Oscar Wilde famously described a cynic as someone who knows the price of everything and the value of nothing. We may perhaps be forgiven for allowing some cynicism to creep into our discussions about Maintenance of Certification (MOC), given the wide gap that had developed between its cost and its perceived worth.

But as we proclaim to members the ACC's remarkable achievements in restoring value to ongoing certification, we should recall that we physicians ourselves created MOC, which we always expected to have some cost, in response to a genuine challenge to our autonomy.

In the late 1980s, as the unsustainable growth of medical spending became apparent, physician competence became an early focus of the nascent sea change we have now come to call "value for volume."

Payers, hospitals and patients rightly began to question the prudence of paying doctors who had obtained board certification for life based upon a single high-stakes examination, taken just out of training, with no need to demonstrate ongoing engagement with lifelong learning. Had physicians not responded to that concern, other bodies of varying competence and intent – federal, state, private or all three – likely would have. We needed to police ourselves or be policed.

The physician-run American Board of Internal Medicine (ABIM) responded by doing what they already knew best how to do: they gave tests. Initially the disconnect between that summative approach to assessment and a more formative approach to learning raised few objections, but with time, the ABIM's approach to maintaining security and keeping up with the growing science of standardized testing became increasingly costly and dehumanizing.

We all know what happened next; as Richard A. Chazal, MD, MACC, so aptly put it, while the ACC developed into an organization designed to teach you, the ABIM devolved into an organization designed to test you.

To its great credit, after initially obtaining a suspension of MOC Part IV and helping end "double jeopardy" for dual-boarded cardiac subspecialists, the College has now negotiated choices that definitively restore value to the continuous demonstration of competence. (The details of options now open to members are outlined at ACC.org/MOC and in the March issue of Cardiology. See key details in Number Check.)

Much has been made of the cost of the Collaborative Maintenance Pathway (CMP) with respect to MOC. Recall that physicians need to meaningfully demonstrate competence, failing to do so puts quality patient care and our autonomy at risk, and the CMP is not mandatory.

Then consider this: a tall latte from Starbucks costs $2.95, which taken daily, comes to a yearly cost of $1,076.75. The cost of CMP, including membership in the ACC, the fee to ACC for the CMP modules, and the fee to the ABIM to maintain MOC, (and excluding the savings from board review, CME, travel, and lost work time) comes to $963.00, excluding section memberships, per year.

Meaning that you can now review your knowledge of your specialty on a continuing basis with the world's experts in your field, identify knowledge gaps, correct them, and then demonstrate competence and maintain certification – all for a fraction of the daily cost of a cup of coffee. The most embittered world-weary cynic should see some value in that.

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