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High or Low: Where Should We Set the Bar?

Last month, we began an examination of the seven principles that support the ABO’s mission: “To serve the public by certifying ophthalmologists through the verification of competencies.” The initial post fleshed out our commitment to our diplomates and to the public that “The ABO stewards its finances with integrity and transparency.” In this column I wish to comment on the principle that “Certification should promote and recognize aspirational goals, not minimum standards.”

Over the past several months, the ABO has conducted numerous focus groups -- a “listening tour” of sorts -- to learn about the experiences and expectations of diplomates, volunteers, and patients related to board certification. A common theme is that ophthalmologists take pride in passing their boards and all patients expect their ophthalmologists to be “above average” (like the mythical residents of Lake Wobegon, which resonates with me as a Minnesotan).

For an ophthalmologist who has recently completed his or her formal training, successfully navigating the written and oral examinations is a major professional milestone and a cause for celebration. Some describe it as a “rite of passage.” A generation or two ago, when the oral examinations were much less standardized, some might have described it as a hazing ritual. That is no longer the case, as the ABO invests considerable time and resources into conducting fair, standardized tests that are psychometrically valid and reliable. We have heard few concerns about the initial certification process and, with rare exceptions, diplomates tell us that they want to see the bar kept high. Patients unequivocally expect that a board-certified ophthalmologist has demonstrated far more than minimal competence.

The expectations for Maintenance of Certification (MOC) are different, at least among practitioners. Since about 98% of diplomates pass the DOCK examination (Demonstration of Cognitive Knowledge) as part of the MOC process, some colleagues ask whether the test is useful and wonder why more people don’t fail. Our response is that we would expect the pass rate to be high – everyone who takes it has already demonstrated that s/he can master the core body of essential information. Identifying that small fraction of practitioners who would benefit from additional study has utility.

However, it has been correctly pointed out that it is possible to “cram” once a decade for the DOCK and then promptly forget most of what was (temporarily) learned, which does little if anything to improve patient care. This is a fair criticism, and one of the reasons why we launched the Quarterly Questions (QQ) option as a possible replacement for the DOCK. Not only are the QQs based on “walking around” knowledge rather than on medical minutiae, but adding recently published articles that your peers have identified as “must read” material should help practitioners keep up with important new developments. Once this process is established, we believe that it will raise the standards of clinical care. Additionally, assessing a diplomate’s recall and reasoning may serve as a means to identify those whose cognitive abilities may have declined as a consequence of age or other factors. Such changes are not always obvious to the individual and could be missed if one relies on continuing medical education participation alone as a surrogate for competence.

Going forward, we hope to offer elective modules or programs, developed in collaboration with the American Academy of Ophthalmology and subspecialty societies, on topics such as safety, diagnostic accuracy, and ethics that would be meaningful to any practitioner, regardless of where he or she is in one’s career arc. Participation would “count” toward continuous certification and these demonstrations of competence and professionalism would be featured on a diplomate’s on-line ABO profile. Engaging our diplomates in this manner will, we believe, “raise the bar” and promote certification as an aspirational achievement.

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