Wednesday, 25 Apr 2018

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The Board Certification Tango

Recently, I was invited to apply for an open seat on the American Board of Internal Medicine (ABIM), the large organization that certifies physicians in the United States. Part of the process is to write a personal statement on my views of the ABIM mission and what I would like to accomplish. 

A lot is at stake as shaping the board certification process would affect my students, my friends, and me.  Becoming board certified in medicine is the pinnacle goal of medical students, interns, and residents; certification is an acknowledgment by the medical community that they have the knowledge to take care of patients without close oversight by a more seasoned doctor.  

I remembered after I initially became board certified in internal medicine and rheumatology my former attending’s asked me to call them by their first names as we are now peers; Dr. John Cush is now “Jack.” The seemingly simple transition in title of my professor who is a legacy in his field was as significant to me as the metamorphosis of a caterpillar to butterfly. 

I had earned the privilege and respect to be his colleague.  

The path to certification for me was challenging but manageable. Long hours were dedicated in reviewing acid base formulas, electrocardiograms, spirometry flow-volume curves, medication interactions, and other information that would allow me to pass the boards and to ensure my proficiency as a physician.  

A decade later, I faced recertification for both internal medicine and rheumatology.  My colleagues around me also were due to demonstrate their competency again. Recertification was unpopular given that before 1990, the maintenance of certification did not exist and most doctors were certified for life.  

My peers grumbled, “Other professionals like lawyers, accountants, and politicians do not have to go through this kind of process that is time consuming, expensive, and does not enhance medical care.”  

During this time, the American Board of Internal Medicine (ABIM) was embroiled in controversy as many complained board questions were outdated or irrelevant, but the most hurtful accusation the ABIM faced was that it was corrupt.   

At the time, part of the re-certification process required physicians to prove they have communication skills, demonstrate teamwork, and promote patient safety. The ABIM’s mission was to ensure the quality of healthcare by certifying doctors who not only have to have knowledge and skills, but also “attitudes essential for excellent patient care.” Hence, the ABIM felt the self-assessment process would improve interactions with patients and foster quality improvement.  

What the ABIM did not realize was the surveys were time consuming and costly for physicians in a busy private practice; furthermore, few physicians in the community were involved in the ABIM’s decision for change to the maintenance of certification process. The board has fallen deaf to the pleas of its constituents.  

Magazine articles and incendiary blogs stamped the ABIM as a shady organization that holds a monopoly on the certification process.  Doctors felt they were blackmailed to pay for the label “board certified.” I was confused. Does board certification mean anything anymore?  Should I proceed with recertification, understanding that my meager free time will be spent on not just reviewing raw medical knowledge, but also in administering surveys to patients without being reimbursed for the cost?   

Many physicians felt the same way. The ABIM was scrambling to uphold its reputation. On February 3, 2015, ABIM president Dr. Richard Baron published an open letter to physicians stating, “We got it wrong and sincerely apologize.” This grabbed my attention; positive change was about to occur.

Despite the controversy, I knew that I wanted to maintain certifications in both specialties because it would hold me accountable to keep my knowledge current in the practice of medicine. Staying abreast of the growing body of medical advancements is essential in avoiding medical errors.  

The Journal of General Internal Medicine recently published a study affirming physicians who did not passed periodic knowledge assessments compared to their peers who did were more likely to face state medical board disciplinary actions (adjusted HR 2.09; 95% CI, 1.83 to 2.39  (JGIM 2018; doi.org/10.1007/s11606-018-4376-z). On the other hand, fulfilling state CME requirements did not influence disciplinary outcomes.  

In addition, patients and insurance companies are weighing in now on the decision for doctors to recertify.  Patients are educated consumers; many review a doctor’s profile (including board certification status) before making an appointment.   Insurance companies are actively excluding doctors from in-network status for failure to meet certification requirements.  Board certification is no longer about bragging rights or demonstrating knowledge required as a physician, it is essential to keeping a business open.

As a private practitioner who is raising a family and who also conducts clinical research while teaching medical students and residents, I understand the pressures from different angles. I feel the burden of maintaining certification while struggling with MIPS/MACRA reporting and trying to meet EHR meaningful use requirements. For these reasons, I want to be able to weigh in on how the board certification process can be streamlined to accommodate the many responsibilities that burden physicians on a daily basis while still maintaining the integrity of the ABIM’s mission.  

The changes made to the MOC process by the ABIM are commendable but still require improvements and revisions as the practice of medicine evolves.  I encourage that you weigh in, too. Silence is implicit acquiescence.  

 

Disclosures: 
The author has no conflicts of interest to disclose related to this subject

Kathryn Dao, MD, FACP, FACR, is the Associate Director of Clinical Rheumatology at Baylor Research Institute in Dallas. She is in clinical practice at the Arthritis Care and Research Center in Dallas, TX and is actively involved in patient care, medical education, and clinical research.  Her interests include Rheumatoid Arthritis, Systemic Lupus Erythematosus, Gout, Infections with Biologics, Osteoporosis, and Drug Safety. She has served as the co-editor for the American College of Rheumatology “Drug Safety Quarterly” 2010-2013.   

 

Rheumatologists' Comments

You are an optimist. The ABIM is corrupt with its main goal being self-perpetuation. Salaries for executives are high and include resort apartments paid for by physician dues. I earn more than 60 hours of specialty specific CMEs each year. I have nothing to prove. I do admit I am one of those physicians who are grandfathered.
ABIM is making $$ off of us;the ceo of it makes a shit load of $ doing zilch.I have recerted in rheum and IM for almost 30 years now.I'm done with the entire process and dont plan on recterting anymore-- and dont think they will change--they were also sued by a cardiologist from scripts in CA a few years ago who refused to be extorted.keep fighting them--no study at all has ever shown that BC makes a difference;in almost 30 yrs only one patient has ever asked if i was certified--they dont care despite the garbage the abim may tell you
Dr. Paul Terstein has been doing a lot of work against MOC, you can get involved by getting in touch with NBPAS https://youtu.be/_fc3BQ-9yMM https://nbpas.org
I took the re-certification exam for the third time 3-4 years ago, without studying or taking the modules, as I have left patient care and am now a full-time clinical trials designer/lead for a Pharma company. The exam was not particularly meaningful, in my opinion, as there was a great deal of opinion rather than fact, and it is unrealistic to practice medicine without access to databases online anymore (why keep so many fact in our heads nowadays? It should be about principles.). I passed without difficulty (as I think all of you can if you were awake during your Fellowship) and sent Richard Baron an email letting him know I think he and the Board have become obsolete and the money grabbing organization they have become is an embarrassment to it's members. I will never pay them again for an exam/modules/etc. I do believe in what Dr. Terstein and colleagues have done and supported them by paying thier much lower fee (< $300, as I recall?) for certification by sending them valid license and proof of up-to-date CME (which comes from our ACR Annual Scientific Meeting).