Certification, MOC: What's required and what may change

Gerald H. Jordan, MD

Board certification and recertification have been the subject of a number of questions and misunderstandings among urologists. In this interview, Gerald H. Jordan, MD, executive secretary of the American Board of Urology, discusses various aspects of certification, including the meaning of board eligibility, why the written exam is so difficult, the future of the oral exam, and which urologists are required to undergo maintenance of certification. Dr. Jordan was interviewed by Urology Times Editorial Consultant Stephen Y. Nakada, MD, professor and chairman of urology at the University of Wisconsin, Madison.

What is the mission of the American Board of Urology?

The mission of the American Board of Urology (ABU) is actually stated in a way that many missions are. That is, we define our target, we define our goals, and then we define our instrument. Our target is the public; we serve the public. Our goals are to ensure that urology is practiced with safety and quality, and the instrument we use to do this is certification. When I say certification, that covers all aspects of certification, which would include recertification for some and maintenance of certification (MOC) for others.

What is your role on the American Board of Urology?

As the ABU’s executive secretary, I essentially run the office. It’s important that urologists understand I don’t have a vote. I help organize the meetings, set the agendas for many of the meetings, and deal with the diplomates at least at the office level.

A question we hear a lot is, what does it mean to be board eligible? Can you explain?

“Board eligible” was a term that nobody would own up to a number of years back, but because credentialers continue to insist that they use it, it has now been accepted. Board eligibility occurs one time in physicians’ lives, and that is the period from when they complete their residency training to a defined time where their eligibility to sit and be certified expires. For urologists, it’s 6 years, and during that time, there are two exams. The part 1 exam is the written exam, which they are given three tries to pass if they need it. If they are successful on the part 1 exam, they would take the oral exam, which is part 2, and they get three tries at that.

If they fail out, meaning they fail all three times in either exam, then they are no longer board eligible. Similarly, if they time out, meaning their board eligibility period expires, they can never be board eligible by that term again.

Let’s talk about the written exam. Can you tell me why it’s so difficult, and perhaps why it may have a little less clinical relevance than the other exams?

Part 1 of the certifying exam is designed to test all aspects of urology and to test them at all levels through the learning process. So there is basic science on it and there is a lot of clinical management on it. It’s an exam in which a great deal of effort is made to ensure that it tests at the mean and not at the extremes.

Our second certifying exam is the oral exam, or part 2, which is designed the same way, but it is designed to allow the candidate to demonstrate his or her abilities to interpret information and then synthesize it. In many cases, that would be very difficult to do just with a written exam.

Next: Will the oral exam always be necessary in its current form?

Do you think oral examination will always be necessary in its current form?

In my mind, there will come a time when the oral exam will be significantly restructured, if we ever get to the point where we have good simulation. As proceduralists, we all feel that’s where the oral exam fails; it doesn’t allow us to assess procedural and surgical skills. For now, I think the oral exam will continue. Again, the goal of the oral exam is to test a candidate’s ability to synthesize a solution based on certain information. As you know, we’ve struggled a bit with trying to reformulate it to be able to accomplish that.

How do you select or identify oral examiners?

By and large, the oral examiners come from the exam committee, which is a joint committee of the ABU and the AUA. Many, if not all of the senior consultants and the task force chairs of the ABU/AUA exam committee are offered the opportunity to be examiners. Some don’t have the time to do this, but by and large, most of our examiners come from there. Trustees form the other pool of examiners, and we maintain our ex-trustees as examiners up to a point.

Tell us a little about MOC and where you see that going.

MOC currently does not apply to all urologists, depending on where they are in their certificate cycle. It’s important for the urologists and their practice to understand that recertification, or the next time they recertify, is enrollment into MOC, and they will not recertify again. Where the misunderstanding comes is that some think they don’t ever have to take an exam again, and as it is structured right now, that’s not the case. They will have to take another exam. MOC is designed to provide urologists with opportunities for patient assessment or practice assessment and improvement throughout the cycle of MOC, with the examination being the demonstration of ongoing medical knowledge.

Do you think we will ever do away with the high-stakes exam, particularly if MOC becomes more thorough or more vibrant?

The answer is yes. There is tremendous traction at the member boards of the American Board of Medical Specialties (ABMS) to either significantly reformulate the examination or do away with it. The mandate now, however, is that we have to have an exam or we have to have a process that is equally secure and rigorous.

Next: Is it necessary to train at a U.S. residency to become board certified?

Is it necessary to train at a U.S. residency to become board certified?

By and large, yes. We do have an alternate pathway for individuals who are international medical graduates and have international training but who are practicing in the United States. Right now, everybody else has to be a graduate of an Accreditation Council for Graduate Medical Education (ACGME)-approved residency program to be board eligible. Also, providing that the structure of training is the same for Canadian-trained residents, they can become ABU certified. The block diagrams for training must meet all requirements of the ABU.

We now have a certificate of added qualification (CAQ) in pediatric urology and one in female pelvic medicine and reconstructive surgery. Do you predict that we will have more?

Not now. In urology, we certainly have a lot of subspecialized practicing physicians, but at the moment, there is not the infrastructure to go ahead with formal subspecialization.

Can you talk some more about how the female pelvic medicine CAQ is going and what its status is?

We gave our second set of tests in June. The certifying test was developed by the joint committee, which consists of three urologists and three gynecologists. The subspecialty is sponsored dually by urology and obstetrics and gynecology. Obstetrics and gynecology has a lot more accredited fellowships. Those fellowships are now all accredited by the ACGME. Urology has ACGME-accredited fellowships as well. Once certification is accomplished, then the processes differ a bit. Obstetrics and gynecology has an oral exam; urology does not. We then roll them into a urology MOC process, whereas the gynecologist would undergo a different MOC process.

The American Board of Urology is part of the ABMS. How does the American Board of Urology compare to other specialties in the ABMS?

We are a small board, so in a lot of ways, we don’t have the same weight at the ABMS as some of the larger boards, such as internal medicine and family medicine. But we have a member on the ABMS Board of Directors, and I happen to be that member at present. At the level of the Board of Directors, we have equal status with the largest of boards.

Next: Advice for young urologists preparing for the certifying exam

Can you give some advice to the young urologists who are preparing for the certifying exam and preparing for their logs? What are some ideas you have to make it go smoothly?

Let’s talk about the logs first, because there’s really no preparation for the logs other than to practice good urology. The logs are there for us to know what people are doing from the aspects of their practice, and that also means resource utilization.

As far as going for certification, there is a great effort by the exam committee to use the established literature for the written exam. That’s what people have to know for that exam. For the oral exam, unfortunately many young urologists think that they prepare by learning protocols, which is impossible. What they need to do is participate in a process that’s a bit synthetic but designed to mimic what their thought processes would be in practice.

More Urology Times Q&A interviews

Violence against urologists: Data, communication neededLow-risk PCa: Patients can make an informed decisionTwitter’s benefits extend beyond ‘social’ aspects

Subscribe to Urology Times to get monthly news from the leading news source for urologists.