ANNOUNCER:

Welcome to ASA’s Central Line, the official podcast series of the American Society of anesthesiologists edited by Dr. Adam Striker.

HOST, DR. STRIKER:

Welcome to ASA’S Central Line. I'm Adam Striker here with Dr. David Martin, Chair of ASA’s section on Education and Research. We're here today to talk about MOCA our discipline of lifelong learning. We plan to shed some light on requirements, resources, and even bust a few myths in today's podcast. Welcome, Dr. Martin.

DR. MARTIN:

Hi Adam. Thanks for having me on the program.

DR. STRIKER:

My pleasure. Thanks for joining us again. First, let's start with the basics, get some of the details out of the way. Um, there's a bit of an alphabet soup when it comes to the topic of medical accreditation. We’ve got ABA, ASA, ABMS, CME, MOC, etc. Can you tell us what these acronyms mean? Which are accrediting bodies vs. accredited bodies, and how they all fit together in the broader landscape of continuing medical education.

DR. MARTIN:

Yeah, great question. I mean from the thirty thousand foot view, we’re talking about how an individual demonstrates that they've gone through these critical steps of education from medical school to residency to coming on a hospital staff and being safe and confident, uh, throughout their lifetime of practice. And so the graduate medical education world, uh, certifies or accredits various medical schools for giving the MD degree. Similarly, we have organizations that accredit, uh, residencies, and then have we boards and medical specialties like the American Board of Anesthesiologists that will accredit or certify that a person's finished the residency and has become a, uh, diplomate in that specialty and then we have licensing boards in various, in, in every state will have a medical licensing board that will speak to a person's ability to practice medicine in that state and then a hospital staffs also have the obligation to credential and privilege their staffs. So, ah, it is a bit of alphabet soup but the whole process is to protect the public. To make sure that when a physician treats a patient that uh, they are a bonefied person practicing the art. And unfortunately, across the nation, there have been examples of people impersonating physicians, uh, doing things they shouldn’t, and so that’s why there are so many regulatory steps to try to make sure that folks uh, really are who they say they are, and that they’re practicing safely.

DR. STRIKER:

Well, since we’re talking about MOCA on this podcast, let’s focus in on specifically the American Board of Medical Specialty, how it relates to the ABA, and how that relates to CME’s and uh, the maintenance of certification program.

DR. MARTIN:

Sure. So when a physician finishes their anesthesiology residency, they can sit for certification by the American Board of Anesthesiology and become a board certified anesthesiologist. Other specialties have other boards and that group of American Board of Medical Specialties kind of make sure that they're all on the same page and in the old days when I finished residency, you were one and done you were board-certified and you had a lifetime certificate and you still had to do regular continuing medical education to maintain your state license, but that's as far as it went. And what happened was that the American Board of Medical Specialties started to recognize that that one and done certification was probably insufficient. We're all lifetime learners, “lifelong learners” is the term and, um, I think that's a really good thing. When I finished residency, we did not have video laryngoscopes. We didn’t have ultrasound for regional anesthesia, and I’ve had to learn those things after I finished my residency. And so I think the the Board of Medical Specialties recognizes that medicine is continually changing and they want to set up some standards to make sure that physicians keep abreast of some of those changes.

DR. STRIKER:

And, the ABA, or the American Board of Anesthesiologists, is one of the 24 medical specialty boards, that's under the American Board of Medical Specialties, correct?

DR. MARTIN:

That's correct, yes, and, ah, I think the other part of your question is, what does maintenance of certification mean? That is the newer version of ongoing certification. So, rather than the old lifetime certificate the various boards required re-upping or renewing certification and initially that took the form of a repeat of the board exam every 10 years. So maintenance of certification initially was just repeating your board exam every 10 years and it's has since become a little more nuanced, and a little more focused in really, in meeting the needs of physicians rather than, um, just your repeat of a high-stakes exam. And we’ll get into that a little bit more when we talked about MOCA and of course maintenance of certification is the generic term, but when you apply to anesthesiology you add the extra “A”, so MOCA is just the ABA’s or anesthesiology’s version of maintenance of certification.

DR. STRIKER:

So, the American Board of Medical Specialties made a shift back in the mid 2000’s toward a stronger emphasis in on-going learning which you mentioned already, um, instead of the one big exam, now there is continuous assessment versus a single high stakes exam. Why the shift?

DR. MARTIN:

Well, I think that it came from a variety of influences. One was a sense from the general public that they wanted to make sure that physicians maintain high standards throughout their career. The second is a recognition from professional educators that had good evidence that the way adults learn and maintain their knowledge, uh, was evolving, and that, uh, more continual assessment and, uh, objective goals were ideally applied to the process. So, I think that there were a variety of influences that went into designing these on-going maintenance of certifications rather than the old school belief that you could pass a big exam and then 30 years later still be competent based only on that demonstration.

DR. STRIKER:

Well, let’s focus in a little bit on the anesthesiology side of this, um, cuz every medical specialty board has their meet and certification program, but can you delineate a little bit on what the anesthesiology board has done to perhaps respond to physicians’ concerns and desires in terms of their on-going lifelong learning.

DR. MARTIN:

Sure, ah, just by way of clarification, because it's not always obvious that we’re talking about the American Society of Anesthesiologists’ ASA, which is a professional organization. And that, that's where I spend most of my time and effort outside of the clinical work, ah, helping the profession. That contrasts the American Board of Anesthesiologists, which is a group of anesthesiologists who are, ah, designing this maintenance of certification program, setting up its criteria, and evaluating the results and although the two names sound similar and even some of the anesthesiologists, you’ll recognize the names, wear hats and both fields, they are separate entities and so when I'm talking about some of the novel work that the ABA has done recently, the Board of Anesthesiologists, I'm speaking as an outsider, as an anesthesiologist that’s working with the American Society of Anesthesiologists. But from my perspective the ABA, the board, has been very forward-thinking in at least two areas. One has been that they emphasize patient safety, recognizing the tradition of anesthesiology as being a leader and patient safety, called out as early as The Institute of Medicine's “To Err is Human” report. Um, we’ve really been at the cutting edge of patient safety and the ABA required 20 hours of the, um, CME to be devoted to patient safety and that was in in excess of any of the other, uh, medical specialty boards and continues to be, uh, the number one Board of Medical Specialties, um, requirements for patient safety. So I think that's been very forward-looking. The other area that I think is very forward-looking and practical is that the American Board of Anesthesiologists came up with a new way of demonstrating on-going certification and rather than requiring that high-stakes exam every 10 years, they've created a product called the MOCA minute which presents those questions on an on-going basis in a much less stressful way, in a way that tailors questions to the clinical practice specialty areas, uh, and individualizes it and yet they've been able to show statistically in a rigorous fashion that they're getting the same kind of results as they got with the high-stakes exam. So, that's taken a lot of the burden off of studying for that big exam every 10 years. So the ABA, I think, is really doing a good job of looking forward towards the future and advancing the profession.

DR. STRIKER:

Do you know if, uh, other Medical specialty boards have taken more of a proactive stance addressing their Specialties specific concerns? I think everybody in anesthesiology would agree that patient safety is a huge part of our practice and I was just curious if, if you know of other specialties have tailored their programs to, ah, certain facets of, of those specialty practices?

DR. MARTIN:

Yeah, I don’t know in a lot of detail what their challenges and opportunities and contributions have been, so I'm sure I'm leaving very important things out by not mentioning them, but I will say, ah, that we offer our patient safety material to all the other boards. So, if you are a cardiologist for example, and you are interested in patient safety, you can take the patient safety materials offered by the American Society of Anesthesiologists and that will count to the internal medicine requirement if you're a special type of cardiologist, for example. So, I know that the other boards, in this case internal medicine, uh, has, you know, followed along with some of the things that the ABA is doing, and I know that the American Board of Anesthesiologists has published some of their results on the MOCA minute and I believe that other medical specialty boards are looking to adopting similar techniques in their areas.

DR. STRIKER:

So as part of maintenance of certification in anesthesiology, CME’s is, are required. The ASA offers CME’s to their members. How does the ASA get accredited to offer those?

DR. MARTIN:

Yeah, that's a great question. So I mean even before maintenance of certification came along, State medical boards required on-going continuing medical education and they recognize that there had to be some teeth to that, some validity to the educational activities. Otherwise, you can have a fly-by-night outfit that just took cash money and gave you CME credits and that you would have a a, um, short circuit around the intent of the medical boards. So they created an organization called the Accreditation Council for Continuing Medical Education or ACCME, which is a governing body and they inspect, ah, accredited agencies like the American Society of Anesthesiologists to make sure that, ah, we are offering true valued CME’s. So it’s a process very much like Joint Commission. They might come to your hospital and go through your policies and your, ah, you know, make sure that you have everything in place. It’s a similar kind of inspection that makes sure that, for example, that ASA is evaluating the needs of the learners, the gaps between what they know and what they need to know, that we evaluate conflicts of interest, that we provide material that is free of bias, that we demonstrate that our medical education actually is connected to desirable outcomes in, ah, performance in the learners. So, it's a very rigorous process and that, uh, is necessary to give credibility to the entire endeavor, weather at the State Medical Board or now maintenance of certification. When a learner completes a CME credit, we need to make sure that all the processes and steps are done correctly to justify that.

DR. STRIKER:

Well, David, um, I know there’s four parts to MOCA, and this is where I think a lot of people get confused. I myself have spent some time at the annual meeting talking with the, uh, representative the ABA just to get a better understanding, and I think it might be helpful here to go to reach part and briefly describe what each represents and the requirements for them.

DR. MARTIN:

Yeah, of course. It is confusing. Um, so the four parts are as follows: Part 1 is your attestation to your professional standing that's basically saying that you have a active unrestricted license to practice medicine, that you have privileges in your hospital. So that's an attestation even though that you can actually practice without that the ABA doesn't know that you have that until you attest to its so that’s Part 1.

Part 2 is the lifelong learning that we’ve talked about - the continuing medical education credits. And, as we mentioned, there is 250 of those credits required over 10 years and have to be distributed in a way that, um, they can be a little bit inhomogeneous, a little bit lumpy, but you do have to have half of them in their first five years and then another half in the second five years and all of those 250 CME’s over the 10-year period, at least 20 of those have to have that special designation for patient safety. And that's where ABA leads the other boards. In your Part 2, you have to have at least the number required number of CME’s and at least twenty of those in patient safety.

Part 3 is that assessment of your knowledge, which ABA now has for the MOCA minute. I think that again depending on when you entered MOCA, you still may have an option to take the high-stakes exam. So either the high-stakes exam or participation in MOCA would be Part 3.

And finally, Part 4 is quality improvement or demonstrating that you can work within a system, working with teams. And there's a variety of ways to, ah, meet Part 4 requirements. One is ,simulation, which could be a on-site live sim-center experience, or recently, the ASA has come up with an online simulation experience called SimSTAT. So this allows you to learn how to work together in in a simulation environment. Another option other than simulation to meet Part 4 requirements are quality improvement projects. So you may take a problem in your local practice and go through, uh, several steps to improve it, report on that, and get credit there. One example might be that, let's say, your rate of eye injury or corneal abrasions is higher than you think it should be. So you start to study the problem, you identify where the solutions might be - protecting the eyes taping them better, for example, and you measure your rate of corneal abrasions before and after your intervention and you learn something about your own practice. That, ah, is something that I think we all do all the time in our practices. We’re always striving to improve and again, ah, even though they were doing at the ABA doesn't know we're doing it until we report it. So a lot of the activities that go into, ah, meeting the requirements for MOCA are things we’re doing already. But we just have to go to that extra step to report them to get credit for them.

DR. STRIKER:

That really helps clear up at least the basics, I'm sure, for a lot of people listening. Um, but let's take a moment here to step back and, um, ask more of a general question. Does it benefit patients when the anesthesiologists keep up with certification? In other words, do our patients know if we’re board certified or care? Why does it matter? Maybe just sort of a general, or your general impression of what all this means in in the broader context.

DR. MARTIN:

Yeah, well, I think that it's essential for anesthesiologists to be lifelong learners, to take advantage of new knowledge as it comes out. I can say without any doubt in my mind that the practice of anesthesiology is different now than when I finished my residency. There are new drugs, there are new pieces of equipment. Ah, we're doing more complex surgeries on sicker patients and without lifelong learning and, and these activities that are being measured in maintenance of certification, I think you can't practice as well as you should and I think our patients deserve the best practice we can deliver. So I think without a question it benefits patients.

Now the question is, do you need an extra regulatory agency to enforce that? And I think that the reality is that this is kind of a low bar that there probably are anesthesiologists out there that, for whatever reason, aren't meeting at minimum standard and I think our patients deserve the assurance that there are the standards out there. But I don't think that this process, I hope this process isn't requiring us to do anything we wouldn't be doing already because I think that commitment to being lifelong learners to taking advantage of new medical knowledge and applying it is something that we signed up for when we took the Hippocratic Oath to, ah, to be physician. So I think, I think it does benefit, ah, patients.

Now does it benefit the anesthesiologist? Well, I think that you could make the argument that in addition to being your best, and doing the best care of patients, having that certification does mean something. If I were contracting with my hospital or an insurance carrier, ah, I would think that would be a real feather in the cap of the group to say that everybody in the group is, ah, is board-certified. You don't need to be board-certified have a medical license. You’re rising to a higher standard and I think there's some competitive advantage in that statement as well.

DR. STRIKER:

You brought up an interesting point, which I hadn't really thought about. Would you say it’s fair to say that an ideal state would be that this program, maintenance of certification, would just be cataloging what all of us do on a daily basis, thereby not increasing our workload but demonstrating to our patients and the public what we're already doing is worthwhile. Is beneficial and is important for their well-being.

DR. MARTIN:

I think absolutely, in an ideal world that would be absolutely true. Now, it is not always so easy to learn new stuff and it is is just like if you, you know, join the gym and you worked hard to get stronger and more fit. Ah, you’d have to put effort into gain that level of fitness and if you didn't maintain it and you just sat on the couch that would all go away. I think our brains are similar. It takes a certain commitment and work to stay current, and if we don't do that out of our own discipline, we atrophy a bit and so in an ideal world, everybody would be ideal body weight and be fit and what we know that we need a little encouragement to get there.

DR. STRIKER:

Excellent point. Can you stay with us for just a moment? We’ll be right back after a quick break.

(ANNOUNCER/MUSIC):

ASA makes it easy to fulfill MOCA 2.0 requirements and enjoy continued learning with quality best-selling education. See what catches your eye at asahq.org/education.

DR. STRIKER:

Most of our listeners are probably going to be anesthesiologists, but some patients may be listening and some anesthesiologists who want to give this information to their patients are, are listening, no doubt. Is there a website or a place where patients can go to see if their anesthesiologist is certified.

DR. MARTIN:

Yeah. There's a great website, uh, called “Certification Matters” - I think the URL is www.certificationmatters.org, all one word.

DR. STRIKER:

Perfect. So let’s do some myth-busting here. Is it true that you could just get requirements out of the way – maybe earn a hundred twenty five creds in year one, so you don't have to worry about it again until year six?

DR. MARTIN:

No, ABA has put some restrictions as to how many can be earned in each year - I think the maximum is 60 per year. Their intention is to try to distribute that learning over the 10-year period, realizing that you know, sometimes you have a really busy year and other times you have more time. So it may not be entirely even but they certainly want to discourage people from putting everything off to the last minute or doing all their, ah, learning in one year and then nothing for the remainder of the period.

DR. STRIKER:

Okay, another myth: Physicians need report CMEs to the ABA directly, and that it can be a big hassle. Truth or myth?

DR. MARTIN:

Well, I mean keeping track of your CMEs can be a hassle. And again, I don't want to speak for the ABA. I think they've done a lot of work to try to make their website as, ah, good as it can be. However, ah, I do want to make a plug for a ASA. ASA's gone out of its way to make it’s, ah, ah, learning activities as easy and relevant to anesthesiologists as possible. And in fact, if you log into the, um, ASA and give them your ABA number, ASA will submit your CME directly to ABA, so it saves that whole step.

DR. STRIKER:

Well, David, now that we’ve covered a lot of this ground. How do anesthesiologist stay on top of all this? Can you tell our listeners where the best places to get more information are?

DR. MARTIN:

Well, sure. I think that if The question is about MOCA in particular, what your current status is, maybe you don't even know if your enrolled in MOCA, uh, if you really need to kind of start at the very beginning, I would go to the ABA website. They have a nice website. They can walk through, you know, when you entered it, what your status is. People have very unique life circumstances that are complicated. Maybe you had to leave practice for a while due to a medical reason and now, you know, the timing doesn't line up. Anything like that, go right to the ABA. ABA has very useful, uh, generic information and then you can speak to a rep if you have a specific problem. And then when you understand what you need for the ABA, then I would say come to ASA because we offer everything an anesthesiologist would need, ah, to meet those Part 2 CME and Part 4 quality improvement activities.

DR. STRIKER

Can you tell us about any resources and opportunities for CME credits, um, provided specifically by the ASA?

DR. MARTIN:

Oh, sure! I mean some of our products are live meetings, like the annual meeting, or a variety of subspecialty meetings offer CME credits. Your State Component Society probably offers CME credits for attendance. There are a lot of online activities, such as ACE and SEE which allow you to, ah, use a question based interactive mechanism to keep up with basic knowledge and emerging knowledge respectively. ASA has the Patient Safety Suite of products that allow you to get those patient safety CME requirements. We have both the live simulation activities that you can sign up for, as well as online simulation SimSTAT, and a variety of highlight materials. If you haven't had the opportunity to go to a live meeting, and let's say that your group couldn't spring you for Anesthesiology 2019, well you can find a lot of that material online and get those CME credits, um, ah, after the meeting's over.

DR. STRIKER:

With regard to Part 4, cuz this is one that I know, as we mentioned before it can be, uh, somewhat daunting for members, can any individual member get all their requirements for Part 4 by just utilizing resources at the ASA?

DR. MARTIN:

Ah, yes, you could do the simulation part in in your first five years and repeat that in the second five years. So, if you were going to do just simulation through the SimSTAT product I believe you have to do that once every 5 years. ASA also has, ah, materials that can help you do the local quality improvement project. But by nature, that involves you to do some work with your local group and it's not all online. Part and parcel of Part 4 is some engagement, ah, some application of that knowledge, whether in simulation or actually live in your hospital trying to improve your practices.

DR. STRIKER:

As we get to the end of our conversation, it seems to me just based on our discussion, that if I was an impartial listener to this, we’ve painted what I think is a really nice picture of why it's important to have maintenance of certification is in our on-going practices. Is there anything else you'd like to add in that regard?

DR MARTIN:

Well, I, I'm just humbled by how rapidly medicine is advancing by the application of new, ah, knowledge and technologies to the practice and I've been excited to see how new educational design is been introduced to help people keep up. We're putting together products now that work on cell phones, augmented reality, machine based learning. I think there's a real exciting phase coming up in the near future that's going to be applied to help anesthesiologists stay current because it's really daunting. It's really overwhelming to, uh, appreciate how fast medicine is changing with, uh, genomic techniques, with um, just the, uh, breadth and scope of the specialty. Anesthesiology touches every aspect in the hospital from pre-op evaluation, to procedural sedation, in, in every part of the hospital to very advanced techniques in the operating room. So ah, I think this is, this is reality and, uh, I think we have to embrace it and really drive it forward into the future.

DR. STRIKER:

Excellent. David if someone wants to find out how many CME’s they have to go within the MOCA program, can that be obtained easily?

DR. MARTIN:

Sure, uh the American Board of anesthesiology has a website that has everything displayed as far as what you're enrolled in, and what your current status is, what areas are achieved and where your deficiencies are. And because every individual circumstance is a little bit unique, ah, the best way is to go to the ABA and see where you are. There very security conscious, so I have gotten emails from the ABA encouraging me to log in and check. They won’t put in an email what your status is. So that's usually good invitation to, ah, dig up your password, login to the ABA website and check. Now, if you have CME that you earned with ASA, ASA will automatically submit that to ABA, but you may have earned CME from another organization. Maybe you went on a, on a trip somewhere and you earned some good CME and they gave you a certificate but they're not ASA. That happens. Then you have to log that into the ABA website. So ABA, ah, \will tell you what credits they know that you have but it’s on the anesthesiologist to make sure that they report all the credits they’ve earned to the ABA.

DR. STRIKER:

You know, one thing I wanted to ask you, is the difference between people that are in the program currently and people that perhaps got their certification a number of years ago, before the program started. How does that all fit together? In other words, do people that got their certification a long time ago have to participate in MOCA?

DR. MARTIN:

Yeah, that's a great question. So the American Board of Anesthesiologists has gone way out of their way to be true to their word. And so, eons ago when I finished my residency, they gave me a certificate that was good for a lifetime and they maintain that that's true that that certificate is good for a lifetime and, you know, and I still have it but my department said in you know, we're moving into the future we believe in this continuing maintenance of certification all the, um, younger folks and staff have to play in that game. And so we expect you old guys, Martin, to go ahead and sign up voluntarily to be in MOCA, which I did, and so you can have both a lifetime certificate and be in, um, MOCA voluntarily. And so that's why sometimes you'll see people having both. Honestly in my opinion, the lifetime certificate is kind of a holdover. It's kind of ah, you know, an interesting conversation piece, but it doesn't have the same meaning in an active, a vibrant department where you have younger partners that expect the older partners to be, you know, walking the same walk.

DR. STRIKER:

Sure. Well, I wonder, when the pediatric anesthesia exam came out, um, for certification as well, for the subspecialty, you know, in our group, even ones that didn't have to, all took it and the ones that didn't have to still volunteered to take it and I, in a proactive manner, and um, so I, I get the feeling at least from my experience that, um, everybody wants to still participate and demonstrate that they are qualified, that they're learning, that they're doing what needs to be done to make sure that uh, their taking care of patients well, and, uh demonstrating tpo others that they can do the job.

DR. MARTIN:

Absolutely.

DR. STRIKER:

How do you navigate all this? Have you had trouble with it? Do you think it’s, uh, has it been easy for you?

DR. MARTIN:

Well um, I work in academic department where there are lectures and research projects and I was just kind of being at the buffet table and I have far more opportunities to learn and get credit for that, than I think somebody that isn't in an academic department. And so the nomenclature was a bit new and I have learned a lot, but actually meeting the requirements has not been difficult in any way. In fact, I earn more CME credit than I need for licensure or MOCA, and for those extra ones, I just don't even bother reporting them. So I, I think I'm blessed in the unique kind of situation where we have a lot going on. Ah, so it makes it easier to stay current but I could understand in areas where you're doing nothing, but, you know hundred percent clinical practice in a private practice arena where there's not a lot of on-going intellectual research kind of stuff, that you would have to make it a priority to seek that out.

DR. STRIKER:

I will say my experience, I, I think the the MOCA minute has been very helpful. I think I was, I was in the last group of people that had to take the large exam which was uh, great. I spent all that time studying and then the next year, they said you no longer have to do that. You can just do the MOCA minute. So for me, it was one last hurrah of a studying for a major exam, if you will, which brought back a lot of, uh, a lot of fun memories. But overall, I would agree, and even, and I'm not necessarily in the same academic setting. Uh, we do have, um, some academics going on in our institution, but it's not quite as much as, uh, some of the major centers and, um, I still have found that it's in pretty easy to navigate. I, I think a lot of us have always been worried about the Part 4 part, but as the options of grown and, uh, the ease with which it is to find which options are available. I think it's become a, uh, a lot, a lot less cumbersome to, to navigate the whole process. And I think my partners would feel the same way.

DR. MARTIN:

Yeah, another thing I would add if folks are feeling frustrated or feeling that they you know, need some special uh, education or opportunities, uh, I had kind of a behind-the-scenes view of how our experts in educational design put together curricula and, um, and programs and they really, really value learner feedback. So if you go to a meeting or you take a course those questions at the end that asked you, ah, if it met its objectives and how you're going to apply this to your practice, be very honest in those if you say “man is spot-on and I really learned what I needed”, say that. If you say “this missed the mark, what I'm really needing is something else”, say that too, because these programs will adapt to what your, what your needs are and what the gaps are between where knowledge needs to be, and where learners are. So, those comments are very, very important and so take those evaluations seriously when you fill them out at the end of an activity.

DR. STRIKER:

That’s a great point. I think a lot of us often times feel that we're riding away without much control, and actually it's quite the opposite. We have a lot of input and a lot of ability to form how these programs evolve over time and, and help adapt to us as well.

DR. MARTIN:

Exactly.

DR. STRIKER:

Well, thanks very much David. I really appreciate it.

DR. MARTIN:

Well, thank you. It's been a pleasure.

DR. STRIKER:

Thanks everybody for joining us today on ASA’s Central Line. I have a quick correction before we sign off: the ABA is the American Board of Anesthesiology—we mistakenly referred to it as the American Board of Anesthesiologists. Additionally, we said that the 10 year exam was a repeat of the Board exam, which isn’t exactly correct—the 10 year exam was a single element exam, as opposed to the multiple-element certifying exam. Just wanted to clear that up. That’s all for now. This is Adam Striker, and we'll see you next time.

(SOUNDBITE OF MUSIC)

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