Getting Maintenance of Certification to Work: A Grounded Theory Study of Physicians' Perceptions

Importance  Despite general support for the goals of maintenance of certification (MOC), concerns have been raised about its effectiveness, relevance, and value.

Objective  To identify barriers and enabling features associated with MOC and how MOC can be changed to better accomplish its intended purposes.

Design, Setting, and Participants  Grounded theory focus group study of 50 board-certified primary care and subspecialist internal medicine and family medicine physicians in an academic medical center and outlying community sites.

Exposures  Eleven focus groups.

Main Outcomes and Measures  Constant comparative method to analyze transcripts and identify themes related to MOC perceptions and purposes and to construct a model to guide improvement.

Results  Participants identified misalignments between the espoused purposes of MOC (eg, to promote high-quality care, commitment to the profession, lifelong learning, and the science of quality improvement) and MOC as currently implemented. At present, MOC is perceived by physicians as an inefficient and logistically difficult activity for learning or assessment, often irrelevant to practice, and of little benefit to physicians, patients, or society. To resolve these misalignments, we propose a model that invites increased support from organizations, effectiveness and relevance of learning activities, value to physicians, integration with clinical practice, and coherence across MOC tasks.

Conclusions and Relevance  Physicians view MOC as an unnecessarily complex process that is misaligned with its purposes. Acknowledging and correcting these misalignments will help MOC meet physicians’ needs and improve patient care.

Rapidly changing medical knowledge and skills challenge physicians to constantly grow professionally and remain current for the benefit of their patients and communities. Physicians, especially in the United States, have enjoyed the privilege of professional self-regulation because of their specialized expertise and extensive training.^1-3 Certification boards grew out of the professional self-regulation framework with a mandate to ensure that physicians who completed formal training were competent for independent practice.¹Quiz Ref IDHowever, evidence suggesting that many physicians’ knowledge and skills decline over time,^4-6 together with evolving public and political pressures, led to the recognition that once-in-a-lifetime certification was insufficient to ensure ongoing competence.^1,7 As a result, the American Board of Medical Specialties formally approved maintenance of certification (MOC) in 2000.

Since the primary constituency for certification is the public, MOC represents a professional demonstration of public accountability and transparency.⁸ Maintenance of certification is also intended to encourage ongoing improvements in physicians’ knowledge and skills, and in the quality of care they provide, through self-directed assessment and quality-improvement activities. Although authors have raised concerns about the effectiveness, relevance, and value of current MOC programs,^1,9,10 growing evidence supports associations between MOC and important clinical quality measures.^11,12 Surveys also indicate that most physicians embrace the concept of MOC¹³ and support the need for ongoing formative assessment and feedback.¹⁴

Less research has focused on the experience of the recertifying physician despite some vocal expressions of dissatisfaction.^10,15,16 Several studies have assessed satisfaction with components of the program,^12-14,17 but we are not aware of research inductively exploring participants’ perceptions of MOC as a complete program. Understanding the perceived benefits, limitations, and barriers of MOC could help certification boards and other stakeholders refine and improve MOC to better meet the needs of physicians and patients.

We conducted a qualitative study focused on the following questions: what are the barriers and enabling features associated with current MOC activities, and how can these activities be changed to more effectively accomplish the intended purposes of MOC?

This grounded theory study used as the primary data source focus groups composed of practicing internal medicine and family medicine physicians. As part of a project exploring physician learning in practice,¹⁸ we held 11 focus groups from September 29, 2011, through April 17, 2012; a total of 7 were at an academic medical center and 4 at outlying primary-care sites.

At the time of this study, MOC comprised 4 phases: part I, professional standing (maintenance of active licensure); part II, lifelong learning (completion of self-assessment and self-study modules); part III, cognitive expertise (passing a high-stakes multiple-choice examination); and part IV, practice performance (completion of a quality-improvement project).

Mayo Clinic is a large multisite health system that includes an academic center in Rochester, Minnesota, and approximately 70 community sites in Minnesota, Iowa, and Wisconsin. Mayo Clinic’s culture emphasizes patient-centered care and continuous improvement. All physicians are required to maintain certification in their primary specialty. Institutional funds cover most physicians’ enrollment fees, and leaders have supported several MOC initiatives such as large-group collaborative completion of part II modules, locally developed computer-based part II modules, and on-site approval of quality improvement projects for part IV credit.¹⁹

Details of focus group sampling and procedures are reported in the eMethods in the Supplement. Briefly, we recruited 50 board-certified family medicine and internal medicine physicians, with the sample size determined using thematic saturation. All physicians provided verbal consent. The Mayo Clinic Institutional Review Board deemed this study exempt from full review.

Each focus group lasted about 1 hour and comprised 3 to 5 physicians. Each session began with a discussion of barriers to point-of-care learning (previously reported¹⁸) and then transitioned to a conversation about MOC. The moderator (K.J.S.) briefly defined the 4 parts of MOC and asked, “Based on your understanding of the MOC process, what is the most difficult part of MOC activities?” Other preplanned questions (see eMethods in the Supplement) included, “What could be done to simplify or facilitate those activities?” and, “What could be done to make part [II, III, IV] easier?” Additional probing questions were used as needed.

Three investigators (D.A.C., E.S.H., and K.J.S.) analyzed anonymized focus group transcripts using the constant comparative method²⁰ to identify a grounded theory model defining features essential in the effective implementation of MOC. We inductively identified initial codes outlining the value of, barriers to, and processes of MOC (open coding) and then examined interrelationships within and between these codes (axial coding) to identify potentially useful changes and eventually build a new conceptual model. We used Dedoose (www.dedoose.com) to facilitate this analysis.

To complement our focus group data, we reviewed key articles^{1,2,7,9-13,21,22} in search of omitted themes regarding value, barriers, purposes, and ideal processes. Finally, near the end of our analysis, we asked 3 focus group participants to review the model (member check); we made minor adjustments in response.

As a prelude to our exploration of physicians’ perceptions, we reviewed the websites of the American Board of Medical Specialties, American Board of Internal Medicine, and American Board of Family Medicine for statements clarifying the purposes of MOC. Although details of our analysis and results are not shown, this examination of information promoted to physicians and the lay public indicates that certifying boards aim to:

1. Protect the public trust and ensure that physicians are likely to provide up-to-date, high-quality care;

2. Encourage physicians’ personal commitment to the profession;

3. Quiz Ref IDIntroduce physicians to the science of quality improvement;

4. Promote self-regulated assessment in the context of real-world practice; and

5. Accomplish this through an evidence-based, multimodal, comprehensive program of lifelong learning (ie, MOC).

Our focus group participants indicated that the purposes of MOC have not translated to the lives of individual physicians and their practice-specific needs. As one participant noted in session 5, “I think the objective is reasonable. The operationalizing that and the way they’ve had to have it set up is lacking.” We discuss specific themes below (see Table 1 and the eTable in the Supplement for supporting quotes).

Quiz Ref IDAll participants acknowledged the high-level purposes of MOC and expressed a firm desire to maintain their clinical competence and professional identity. Yet, they simultaneously expressed deep frustration and discontent with the current MOC system. Participants perceived MOC as offering little, if any, value to themselves as individual physicians and questionable value to patients or society. Such sentiments agree with statements by previous authors,^9(p946) such as, “The experts for and against MOC agree that the concept of recertification is sound—what they disagree about is the process.”

Participants noted that the primary reason they participated in MOC was to maintain needed professional standing—a hoop to jump through. Maintenance of certification activities were relatively inefficient for learning or improvement: “A lot of work for a little bit of gain,” as one participant noted in session 8. The extreme paucity of comments suggesting benefit was as noteworthy as the presence of outright criticism.

Participants noted that both part II (self-assessment modules) and part IV (practice performance projects) were largely irrelevant to their practice and an inefficient means of updating clinical knowledge and skills. Part IV also lacked optimal integration with patient care.

Quiz Ref IDNearly all participants named part IV as the most difficult and frustrating part of MOC: “It’s time consuming; it’s cumbersome.” Some participants expressed disappointment that their day-to-day practice improvement efforts did not merit credit while others noted that eligible projects were ongoing in their department but that they were unaware of these group projects until it was too late. They lamented that many current activities consist of paperwork and related tasks of low learning value (eg, data abstraction) and suggested that these could be delegated to someone else. Participants also believed they lacked needed skills or training to lead and evaluate a quality improvement project.

Part II activities were also believed to be challenging for similar reasons, albeit less so than part IV. Although some participants perceived benefits, many expressed concern that questions and answers were irrelevant to their practice, narrowly focused, out of date, or simply wrong. Most expressed concerns about the time required. Several described approaches that improved efficiency (eg, investing minimal effort to answer questions), but these efficiencies occasionally required an explicit trade-off with learning effectiveness. Others detected a conflict in the dual purpose of simultaneously assessing knowledge and facilitating learning, and suggested that it accomplished neither purpose particularly well.

Several participants expressed confusion and anxiety about complicated and continuously changing requirements, especially early in the process. Participants also noted the lack of systems support and the challenge of fitting activities into their already busy schedules. Because of these logistical issues, as well as low perceived value, participants almost universally procrastinated completion as long as possible. However, those who had completed recertification noted that the process was ultimately less complicated than anticipated.

Participants noted the financial cost of MOC, but in contrast to previously raised concerns,^2,21 they did not perceive this as a major barrier.

Quiz Ref IDParticipants emphasized that all phases of MOC were more effective and efficient when done as a group, especially the large-group part II sessions.

Part III (the secure examination) generated little discussion and seemed to present little stress. Many participants found it potentially useful as an impetus to purposeful study. While several commented on the esoteric nature of the questions (“it’s test world” [session 6]) and the lack of feedback, and others disliked the need to complete the examination in a secure testing facility, no one seriously questioned this aspect of MOC. As one participant noted in session 1, “We’re used to doing that.”

Based on the focus group discussions, we distilled a grounded theory model defining 6 areas in which MOC needs to change. These interrelated themes, inductively identified from participant comments, highlight features that, if enhanced, will align MOC with its intended purposes and thereby enable it to better meet the needs of individual physicians. Table 2 illustrates the model’s development and Table 3 contains supportive quotes.

Despite the certifying boards’ outreach efforts and published evidence, physicians pursue MOC only because it is required of them and not because they perceive intrinsic benefit to themselves or their patients. Something more must be done to convince physicians that MOC offers inherent value. Dewey’s century-old quote is perhaps relevant: “When things have to be made interesting, it is because interest itself is wanting. ...The thing, the object, is no more interesting than it was before.”^23(pp11-12) In other words, if physicians must be reminded of the benefits they receive, perhaps the benefits are not beneficial. Instead of marketing and rhetoric to tell physicians about the potential benefits of MOC, the system needs a fundamental change that will create tangible, easily observable benefits. The following additional changes will help increase value.

Maintenance of certification activities should serve the needs of the clinical practice rather than demand that physicians manipulate their practice to fulfill MOC requirements. Both MOC topics and MOC credit should emerge naturally from the physician’s daily clinical workflow with minimal extra effort. As one person stated in session 11, “The programs that we have running and the incentives that we have [to improve patient care] are already there. ...I think we should get easier credit for what’s already being done.” Ideally, real patients (as contrasted with case-based questions or scenarios) would provide both the trigger for learning and the evidence that learning has occurred and has been translated into practice. This serves a 2-fold purpose: directly improving patient care and ensuring that needed skills are developed and maintained.

As stated above, many physicians noted a distinct absence of meaningful learning as a result of their MOC activities. In the absence of meaningful learning, the motivation to participate derives almost exclusively from the need for credentials. To elevate MOC from its current perception as an imposition to its intended purpose as a desirable, self-regulated learning activity, activities must be more meaningful—more effective, efficient, and relevant.

Building on the concepts of integration and effectiveness, participants suggested that learning and value would be enhanced by amplifying the relevance of learning activities, in particular by allowing most topics and activities to emerge from and remain embedded within the local clinical practice. This serves at least 3 purposes: directly improving patient care, ensuring that needed skills are developed and maintained, and providing a context that stimulates knowledge retention. Electronic tools might facilitate this process. However, participants also acknowledged the appropriateness of studying uncommon but still important topics to reflect the full breadth of their practice.

Participants noted the lack of cohesion among the 4 parts of the MOC program. As MOC becomes more tightly integrated in the context of a highly functioning program and embedded within the clinical practice (as we suggest above), a corresponding change will be required across the different components. For example, the learning in part II would ideally prepare physicians for part III and might also provide the skills required for part IV, in addition to having a more direct and timely application to their patients and community. The work in part IV should be used to define the learning agenda for part II. Detailed feedback on part III could also inform the part II learning agenda.

Coherence will also be improved by minimizing redundant data collection tasks,¹ linking certification with licensure and staff credentialing,^1,24 and implementing a truly continuous process of MOC. A more coherent, better-integrated, less-redundant package will not only strengthen program effectiveness but will make it more efficient and more relevant to local needs.¹¹

Much of the burden of MOC could be alleviated by better supporting physicians in their efforts. Administrative support could include assistance with registration and other paperwork tasks, targeted communication regarding opportunities for credit, orchestration of group efforts, and training in needed skills. Peers could offer support in collaborative activities. Such support can derive from multiple sources, including local institutions, regional collaboratives, national professional organizations, and certifying boards. An overall simplified process would help, as would improved communication and bidirectional data sharing between local institutions and certifying boards.

Participants identified several local initiatives as having tangibly improved the ease and success of MOC activities, including group sessions to complete part II modules, a local board authorized to grant part IV credit, and administrative coordination of part IV quality-improvement projects in the Mayo Clinic Department of Family Medicine.

The overarching purpose of MOC is to improve patient care by ensuring the competence of individual physicians. However, the results of this study suggest that MOC, as currently configured for physicians in this organized health system, does not yet successfully address the specific practice and professional development needs of the individual. We identified 6 changes that may help realign the practice of MOC with the intended purposes. When reordered, the 6 changes (support, effectiveness, relevance, value, integration, and coherence) offer a useful mnemonic, SERVIC, reminding us that all involved—certifying boards and physicians—are ultimately in the service of our patients and the public health.

As with many qualitative studies, generalizability may be limited. For example, Mayo Clinic requires all physicians to maintain board certification, financially supports MOC, and has pioneered efforts to streamline MOC. However, the fact that participants identified significant deficiencies despite this favorable culture underscores our conclusion that current programs require change. We acknowledge some overlap among themes, yet we believe the reported models accurately reflect participants’ perceptions as determined through our iterative inductive analysis. Our data do not provide quantitative evidence to support the proposed solutions, and MOC has continued to evolve since these focus groups were held. Our design did not permit analysis by subgroup (eg, participants who had or had not recertified). Physicians who agreed to participate in these focus groups may represent more strongly held (and possibly more negative) beliefs about MOC than nonparticipants. Strengths include empirical model development using rigorous qualitative methods and participants from diverse practice settings (representing community practices, academia, primary care, and multiple medical specialties).

Our findings agree with recent calls for greater coherence,^1,11 relevance,⁹ effectiveness in learning and assessment,²⁴ and integration.¹ Our contribution is unique in that it emerges inductively from the perceptions of physicians reflecting a variety of medical specialties, and organizes distinct ideas into a unified model suggesting specific targets for improving MOC. Moreover, few other studies provide suggestions for systems support, an area of great emphasis among our participants.

Maintenance of certification is in an ongoing state of evolution. Certifying boards have placed progressively increased emphasis on maintenance,¹¹ and the American Board of Medical Specialties recently approved changes effective January 2015 that begin to address several of the barriers and shortcomings identified in this study.²⁵ We believe our findings will help to clarify key issues and provide guidance on how the 2015 standards can be operationalized to enhance MOC value and experience.

Physicians view MOC as an unnecessarily complex process that is misaligned with its purposes and largely fails to meet their needs. While certifying boards cannot escape their ultimate accountability to societal needs and priorities, it seems unlikely that current tensions will resolve until physicians’ needs have been adequately acknowledged and addressed and the misalignments between purposes and processes have been corrected.

Accepted for Publication: August 2, 2014.

Corresponding Author: David A. Cook, MD, MHPE, Division of General Internal Medicine, Mayo Clinic College of Medicine, 200 First St SW, Mayo 17, Rochester, MN 55905 (cook.david33@mayo.edu).

Published Online: November 3, 2014. doi:10.1001/jamainternmed.2014.5437.

Author Contributions: Dr Cook had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Cook, Holmboe, Wilkinson.

Acquisition, analysis, or interpretation of data: Cook, Holmboe, Sorensen.

Drafting of the manuscript: Cook, Wilkinson.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Cook.

Administrative, technical, or material support: Cook, Sorensen, Wilkinson.

Study supervision: Cook.

Conflict of Interest Disclosures: Dr Holmboe reports receiving royalties from Mosby-Elsevier for his textbook, Practical Guide to the Evaluation of Clinical Competence; and, during the initial phases of conceptualization and analysis, serving as Chief Medical Officer of the American Board of Internal Medicine. No other disclosures were reported.

Funding/Support: This work was supported by internal funding through the Knowledge Delivery Center, Mayo Clinic, Rochester, Minnesota.

Role of the Funder/Sponsor: The Mayo Clinic had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.