The Board Certification Tango Save

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the American Board of Internal Medicine (ABIM) was embroiled in controversy as many complained board questions were outdated or irrelevant, but the most hurtful accusation the ABIM faced was that it was corrupt.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