You have the credentialing to do outpatient medicine only should you choose to do so.

          • Eric Strong

            I may have the credentialing, but not the temperament.

    • Dr. Drake Ramoray

      And also, I don’t think docs need to donate money to anything, or join any particular group. But mindlessly paying dues to organizations actively working against your best interests is insane.

  • Paul Kempen

    I also agree that there is a great deal of income at stake and replyed to the editorial board of PEDIATRICS with the following text regarding the PRO MOC article which is basically NON science: This of course was not what the Journal editors and ABP wanted to hear and was also not accepted with the following explanation!

    Maintenance of Certification research, publications,
    practice improvement modules and questionable ethics

    The article by Vernacchio is a published research
    project cleared by the home Institutional Review Board after being classified as a Quality Improvement (QI) project. (1) This absolved the researchers from obtaining informed consents from the 56 physicians or the 395 patients, circumventing the Nuremberg Code, Declaration of Helsinki and probably their institutional guidelines for research subjects as well. (2) A QI project is typically an internal event and not subject to subsequent publication as a research paper. That typically requires formal advanced review as a research project prior to submission, including all aspects of informed consent. Publication as research in this specialty Journal should require conformance to research guidelines. These circumstances raise significant questions regarding these American Board of Medical Specialties (ABMS)
    Maintenance of Certification (MOC) program’s related ethical research involving human subjects: physicians and patients. MOC apparently seduces good physicians to neglect human research subject’s and fundamental patient rights.

    The physicians who participated in the program overwhelmingly “qualified to receive 25 Part 4 credits toward their recertification by American Board of Pediatrics” (payment = personal rewards for their work) , conscripting unwitting or otherwise uninformed patients into this research project. There was no randomization or patient information provided. While the paper states:
    “FUNDING: This work was funded by internal funds of the Pediatric Physicians’ Organization at Children’s.” and “but requires a substantial investment of organizational time and staff”, there is
    no indication, whether patients or insurance programs were either offered or actually reimbursed for time, drugs and incidental and material expenses associated with this research.
    Completing the MOC module for MOC credit removes the “patient first” principle under the guise of QI, making it subservient to personal physician gain-irrespective of research submission for
    publication. This alone seems unethical.

    While the title exclaims “Effectiveness of an Asthma Quality Improvement Program Designed for Maintenance of Certification”, in reality only one of the 3 cohorts reportedly produced any statistically significant outcome reduction in asthmatic attacks. This does not support this title. With only 1/3 of these cohorts showing reductions
    in asthma attacks, I must ask if this is even a significant “finding”? Perhaps we have merely documented a Hawthorn effect (Improvements due to the study situation), which is not
    significant. Clearly increased expenses for “asthma action plans and control tests, seasonal influenza vaccines, controller medications, and asthma follow-up visits” were documented. There is
    no follow up of the “improved groups” after an interval, even attempting to demonstrate long term effects/benefits, without the intensive and expensive formal QI program mechanisms. Is the program effective in changing behavior and
    increasing healthlong term? Does it have VALUE?

    Value = Quality/Cost and costs
    are increasingly targeted by those paying for healthcare. Costs are completely ignored in this report
    and by the MOC program itself: MOC tests all physicians to document quality improvement, yet never has quality improvement been validat ed in research trials or even the ABMS’s own meta-analysis. (3) What is the cost of this program to the sponsors and patients in dollars/patient? Finally, QI initiatives are not research trials, but apparently can be served up as such, as a means to avoid IRB review (Quality control for research) and informed consent.

    This paper exemplifies the increasing attempts to sell the new and evolving requirements of M aintenance of Certification to the general physician population, as well as the solicitation of “MOC Products”, which may result in financial gains to the producers. The problems described here raise many ethical questions and specifically, if
    retraction of this article is warranted at this time. With increased pressure by the ABMS to convince everyone their products have value, it is time to place all requirements equal to other types of scientific research. No longer should a publication advantage be provided to Pro MOC groups, especially as physicians are increasingly
    skeptical of any value or utility of MOC programs, beyond simple corporate profit. (4)

    1) Vernacchio L1,
    Francis ME2,
    Epstein DM3,
    Santangelo J2,
    Trudell EK2,
    Reynolds ME2,
    Risko W3.
    of an Asthma Quality Improvement Program Designed for Maintenance of
    Certification. Pediatrics. 2014 Jun 16. pii: peds.2013-2643. [Epub ahead of

    Kempen PM: Maintenance of Certification and
    Licensure: Regulatory Capture of Medicine. Anesth Analg.
    2014 Jun;118(6):1378-86.

    3) Sharp LK, Bashook PG, Lipsky MS, Horowitz SD, Miller SH.
    Specialty board certification and clinical outcomes: the missing link. Acad Med

    4) Ault A: Backlash Grows Against MOC Process. GI and
    Hepatology News. Vol 8 (6) June 2014 Page 1. Available at:
    accessed 6/18/2014

    Dr. Kempen,

    The Executive Editorial
    Board has reviewed the e-letter that you submitted on June 18, 2014, and has
    decided not to publish it.

    The issues that you raised about human subjects protection and quality improvement have been previously addressed by the US Department of Health and Human Services. Based on this federal guidance, there has been no ethical breach and no reason to consider retraction of this work. Please refer to:

    The Executive Editorial
    Board is aware of your position on MOC based on your recent publications in Medical Economics and elsewhere. The consensus of the Executive Editorial Board is that your criticism of MOC is not directly germane to the article, and has therefore reached the decision described above.


    Alex R. Kemper, MD, MPH, MS

    Deputy Editor,

    • DeceasedMD

      Good for you to write an official complaint letter to pediatrics board. Thanks for posting their reply. Amazing how “THe lady doth protest too much.” What a defensive answer. They need to be sued.

    • Eric Strong

      My opinion of Pediatrics just dropped.

  • DeceasedMD

    With good reason-your cynicism. Above is the pediatric boards reply to a complaint and their defensive response. I think the answer is don’t work for a hospital. That may be next to impossible for many. But doing outpt at this point board cert is not mandatory and most pts don’t really think about this. They just want a good doc.

    • EmilyAnon

      Re: ” They (patients) just want a good doc.”

      It’s very confusing for patients when choosing a new doctor. When we get a list of doctors from our ins. company who are in-network, how do we know who’s “good”. When this question was posed other times on this blog, a few doctors here said, if you can’t get a recommendation from another doctor, look for board certified. It seems that’s all that’s available for a patient to go by.

      • DeceasedMD

        Board cert was the old way. Now it seems somewhat meaningless. I don’t know other than interviewing and using one’s judgment but board cert is not the way.

        • rbthe4th2


      • Eric Strong

        When choosing a new doctor, board certification is irrelevant. It may mean something about credentialing requirements at a local hospital, or about his/her reimbursement model. But it says nothing about his/her actual skill at being a doctor. Unfortunately, there is no great alternative for laypeople to rely on.

        When an out-of-town friend recently asked me if I happened to know any OB/Gyns for a specific and uncommon problem (I did not), I approached the problem by cross-referencing lists of Ob/Gyns in her area against their academic pedigrees as searchable on-line, against peer-reviewed publications on the uncommon problem my friend has, and against patient-satisfaction references on-line. None of these parameters are adequately accurate by themselves – great doctors can come from unremarkable schools, have no formal publications, or have a few disgruntled and vocal patients about something ridiculous. However, I think the summation of the data was useful. There was one physician who fit the bill, and my friend has been very satisfied with her. Unfortunately, many laypeople cannot reproduce this time-consuming method of identifying a new doctor. As far as I know, there are no alternatives.

        • rbthe4th2

          This is what we do – the other half and I. Many friends are starting to do the same.

  • W. X. Wall

    In my specialty (neurosurgery), my understanding is that our board fought the MOC requirements tooth-and-nail. It was forced on us by the ABMS, which oversees all of the medical boards. My chairman was part of the neurosurgery board and he said none of the other board members thought it was a good idea, but they had to go along (and then delayed it for as long as possible).

    I say this because you might be misdirecting your ire. Are you sure it’s the peds board and not the ABMS that is the real culprit?

    Going back further, the impetus for MOC came from the public, not anyone in the medical field. They had a fear about old, incompetent docs still practicing and the medical boards responded to this by establishing MOC. Interesting that such fears never materialized about lawyers knowing the latest laws, or college professors who got their PhDs before the structure of DNA was known…

    Ironically, at least according to my chairman, our board was acutely aware of the problem of failing established doctors. If you fail a newly minted doc, everyone believes the board’s assessment since the new doc isn’t established yet. But if the board fails a doctor who’s been practicing competently for decades and is well established in his community, then it might just be the board that loses legitimacy, not the “failed” doctor. If you’re a well established surgeon who’s bringing a few million in revenue to your hospital, I doubt they’re going to restrict your privileges if you decline to participate in MOC.

    That means we established physicians actually hold the power here: all we have to do is simply refuse MOC, or continue practicing even after our board certification “expires”, and the boards would be thrown into an existential crisis.

    • SteveCaley

      As an Internist, I am particularly empathetic to the surgeon in the throes of MOC. How, exactly, does deftness in wielding the #2 pencil demonstrate one’s surgical skill?
      The boards, like panderers, do not like it when the working girls get out of line or become unprofitable. The ability to surgically remove and repair complex and terrifying things in the brain is impressive. I am not sure that a newly-minted neurosurgeon has the edge over some codger with twenty years experience.
      “Experience Not Necessary” is the message of the boards. If it’s been five years since you were under the thumb of residency or fellowship, well then – you have picked up bad “individual” habits and must be reminted.
      I foresee the boards as like a monthly subscription service. Pay your grand-a-month, take the CME, and shake what the good Lord gave you.
      As Dr. Kempen notes later, his points are valid but have already been discarded – there is no need for boards to individually respond to good ideas when they are offered.
      I can disentangle myself easily from the whole process, by simply hanging up the coat and doing something else that I am good at. I am not John Galt. But I am very tired.

    • DeceasedMD

      “That means we established physicians actually hold the power here: all we have to do is simply refuse MOC, or continue practicing even after our board certification “expires”, and the boards would be thrown into an existential crisis.”

      And loving it!

    • Margalit Gur-Arie

      Are you sure that “the impetus for MOC came from the public”? As far as I can tell the “public” has no idea that the MOC even exists, let alone what it is.
      It may have come from so called “public representatives” or “thought leaders”, which is not the same thing as “public”, and perhaps this was a license to make money granted to the boards in return for their support on this or that policy initiative, or whatever else is being exchanged in those rarefied circles….

      • rbthe4th2

        I agree to a point. I want docs to have something that demonstrates keeping up with their fields, etc. and basic patient care. The MOC’s, as they stand now, do NOTHING for that. They are simply money grabs. They don’t do what they’re supposed to do.

        I don’t care whether someone is board cert’ed. I actually condole docs when they have to go through it. If it meant anything I wouldn’t.

        • W. X. Wall

          I agree with you. The fact is that medicine changes rapidly and people need to keep up. But I think the best way to achieve this is to reform CME, not board certification. Most physicians *do* want to keep up with the latest stuff. Although they may be busy, the desire is there. If you make it easier to get *good* CME, physicians will do it.

          As it is, for a busy clinician, separating the wheat from the chaff in journals is very hard. Plus many of the articles are basic science articles or such that can’t be applied to clinical practice yet. And conferences for a lot of physicians are nothing more than a tax-deductible vacation where you get to see your old buddies from residency.

          Most national meetings are run by academics who are seeking a forum in which to proudly proclaim their new findings of curing cancer in a petri dish or flicking on a gene in a rat. Actual peer-reviewed summaries of clinical advances in the field or overviews of new treatments that have come online are few and far between.

          Quite frankly, I learn more discussing cases with my residency buddies over dinner and talking about new treatments we or our partners are trying, than any number of basic science talks about gene expression in glioblastomas.

          Some of the European meetings I’ve been to had “fireside chats” with the speakers in which you could bring your own cases to discuss with them in a small group setting. Discussing your toughest cases with international experts, with an audience of practicing surgeons from around the world who could give you real-world, practical advice and different perspectives you never had, was incredibly useful. I don’t see such small group discussions here in the U.S.

          I’m not saying I don’t find gene expression in GBMs interesting (and certainly not saying such research isn’t important to advancing our field) but in terms of what I can change in my clinical practice to improve my patient’s lives today, it has no meaning, yet such talks dominate over clinical research (at least in my field).

          I wish I could pull it up but I remember a study in which they found that new medical innovations take about 20 years to become widespread in medical practice. Given that the average practicing lifetime is ~30-40 years, what that means is that physicians aren’t actually learning anything new: new treatments become established simply because old physicians gradually get replaced by new ones. That’s the real problem.

          • DeceasedMD

            That is the best description so far of what medicine is like. Plus all the conferences sponsored by Big Pharma are suspect and difficult to sort out what to trust-and that is often most of the conferences financial support.

          • rbthe4th2

            Thanks DMD.

          • rbthe4th2

            Instead of “good” I think we’re looking for “useful”.

            What about some of the more research savvy patients, get a group together and have them come up with 3 articles or 5 articles that might be useful. They’re free, and then you know who truly is going to be a partner in the health care because they’re committed. I’m one of the oddballs that checks out the clinical advances stuff.

            Are you serious? I thought that some of the specialty conferences, that’s what you did: fireside chats. That would explain why I see so much variation in what doctors know. I thought you all shared info. You can beef about patients and CMS requirements, but you all don’t get together and talk on cases? Ye Gods … IT would be dead if we didn’t pool knowledge.

            Your last paragraph (actually several of them) shed light on a number of questions I had regarding learning. Thank you for the post.


  • James O’Brien, M.D.

    Considering that most medical research can’t be replicated, I’d argue that reading 30 journal articles that are not summary review pieces after copious research has been done is a waste of time.

    So in terms if this requirement academia is once again acting like a sadistic schoolmaster, forcing you to eat their nutritionless gruel.

    I wouldn’t wait to join a suit, contribute whatever you can to AAPS to end this nonsense now.

    To all physicians who plan to “stay the course”, I’ll quote Tyler Durden from Fight Club, how has that been working out for you?

    • William Viner

      I very well might do that. Truth is the article reading is not all that bad as many are reviews.

      • James O’Brien, M.D.

        Reading original psychiatric research is frustrating as I typically find about four design flaws in most published studies. Not to mention that DSM is overly broad and who knows how serious the pathology is anyway. It’s really frustrating what they let through.

  • James O’Brien, M.D.

    This is why I have no faith that physicians can better their situation…they cave too easily:

  • A Banterings

    You said:

    “…subjected to a body scan, I had to lift my pants above my knees and show my bare arms to the proctor. For administering this humiliation…”

    I see nothing wrong with this. As a nurse told me when I refused to get naked and put on a gown for a sore throat, “We are professionals,” and “Nothing we haven’t seen before.”

    I’m sure the Prometric people “are professionals,” and “nothing they haven’t seen before.” Besides, that is the way they have always done things.

    It is no different than a 17 year old girl who is not sexually active having to get a pelvic exam just to get birth control pill prescription filled.

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