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Berquist.Thomas{at}mayo.edu
In his presidential address to the Radiological Society of North America in 2006, Dr. Robert R. Hattery stated, "As physicians, we are given the privilege, by the public, for credentialing, certifying, and maintaining ourselves as professionals. We have the freedom to determine our own destiny. We must forge a course that will ensure this privilege" [1]. Dr. Robert J. Stanley, AJR Editor Emeritus, dedicated his editorial to national heath care concerns in the April 2004 issue of the American Journal of Roentgenology. In the editorial, titled "Earning and Maintaining the Public Trust," he said we must "develop a program to show measurable quality improvement and restore confidence in the American health care system" [2]. In a second editorial in January 2005, dealing with maintenance of certification (MOC), Dr. Stanley commented, "voluntary enrollment by many of the lifetime certificate holders undoubtedly will improve and enrich our great specialty" [3].
Why is MOC so important? A brief walk through the history of organized, or disorganized, medicine is necessary to grasp the problem and need for all practicing radiologists to commit to enrolling in the MOC process. In the early 1900s, there was little organization and oversight of medical training and practices. The Flexner report in 1910 began to address standardization of medical training [4, 5]. Organization of medical subspecialties followed to assure the public of physicians' subspecialty credentials. In 1933, an advisory board was formed to oversee the first four subspecialty boards. These boards included ophthalmology, otolaryngology, obstetrics, and dermatology. The American Board of Radiology (ABR) was established in 1934 and today includes three categories: diagnostic radiology, radiation oncology, and radiologic physics. In 1970, the advisory board evolved into the current American Board of Medical Subspecialties (ABMS) [6]. Since 1991, the ABMS has expanded to oversee 24 subspecialty boards. The mission of the ABMS is to establish standards for specialty certification, MOC, and performance assessment [6].
In the late 1990s, the ABMS established a Task Force on Competence that was followed by a commitment to MOC by all 24 member boards, including radiology. Radiation oncology began awarding time-limited certificates in 1995, followed by radiologic physics in 2002. From 1934 until the end of 2001, all residents in diagnostic radiology who passed the final oral certifying examination were given life-time certificates. Beginning in 2002, the ABR established time-limed 10-year certificates in diagnostic radiology. Every board-certified radiologist since that time must enter MOC to maintain certification in the specialty. The change has resulted in two distinct groups of practicing radiologists, those who must enter MOC and those with lifetime certificates (1934–2001) who should enter MOC.
Focusing on the lifetime certificate holders, one could ask, "What do I have to do, and how can I get started?," and not, "How much time does it take, and what will it cost?" We would prefer that this large group of radiologists ask themselves, "Why would I not want to focus on lifelong learning and improve my practice, my patient care, and our specialty?"
MOC has four components based on the six competencies established for residency training programs by the Accreditation Council for Graduate Medical Education (ACGME). The six competencies include:
MOC focuses on a commitment to lifelong learning but also allows radiologists to choose their own continuing education and career paths. The four parts to MOC include the following [7]:
Lifetime certificate holders have nothing to lose because their certificate is a lifetime certificate. To begin the process of MOC, one can simply log on to the ABR Website at www.theabr.org, click on Maintenance of Certification for Life-Time Certificate Holders, and enroll. My personal experience with MOC has been quite positive. Radiologists should not focus on the examination (Part III of MOC). Study guides will be provided for each subspecialty area, and the examination will be based on our practice profiles. Therefore, you will be tested on what you do in your practice. This approach allows flexibility in your practice, permitting radiologists to modify the selected focus in lifelong learning with changes in practice or location throughout their careers. Participation in MOC and taking the exam ination may also simplify relocation and licensure in different states [5].
The focus of MOC is on Part II (lifelong learning) and Part IV (practice quality improvement). I am able to obtain my two required SAMs at the annual meeting of the Society of Skeletal Radiology each year. This requires limited time and effort. The results allow me to compare myself with peers in the field and to identify the strong and weak areas in my knowledge base. These CME products are not pass–fail. Therefore, there should be no anxiety about taking the test. SAMs are also available online at www.arrs.org and in our quarterly publication, AJR Integrative Imaging. The AJR provides CME articles in each issue (six articles are in this issue alone). The ARRS provides these free resources as a benefit of society membership. Therefore, meeting the requirements for Part II of MOC is quite painless.
Fulfilling the requirements for practice quality improvement (Part IV of MOC) can be accomplished by participating in individual-, institutional-, and society-based projects. I personally participate in several department projects that fulfill Part IV of MOC. The American Roentgen Ray Society also provides information about practice quality improvement on its Website, www.arrs.org (click on "pqi Connect" on the right side of the page).
Currently, there are no requirements to force lifetime certificate holders to begin the process. Many lifetime certificate holders are waiting for third-party payers or state licensing boards to mandate participation in MOC. Part I of MOC requires that an unrestricted state license is maintained. Interestingly, what some are waiting for is beginning to happening in several states. At its May meeting, the House of Delegates of the Federation of State Medical Boards "took the next steps to develop a model policy that will assist states requiring physicians to demonstrate continuing competence as a condition for relicensure" [8].
With this information and the national focus on quality, patient safety, and professionalism, the reasons for all to participate in MOC should be obvious. We should already all be committed to lifelong learning. We should all be engaged in programs to improve our practice and patient care. The most obvious reason for all to enter MOC is to fulfill our obligation to patients, the public, and the medical profession.
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  T. H. Berquist The AJR Education Mission: How Are We Doing? Am. J. Roentgenol., June 1, 2009; 192(6): 1453 - 1453. [Full Text] [PDF]
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T. H. Berquist To Print or Not to Print: Are We Ready for Online Only? Am. J. Roentgenol., October 1, 2008; 191(4): 949 - 950. [Full Text] [PDF]
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