Unresponsiveness versus unconsciousness.

who received certification before 2000 to participate in its Maintenance of Certification in Anesthesiology process. She suggests that this approach may contribute to skepticism related to maintenance of life-long learning and the board certification process. I would suggest that clinical competency is primarily an assessment best performed locally in health facilities and systems. Although board certification and participation in maintenance of certification processes provide local facilities and systems with valuable information and help assure them that participants have met minimal but important requirements related to medical knowledge, performance reporting, and licensure, these processes do not necessarily reflect clinical competence. The ABA and its parent organization, the American Board of Medical Specialties (ABMS), have appropriately recognized during the past several decades that diplomates who were issued nontime-limited board certificates should not retroactively have time restrictions placed on them. Instead, the ABA and other ABMS member boards have encouraged voluntary participation in maintenance of certification processes for their diplomates who hold nontime-limited certificates. It is a decision best left to local health facilities and systems as to whether they wish to require participation in maintenance of certification processes by physicians who hold nontimelimited certificates as one measure within a continuum of methods of evaluating clinical competence. Eger provocatively suggests that one potential factor associated with the findings of Tessler et al.1 may be that older anesthesiologists as a population are generally less competent physicians than younger anesthesiologists. Given the context, it appears that he is directing his comments at Canadian anesthesiologists. However, I presume he means to suggest that his postulated factor applies to the United States as well, since he quotes John Lundy, formerly of my own institution. Interesting thought, yet clearly not provable or disprovable. What we do know is that pass rates of ABA written exams during the 50-yr period of 1960–2010 do not vary significantly. These exams do not measure clinical competence, but they do reflect minimal knowledge acceptable to the ABA for physicians who took these examinations annually during this period. Whether or not this information would alter Eger’s thinking rests solely with Eger.