Many of the physicians who practice ophthalmology in the United States have been certified by the American Board of Ophthalmology (ABO). Whereas certificates issued by the ABO before July 1, 1992, are valid for the diplomate's lifetime, those awarded after this date require physicians to participate in the ongoing Maintenance of Certification (MOC) process.

Through the positions we hold on the American Academy of Ophthalmology's (AAO) practicing ophthalmologists curriculum (POC) panels, we have been involved in the MOC process since its inception. Dr. Bacharach not only went through the recertification process in 2005, but he is also currently completing his recertification as an ophthalmologist for the second time. This article reviews the history of the MOC and shares our experiences as developers of the study curriculum and participants in the recertification process.

EMPHASIS ON ONGOING EDUCATION
The current MOC process differs from the original version developed by the ABO in several important ways. According to the ABO's Web site, ophthalmologists whose certificates expire between 2006 and 2009 can complete the required components in any order over their limited 10-year certification cycle. The new model, which applies to diplomates whose certificates expire in 2010 or later, states that ophthalmologists must complete the components in a specific, predefined order. The goal of the MOC process is to encourage the ongoing acquisition and retention of key knowledge. Developed in accordance with the standards of the American Board of Medical Specialties, the MOC process includes the following elements.

EVIDENCE OF PROFESSIONAL STANDING
Diplomates must hold a valid and unrestricted license to practice medicine in the United States, its territories, or a Canadian province.

EVALUATION OF PRACTICE PERFORMANCE
Diplomates seeking recertification must complete an office review using patients' records. They must review 15 records according to three modules of their choice (five records for each module).

EVIDENCE OF COMMITMENT TO LIFELONG LEARNING AND SELF ASSESSMENT
The first part of this component requires diplomates to complete an average of 30 category 1 continuing medical education credits per year from an organization approved by the Accreditation Council for Continuing Medical Education. Eighty percent of the credits should be in ophthalmology, and at least 3 hours must be in ethics. The second part of this component—the periodic ophthalmic review tests (PORT)—comprises a series of 50-item, online assessments of core ophthalmic knowledge. As defined by the ABO, core ophthalmic knowledge is that considered fundamental to the practice of ophthalmology regardless of the emphasis of an ophthalmologist's practice. All physicians are required to achieve a passing score of 80% in one PORT covering core knowledge and one PORT covering a practice emphasis area (PEA) (eg, glaucoma). The ABO strongly encourages physicians to select the same PEA they plan to choose for the demonstration of ophthalmic cognitive knowledge (DOCK) examination.

EVIDENCE OF COGNITIVE EXPERTISE
To satisfy this section, diplomates must complete the DOCK examination once during the 10-year MOC cycle. The DOCK is a secure, proctored, 150-question examination administered every September at 230 computerized testing centers. The test consists of one 50-item module on core ophthalmic knowledge and two 50-item modules covering a PEA.

PREPARING FOR THE DOCK
The DOCK examination is typically the greatest source of anxiety for physicians completing the MOC process. How can they prepare for an examination that covers areas of ophthalmology (eg, pediatric, refractive surgery, neuro-ophthalmology, oculoplastics, retina, uveitis) that they do not practice regularly? Fortunately, several resources are available to help physicians get ready for recertification.

When the ABO was preparing the DOCK examination, it asked the AAO to identify and define the areas it thought were important for delivering quality eye care. In response, the AAO assembled panels of practicing clinicians, most of whom have time-limited certificates, to create the POC. This free online resource is available to all members of the AAO as part of the MOC Exam Study Guide (http://one.aao.org/ce/moc/mocstudyresources.aspx). Physicians preparing for the DOCK examination may access the guide whenever they want and study at their own pace.

The study guide for every PEA follows a standard format. Each of the 47 topics in the glaucoma PEA consists of a two- to four-page outline that is usually accompanied by images. The documents are easy to read and discuss subjects such as differential diagnosis, risk factors for ophthalmic diseases, and patients' management.

The MOC Exam Study Guide also includes tools for self assessment. Clinicians receive immediate feedback as they answer hundreds of multiple choice questions or take timed examinations that simulate the online test-taking experience. This feature allows physicians to identify gaps in their knowledge and take steps to improve areas of weakness.

Many physicians prefer to prepare for the recertification process by completing the AAO's MOC exam review course. In addition to receiving intensive instruction on the topics covered by the DOCK, physicians can earn a maximum of 25 CME credits by attending the weekend program. Registration is now open for the next session (scheduled for July 24 to 26, 2009) at one.aao.org/ce/moc/mocexamreview.aspx.

The MOC exam review course is taught by the same ophthalmologists who wrote the curriculum on which the DOCK is based. Instructors devote 1 full day to the core curriculum and a second full day to the materials covered by a specific PEA (eg, glaucoma). Attendees usually have ample time to interact with faculty and ask questions during the day devoted to reviewing PEAs. They may also sign up for an optional third day of instruction dedicated to a second PEA.

In the past, Dr. Bacharach has noted that many glaucoma specialists who complete the MOC exam review course already hold lifetime certificates and therefore are exempt from the MOC process. These clinicians are instead interested in furthering their education and improving the quality of care they provide to their patients. Many of the physicians who have attended the course have reported that it is an excellent review of clinical ophthalmology.

CONCLUSION
As the current chair of the POC's glaucoma panel (the source of the content for the glaucoma portion of the DOCK test), Dr. Bacharach can assure his colleagues that a broad range of experts from academia and private practice carefully chose the materials included in the AAO's study guides to reflect the information that is most relevant to practicing glaucoma specialists. He and his fellow panel members also have assurances from the ABO that the DOCK is based on information contained in the AAO's MOC Exam Study Guide and the materials prepared for the MOC exam review course.

Because we and the other members of the glaucoma panel hold time-limited certifications from the ABO, we are obligated to complete the MOC process. We are therefore very mindful of the burdens faced by busy practicing ophthalmologists and use this awareness to add only clinically relevant material to the POC.

We wish the glaucoma specialists who are currently renewing their ABO certification through the MOC process the best of luck.

The authors acknowledge the assistance of past and current members of the POC glaucoma panel for creating the study materials as well as Anne Coleman, MD, Dr. Bacharach's mentor and the first chair of the Glaucoma Panel; Rayna Ungersma of the AAO's support staff; and Rich Abbott, MD, past chair of the AAO's POC Committees. They wish success to Jeff Nerad, MD, who has succeeded Dr. Abbott as the chair of the AAO's POC Committees.

Jason Bacharach, MD, is the director of research at North Bay Eye Associates, Inc., in Sonoma, California, vice-chair of the Glaucoma Department at California Pacific Medical Center in San Francisco, and chair of the Practicing Ophthalmologists Curriculum Glaucoma Panel. Dr. Bacharach may be reached at (707) 762-6622; jb@northbayeye.com.

Flora Lum, MD, is policy director, Quality of Care and Knowledge Base Development, AAO. Dr. Lum may be reached at (415) 561-8592; flum@aao.org.