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Testing the test—ABP administers pilot part 3 MOC exam

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Rebecca L. Johnson, MD

February 2014—All primary and subspecialty certificates that the American Board of Pathology issues are now time limited, and diplomates must successfully participate in the ABP’s Maintenance of Certification, or MOC, program to maintain certification. Part three of the four-part MOC program is the evaluation of cognitive expertise, which consists of a secure examination that assesses a diplomate’s pathology-specific knowledge, judgment, and skills. In July 2013, the ABP administered a pilot MOC part three examination. Here, I report the results of this pilot and the feedback from diplomates.

First, an overview of Maintenance of Certification. The ABP, as one of the 24 member boards of the American Board of Medical Specialties, is committed to continuous professional development through its MOC program. MOC assists physicians in maintaining standards necessary for them to provide quality care throughout their careers. MOC assures that the physician is committed to lifelong learning and competency in pathology and is a continuous process that begins Jan. 1 immediately after board certification. It requires ongoing measurement of the six competencies adopted by the Accreditation Council for Graduate Medical Education and the ABMS to ensure that all aspects of practice are evaluated and outcomes are measured.

The six competencies are patient care and procedural skills, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice.

The ABMS and ABP have incorporated an assessment of these six competencies into the four-part MOC program, which consists of professional standing, lifelong learning and self-assessment, cognitive expertise, and evaluation of performance in practice.

The MOC part three examination is mandatory for all participants in MOC. Beginning in 2014, it is given twice each year and may be taken as soon as the seventh year of the 10-year MOC cycle, but it must be passed no later than the 10th year of the MOC cycle. Diplomates may take the exam as many times as necessary to pass. Satisfactory completion of the examination in the seventh, eighth, or ninth year of the 10-year MOC cycle does not change the end point of the cycle, which is Dec. 31, 10 years after the date of certification.

The examination is a proctored, closed-book assessment based on practical, need-to-know, day-to-day skills, judgment, and knowledge that a competent practitioner would be expected to possess without access to reference materials. It is very different from the initial certification examinations in content. The ABP recognizes that certified diplomates have already passed the high hurdle of initial certification and the MOC examination is intended to verify that they have maintained the current knowledge, judgment, and skills in the field to practice safely and competently. The modules contain questions on fundamental practical knowledge and current, clinically valid, practice-related knowledge new to the field since the last certification or MOC exam. About 20 percent of questions in each module (as applicable) assess knowledge of practice environment and lab management such as regulations, patient safety, billing and coding, CLIA, AABB standards for transfusion medicine, cytology guidelines, quality assurance, laboratory accreditation, and professionalism and ethics.

Each examination (AP/CP, AP only, CP only, and subspecialties) is composed of 150 multiple-choice questions in the single best answer format. Diplomates with subspecialty certification have the option to take together a 50-question module in their area of primary certification (AP/CP, AP only, or CP only) and their 150-question subspecialty examination. The two sections are scored as a single exam, and the successful diplomate will meet the part three requirement for their primary and subspecialty certificates. A diplomate with multiple subspecialty certificates will be able to complete two subspecialty examinations in one day.

The ABP recognizes the breadth and variation of pathology practice; therefore, the primary MOC examinations (AP/CP, AP, and CP) are modular and diplomates are able to select modules at the time of the examination that are as relevant as possible to their individual practice settings.

The MOC subspecialty examinations in hematology, molecular genetic pathology, neuropathology, and pediatric pathology are modular, with a total of 150 questions. All modules are graded together as one examination. The other MOC subspecialty exams are single 150-question exams without modules. The ABP Web site has a list of the modules available this year and the deadlines for application and dates of exam administration.

Initially, the MOC examination will be given at the ABP examination center in Tampa, Fla. The ABP is pursuing an additional site for administration in 2015, depending on the number of registrants.

The MOC part three cognitive examination is based on the same proven psychometric principles used in the primary certification examinations. The examinations will be criterion referenced. As with all current exams, aggregate results of the MOC examinations in each primary and subspecialty area will be published annually in the ABP newsletter on the ABP Web site. The cost of the examination is $500 and includes all exams taken during the same session (spring or fall) of administration.

The ABP administered a pilot examination on July 27, 2013 at the ABP examination center in Tampa. Sixty-four diplomates who were certified in 2006 or 2007 volunteered to take the exam. They were required to pay a $100 registration fee, which was refunded after they appeared for the exam. Only primary exams in AP/CP, AP only, and CP only were administered. No subspecialty examinations were given. Fifty diplomates took the AP/CP exam, 11 took the AP only exam, and three took the CP only exam.

The purpose of the pilot exam was to test the ABP system’s ability to administer exams in a modular format, with diplomates selecting the modules at the time of administration. This worked well. Another purpose of the pilot exam was to solicit feedback from diplomates, who completed an exit survey using a Likert scale, with 1=strongly agree, 3=neutral, and 5=strongly disagree. Survey questions and results from the AP/CP diplomates were as follows:

The content was appropriate and reflected knowledge and skills used in my day-to-day practice. Score 2.67.

  • Image quality was excellent. Score 2.13.
  • Issues relevant to my practice were represented. Score 2.57.
  • Difficulty was appropriate for a MOC exam. Score 2.20.
  • CME and SAMs and my professional experience prepared me for this exam. Score 2.65.
  • The time allotted for the exam was adequate. Score 1.32.


Overall, most diplomates felt that the examination was fair and reasonable. Some concerns were voiced about the content of the exam modules not always reflecting new knowledge in the field. Other comments from the exit survey included the following: “Fairly written and questioned practical issues in a day-to-day work routine,” “…the test covered a broad topic base of mostly relevant and important issues,” and “Overall questions are simple but appropriate in difficulty.”

Sixty-one of 64 (95 percent) diplomates passed the examination and therefore met the MOC part three requirement. Two of the individuals who failed the exam did not have modules relevant to their practice available for the pilot exam and probably should not have volunteered to take it. The high pass rate is similar to the experience of other ABMS boards that have been giving recertification examination for some time. To reiterate, the MOC exam is intended to demonstrate that a diplomate had remained current in his or her knowledge, judgment, and skills. It is not intended to be the same high-stakes exam required for initial certification.

The pilot MOC part three examination given in July 2013 demonstrated favorable acceptance of the modular format and content of the examination by diplomates. The ABP plans to use the feedback from exam exit surveys to continually improve the relevance of MOC and reduce the burden of MOC to diplomates. To provide feedback to the ABP, send e-mail to questions@abpath.org.
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Dr. Johnson is chief executive officer, American Board of Pathology, Tampa, Fla. Details of the MOC requirements can be found in the MOC Booklet of Information at www.abpath.org.