In matter of style, swim with the current; in matters of principle,
stand like a rock. —Thomas Jefferson
I get to a stream once a year if I’m lucky, but I do enjoy fly fishing.
For one thing, it reminds me that I can be patient when I want to be.
For another, it resurrects a host of useful lessons learned in other
I have a bit of trouble explaining what draws me to the sport. It’s often a beautiful site. The skills involved—taking a visceral “read” of the water, remaining at once at ease and alert, learning to finesse a proper cast, following your instincts, adjusting strategy as you go—put you in the moment. Clears out the cobwebs.
I practice catch-and-release with barbless hooks. I enjoy the pursuit, catch my fish, we have a look at one another, I let him go. There is a contest between us, but I know when I’ve won; there’s no need to go for blood. We still need to swim in the same water. We’re both fighting the same current.
All of this came in the side door when I was thinking about what I had to say on the new Maintenance of Certification, or MOC, requirements for pathology that went into effect this summer. I understand that there is an interview elsewhere in this issue of CAP TODAY with Elizabeth H. Hammond, MD, who chairs the CAP Education Committee. I’m sure Dr. Hammond will present the essential facts, so I won’t go into those.
Though the American Board of Pathology, or ABP, has not yet published all the concepts and topics it feels are important, it has indicated something about the structure of MOC. After the first 10 years of receiving a time-limited certificate the current plan is to offer a closed-book exam in anatomic pathology, clinical pathology, and the various subspecialties. To recertify in both anatomic and clinical pathology, diplomates would need to take separate examinations with separate fees.
I have no quarrel with the concept of MOC; in fact, we are long overdue in offering MOC. Implementation, though, is where the rubber meets the road. My concerns relate to structure of our Boards that separates the profession as if pathology is made of two separate areas, anatomic and clinical pathology. I fear that many of those pathologists who sit for the first recertification examinations 10 years from now will choose to be tested in only one area of practice. We could see a sharp drop in the number of pathologists who are AP/CP certified and a rise in the number who are boarded only in their special interest.
Like fly fishing, this is all about reading the water. Medicine has witnessed increasing specialization, and pathology is no exception. More and more of us are focused on individual components of pathology. It’s fine for us to do that, but it is not acceptable to abandon the general profession. Each of us is professionally obliged to support the profession. Our authority in advocating for patient safety, our credibility in fostering quality improvement, and our ability to set a standard of excellence for all branches of pathology would be endangered if we were to splinter into so many isolated cells.
The adaptability of those who might elect limited certification would degrade the profession significantly. The worry here would be a potentially dramatic adverse effect on coverage of services. Right now, when there is a need to cover a laboratory service for a period of time, most pathologists can provide coverage. Ten years from now, as pathologists become more selective in recertification, many institutions or pathology groups may find coverage difficult. Those who recertify only in anatomic pathology might no longer be qualified to provide laboratory services for the clinical laboratory. The scope and depth of our profession could be deeply compromised.
If limited certification were to become commonplace 30 years from now, what would happen to the essential role of the pathologist as the physician whose work bridges the profession? I am reminded of a bit of light wisdom from my training days. What is a pathologist? A pathologist is what a pathologist does. With limited board recertification, we could be doing a lot less.
In the traditional framework, the pathologist has flexibility. Adjusting to a new practice realm might require a bit of finesse, some CME, but it is doable. In the fly fisherman’s parlance, if one fish gets away, there are other fish; opportunities to pursue new roles in the laboratory are plentiful.
I doubt seriously that the intentions of MOC are to limit the profession but rather to ensure a base level of competency. So we have much to talk about as a profession. My hope is that the ABP will be willing to hear what we have to say. The CAP is trying to engage the ABP in this important dialogue. We will need to be patient and persistent. Time is on our side, as is the pace of our science. I would like to hope so, but we can hardly afford to stand passively in our waders waiting for the next fish to strike.
MOC is mostly a matter of style; a new way to frame the continuing education that we’re already doing. But the interdisciplinary nature of our specialty is a core aspect of our identity as specialists, and preserving the character of our specialty is a matter of principle.
In the meantime, the only pathologists required to participate in MOC are the residents who graduated this summer and took their boards. For them, the clock is already running. For the rest of us, lifetime certification remains safely in place.
Dr. Sodeman welcomes communication from CAP members. Write to him at email@example.com.
The interview with Dr. Hammond appears in Recertification
a good bet for all. The MOC requirements are posted under Maintenance
of Certification on the ABP Website.