Effects and Unforeseen Consequences of Accessing References on a Maintenance of Certification Examination: Findings From a National Study

Acad Med. 2018 Apr;93(4):636-641. doi: 10.1097/ACM.0000000000002024.


Purpose: Increasing criticism of maintenance of certification (MOC) examinations has prompted certifying boards to explore alternative assessment formats. The purpose of this study was to examine the effect of allowing test takers to access reference material while completing their MOC Part III standardized examination.

Method: Item response data were obtained from 546 physicians who completed a medical subspecialty MOC examination between 2013 and 2016. To investigate whether accessing references was related to better performance, an analysis of covariance was conducted on the MOC examination scores with references (access or no access) as the between-groups factor and scores from the physicians' initial certification examination as a covariate. Descriptive analyses were conducted to investigate how the new feature of accessing references influenced time management within the test day.

Results: Physicians scored significantly higher when references were allowed (mean = 534.44, standard error = 6.83) compared with when they were not (mean = 472.75, standard error = 4.87), F(1, 543) = 60.18, P < .001, ω(2) = 0.09. However, accessing references affected pacing behavior; physicians were 13.47 times more likely to finish with less than a minute of test time remaining per section when reference material was accessible.

Conclusions: Permitting references caused an increase in performance, but also a decrease in the perception that the test has sufficient time limits. Implications for allowing references are discussed, including physician time management, impact on the construct assessed by the test, and the importance of providing validity evidence for all test design decisions.

MeSH terms

  • Analysis of Variance
  • Attitude of Health Personnel*
  • Certification
  • Clinical Competence
  • Education, Medical, Continuing
  • Humans
  • Physicians*
  • Specialty Boards*
  • Time Factors
  • United States