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.

Kevin 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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