After serving on the board of the American Board of Internal Medicine for the past few years, I’ve come to truly appreciate the value of board certification in demonstrating – and enhancing – our competence and commitment to professionalism. But not all boards are created equal: the ABIM, like all the members of the American Board of Medical Specialties (ABMS), is frequently challenged by organizations that call themselves boards and offer “certification” but whose rigor is questionable. This is a big deal, since patients need to know what it means when they hear that their doctor is board certified.
You might say that competition is good, and it generally is, but there is a fundamental problem in the worlds of certification and accreditation: the free market just doesn’t work very well. Just envision two boards – one like the ABIM, with rigorous exams and high standards. (Just one small window into this: the ABIM employs several amazingly talented psychometricians whose sole job is to ensure that its tests produce fair and accurate results.) Now pretend there’s another board with very low standards – just pay your money, answer a few simple questions, and voila, you’re certified. While most physicians are ethical folks who would gravitate to the former, clearly some would find the latter deal quite appealing… particularly if patients, hospital credentials committees, and payers failed to differentiate between the two paths to “certification.”
Enter into this arcane but important debate one Dr. Rand Paul, libertarian, Tea Party heartthrob, son of presidential candidate Ron Paul, and (gulp) perhaps the future U.S. Senator from Kentucky. Paul, an ophthalmologist, has long claimed that he is board certified.
But it turns out that the American Board of Ophthalmology (ABO), the official ABMS board for the field, hasn’t heard from Dr. Paul since 2005, which was when his initial certification lapsed. As the Louisville Courier-Journal reported this week, Dr. Paul is now certified by an organization called the National Board of Ophthalmology (NBO).
Which is convenient, since when the NBO incorporated in 1999, the documents list one Rand Paul as both its founding president and director. The NBO went out of business in 2000, but Paul resurrected it in 2005, just in time to revive his lapsed board certification. In contrast to the ABO, which has a staff of 11 in its Philadelphia office, the NBO’s address is a UPS box in Bowling Green. Rented by, well, you know.
In a letter to a Washington Post blogger after the story broke, Paul claimed that he let his ABO certification lapse and founded an alternative organization “to protest the American Board of Ophthalmology’s decision to grandfather in the older ophthalmologists and not require them to recertify.”
I can appreciate a good protest (and the grandfather issue bugs quite a few younger docs), but this is a bit much: Paul ditches the ABO on principle but holds himself out to be board certified via an organization he invented; one that, as far as anyone can tell, has precisely no requirements or public footprint.
While this concerns me (perhaps not as much as Paul’s stated preference to allow restaurants to re-segregate or his heartfelt support of British Petroleum post-spill), I probably wouldn’t have brought it up if Stephen Colbert hadn’t done a hilarious send-up on Paul and board certification a few days ago. “He has inspired me to exercise my constitutional right to call myself an ophthalmologist,” Colbert quips, and then proceeds to diagnose glaucoma in one of his show’s interns. Luckily, “Dr.” Colbert has a prescription: “You are going to want to smoke a lot of weed.” He then sends in a “board-certified” cat, Professor Buttons, to perform nightmarish Lasik surgery on the hapless intern. If you can spare 5 minutes, the video clip is well worth watching.
The bright side of all this bad news about board certification – last week’s cheating scandal and Rand Paul’s present predicament – is that it demonstrates that physicians really seem to value being certified. Good. We just need to ensure that they are doing it the right way.
Unfair to single out a pol from the opposite end of the political spectrum. How about Dr. Cassel, who won’t take her own ABIM recertification exam?
This issue got a lot of traction on the WSJ health blog ( http://blogs.wsj.com/health/2010/06/09/abim-cheating-scandal-take-a-look-at-some-test-questions/tab/comments/). Clearly, there is more to this than the eye can see.
Me thinks there are charades pervading the country’s leadership moreso than ever. Beginning with the Watergate breakin and the no sex sex of Clinton, it has now become fashionable to make up the truth with lessons learned from a former mayor of the District of Columbia.
Board certification is a right of passage. However,
clinical acumen in situ can not be tested by exam. Having said that, the Board exam is a challenge, but when I see the practicing jerks at the bedside who are “Board Certified”, Paul is merely performing in the circus of politics, health care, and law. Newbies are coming in every day, worse than described in the Paul report.
Cast your eyes on CCHIT and the LIEber run HIMSS lobbyists who have made up a certification to convince Congress to spend money on unusable medical care equipment.
We are watching America deteriorate in front of our very eyes.
I wanted to respond to Exodus’s comment:
All of the board members of the ABIM are required to complete their Maintenance of Certification; I completed my MOC in 2008 in internal medicine. Dr. Chris Cassel, the CEO of the ABIM, recertified in 2005 in geriatrics, which makes her certificate valid until 2015. Chris also has a lifelong (“grandfathered”) certificate in internal medicine.
The ABIM’s official position is that diplomates should maintain their certification in the area that best reflects their career focus, which for Chris is geriatrics. I hope this clarifies things.
You gotta love all the conservatives in Kentucky who voted for Rand Paul (Mr. certifiable not certified) and brought him to national prominence, priceless. Let’s face it, this is the same guy who wanted to apologies to BP, he gave us an “OP Ed” where he planned to give himself a “Pardon” if ever he became Governor and the same guy who many say is not a racist (even though he said “private businesses should have the right to discriminate against black people”). Let’s face it they will try to vote this liar in but we can only wait and see if there are other skeletons in his closet. Great thing is we are talking about Kentucky, so being a racist may be a positive, we will see.
Note: sorry for typos in advance, I was in a rush. The hope is to promote conversation that promotes healing.
I think just as there is a healthy…and then too austere separation between church and state: there is a healthy…and then too austere separation between medicine and politics.
In this case, it is important to stay focused delineate and discuss potential solutions to the problem, not politics.
The problem (clearly elucidated according to two parameters):
(1) physicians and other healthcare professionals continue to make unnecessary medical errors
(2) the medical system is not transparent with respect to permitting patients easy access to data relating to their doctors quality of care or even the safety of care. If you were a patient, which be patient and with time you will be, would you want this?
Ok, now. Keeping in mind, medicine is a calling, not a business; therefore, a patient centric safety system is needed.
This is where the focus should be: potential solutions…systemic solutions…sharp solutions…not surgical solutions (not a laughing matter, look at my other posts).
Acknowledge issues stated in other posts
(polite, professional, non-political version)
-multiple choice board scores do not necessarily translate into safe, high quality care
-our patients deserve respect and transparency regarding our qualifications.
One potential solution.
Multiple choice boards should be used as screening tests. (high sensitivity, low specificity)
Boards should be pass or fail. No score should be released. And, all doctors, regardless of specialty, should have to take an exam yearly. This should be a short 2 hour test. The clinicians can choose the time of day, and date. All circumstances should be accommodated and all the physicians should take the test at a time convenient to them (we understand this is an added stress, and it should be applied gently).
Two, all physicians who pass this test, should be allowed to have an identity card. The card shows they are legit (passed an exam).
The card has four (4) sides and will be placed visibly in the careholder’s pocket. But, what does it not show? Experience or quality and safety of care.
How can we ameliorate this?
With bar graphs…excel deja vu? Yes, Madam!
Note: excel is a systematic program on the computer you may be using. To access it press start. Thank You!
How can we improve this?
With Scales, ‘little bars’ that humble physicians by never saying 100%.
Ok, now.
Have the care have levels, years practiced: 1 to 200 (color of scale on side of card green). No one will have a completely filled scale and it may keep physicians humble. Humble servants to patient care in a patient centric medical system.
There are three other sides of the card that can be filed. Two, number of lawsuits filed, reminds physicians to be wise in the words they choose. Scale 1 to 200 (color of scale on side of card red). Does not matter who wins the lawsuit, keeps keen sharp surgical communication and expectation setting skills on-line and operational.
Three, philanthropic activities as evaluated by the board. Scale 1 to 200 (color of scale on side of card green)
For data fidelity, card should be thick and have electronic components. Patients should be able to use cell phone to call a toll free number and have the three scales verified with a quick message “doctors are human, not perfect, no scale is intended to be completely filled. Please have reasonable expectations when perusing medical care. ” The goal would be to get a group of doctors to implement this voluntarily. The hope would be to reduce lawsuits and insurance doctors have to pay in the pilot phase of the project.
Four, one side left unfilled. Designed to symbolized limitations of any system. And, reality of doctor patient fit. Some doctors fit better with some types of patients; other doctors fit better with other types of patients. In the age of chronic disease, increasing awareness of this is important in our bold, brave, patient centric medical system.
Note: It should not become a brazen patient centric medical system. Balance and cordiality is important in running any system.
For the sake of our patients (who also read these boards…please keep that in mind), let’s please be representative of the best medicine has to offer…and let’s discuss solutions.
Thanks.
Is the conduct you describe about boards really any thing different than the conduct described by the NY Times of your boss:
“When Dr. Susan Desmond-Hellmann was named chancellor of the University of California, San Francisco, last summer, she took over a medical institution focused on world health generally and tobacco control in particular.
But she forgot one thing in adjusting to her new role: personal stock holdings listed last year in the range of $100,000 to $1 million in Altria, owner of Philip Morris USA, the maker of Marlboro cigarettes. Altria has been blamed for thousands of deaths and repeatedly criticized by the Center for Tobacco Control Research and Education at the university….”
UCSF seems to have similar problems of deceit at its leadership level leading to failures of transparency. For example, the magnitude of the adverse events from the failed GE HIT EMR deployment were kept close to the vest. Let the doctors speak freely.
http://www.newsweek.com/2010/06/08/black-market-m-d-s.html
Like father, like son.
The Association of American Physicians and Surgeons, Inc. (AAPS) is Ron Paul’s organization, which claims to be “non-partisan,” but rails on and on about “Obamacare”, “socialized medicine in the US,” the scourge and immorality of Medicare and Medicaid, etc., etc. They believe that there should be absolutely no oversight or “interference” by government in the doctor/patient relationship, they are against evidence-based medicine or any medicine with a scientific basis, and they advocate that doctors should be allowed to experiment on their patients as much as they want to. Curiously, they also believe that there should be a federal law against abortion. Go figure.
Bob,
How about being a dedicated and passionate doctor striving for best patient’s care and having excellent track records with colleagues and patients and BEING sanctioned over the testing cheating scandal ( there were no cheating!!! but loose conveyance of verbatim of what was tested and it was not for any specific favors/money etc.. ) by people who do not really know you. By the way, ABIM certification exam was one of the easiest tests.
What would one feel if I tell him/her now you are a criminal and go behind bars? Believe me I do feel this way. ABIM took away my dream. I am losing a faith in a profession at all and I would never agree I am a dishonest doctor. NO MATTER WHAT. IT IS A LIE ABIM TRIES TO CONFUSE PUBLIC WITH. WHY?????
Bob:
Why would not you answer my question? Are you still proud to be one of the members of this corrupt organization? I know that you have a lot to think about. Some day people will know the truth behind ABIM actions.
Dear Heartbroken —
There is an active appeals process underway at ABIM — many of the physicians who were sanctioned by the board have availed themselves of it.
And yes, I am proud to be part of the Board. In particular, I remain impressed by the commitment of the organization to do the right thing and to be fair.
— Bob
Thank you for response.
Regarding the multiple issues of certification / testing / recertification / MOC: I find the ABIM unhelpful and unresponsive to suggestions of improving their process (for all physicians) and in a manner that would relieve the stress and inconvenience of the testing regimen. I have suggested to them formally a way to keep people educated and certified with a great deal of satisfaction and up-to-date information; this would involve the initial board-certification exam for first time takers, followed by an MOC process that would require completion of 2-4 CD-based programs or web-based programs involving different subjects. These would be performed for a total of 10 “units” over a 10 year period, and fulfill all requirements for recertification at the end of that period, and do away with the wasteful exam. This would also keep all physicians up to date in a quickly changing field. As a member of the board, I would appreciate your input on this, and would also like to know what it would take to accomplish this?
To Bob Di Giulio:
Thanks, Bob. I think you’ll be pleased by a shift in the philosophy of the boards. Namely, all the ABMS boards, including ABIM, are now moving toward “Continuous Maintenance of Certification” – breaking up MOC into smaller ongoing activities that reflect the effort that all good docs put into staying up to date. This will dovetail much more with existing (and hopefully, improved) CME; it doesn’t seem right that the boards’ MOC process and the CME you need to do to maintain your license are presently so dissociated. Stay tuned…
On the other hand, I don’t think the exam is going away, nor should it. There is a part of medicine that involves knowledge, synthesis, diagnostic reasoning, etc.; right now, we have no better way to test this material than, well, a test. The secure exam, as it’s known in Board-speak, needs to be improved and modernized – better AV materials, maybe some simulation, perhaps some sections that allow you to look at web-based resources (as we all do in the real world), that kind of thing. ABIM, and all the boards, are working on this; one problem is that these innovations are quite expensive and we are sensitive to the cost. But the exam does need to be improved, and I am confident it will be.
That said, when I completed MOC a couple of years ago, I found the exam to be fair, reasonably relevant to my practice (it will get better for hospitalists with the new focused practice exam), and challenging but not unduly so. It felt like a pretty fair test of what an up-to-date internist should know, and I’d hate to see it go away.
— Bob
Bob
Please read the comment posted in the WSJ blog on Aug 19th. I have no idea who posted it but wholeheartedly agree with:
“To Recent Article wrote:
Thank you for posting the article.
I am not a physician but know of several physicians who are affected by the scandal. After reading the long articles and comments, I feel like pitching in my 2 cents.
People who just took the exams and exam preparers talk and discuss about the exam questions all the time. This is just first amendment right. They talk on the phone, in a kitchen. After all, aren’t we all supposed to study all the past questions to prepare and familiarize for the exam so the chance of passing is the greatest? Every standard test (MCAP, GMAT, SAT, LSAT, etc.,) does has multiple web sites and blogs to share the past exam contents. If ABIM thinks this kind of behavior is unethical and unusual practice, they are not being realistic to human behavior (of seeking help when available) which is much stronger than ABIM’s “Pledge of Honesty”.
Punishing 139 physicians by destroying their careers is NOT the answer. By doing so, ABIM is imposing the extreme financial and emotional hardship for these doctors who may lead to bankruptcy filing, families breaking apart and sending kids to the streets. In addition, many communities will lose perfectly capable and caring physicians. (Aren’t we facing IM physicians shortage?) And, I imagine many of the affected physicians are just about to start a family or to make money to pay back for Medical school. I don’t believe their alleged crimes do not fit the punishments.
I know that appealing process is on-going. Please be fair by letting the affected physicians (and/or their lawyers) present their side of story (if they wish to) in front of decision makers because some evidence against them can be circumstantial.
On behalf of 139 physicians, please, please consider other “non-career ending” ways to punish them if they are found guilty of cheating by making them retake the exam or impose fines, etc.,
Thank you so much for reading this comment.”
In the last response to me you mentioned “In particular, I remain impressed by the commitment of the organization to do the right thing and to be fair”. Destroying somebody’s career, family, and perhaps life is fair? Have you ever thought about consequences of your actions?
Thank you.
ABIM = Giant Physician Taxing Authority. Recertification is such a wonderful way to ensure the ABIM’s never ending revenue streams of testing fees, preparatory courses/materials, and physician contact lists. All under the guise of education and improvement of medicine. Please.
Here’s an idea: move the ABIM headquarters out of Center City Philadelphia. That way you get to avoid the 4.8% city wage tax (and who do you think offsets that tax with their membership dues?) and a county which, only after Madison county Illinois, has been referred to by tort reform advocacy groups as a judicial hell hole for physician defendants.
I don’t know about certification but Rand Paul is certainly certifiable.
A conservative physician group has filed an antitrust suit against the American Board of Medical Specialties in federal court, claiming its board recertification program is “a money-making, self-enrichment scheme” that reduces patient access to physicians.
The Association of American Physicians and Surgeons (AAPS) filed its lawsuit Tuesday in U.S. District Court for the District of New Jersey, seeking to end the ABMS’ sometimes criticized Maintenance of Certification (MOC) program, according to its 20-page complaint.
The Tucson, Ariz.-based AAPS, representing a New Jersey physician in its suit, said the ABMS program offers “no benefit to patient care” and violates antitrust laws by having worked with the Joint Commission since 2009 to require physicians to obtain MOC in order to renew hospital medical staff privileges. Health insurers also use ABMS’ board certification as a recognition of credentials, the lawsuit states.
“There is no justification for requiring the purchase of [ABMS]’ product as a condition of practicing medicine or being on hospital medical staffs, yet ABMS has agreed with others to cause exclusion of physicians who do not purchase or comply with [its] program,” the complaint stated. “Defendant’s program is a money-making, self-enrichment scheme that reduces the supply of hospital-based physicians and decreases the time physicians have available for patients.”
ABMS works with 24 specialty boards, which cover nearly every medical specialty, to develop recertification programs and promote continuous professional development. Those 24 boards aren’t named in the lawsuit.
MOC requires most certified specialists seek recertification — typically every 10 years — by successfully completing a four-part assessment. The program started in 2000 but recertification has accelerated since 2009.
AAPS said in the lawsuit it seeks to stop the MOC program from continuing, end “misrepresentations” about doctors who decline the program, and receive a refund of fees paid by its members for MOC-related activities.
MOC Evidence Slow, but Coming, ABMS Says
ABMS hadn’t yet seen the AAPS lawsuit as of late Wednesday. “Until we see a lawsuit, there’s no comment we could make,” ABMS spokeswoman Karen Metropulos told MedPage Today.
However, the group defended its MOC program, saying in an eight-page “myths and facts” document posted March 20 on its website that the program is “anchored in evidence-based guidelines, national clinical and quality standards, and specialty best practices.”
“Because the MOC program is relatively new (as it has been introduced gradually during the past decade), we don’t yet have evidence that results from decades of gathering data, but the data are emerging,” the ABMS said. “Early studies show a link between MOC and improved clinical performance and outcomes by participating physicians.”
As further support of its MOC, Metropulos pointed to ABMS’ “evidence library” which has compiled nearly 50 peer-reviewed articles related to the MOC process.
More than 450,000 physicians participate in the MOC program, which ABMS says is to help assure a doctor has successfully completed a rigorous evaluation process and assures competency. The pool grows by roughly 50,000 physicians a year.
AAPS said every state licenses physicians to practice medicine, and patients have a right to seek care from any of them. The group said ABMS’ work with the Federation of State Medical Boards for maintenance of licensure as a requirement of state licensure was a further antitrust violation.
ABMS’ “actions have no legitimate purpose and reduce the supply of physicians available to treat patients in various settings,” the lawsuit said.
The MOC “program imposes far greater burdens than any analogous program in any other profession, and surveys demonstrate that an overwhelming majority of physicians – perhaps more than 90% – feel that this program is unjustified,” the complaint stated, referencing a 2012 survey of its members.
The lawsuit cites the “unjustified exclusion” of an AAPS member with 29 years’ experience — identified only as “J.E.” in the complaint — from the medical staff at Somerset Medical Center in Somerville, N.J. The physician wasn’t allowed on the medical staff in 2011 until he had been certified by the American Board of Family Medicine.
Recertification would have exceeded 100 hours for a typical physician, “thousands of dollars in fees and travel expenses,” and time away from patients. Furthermore, the American Board of Internal Medicine earlier this month told physicians it “is requiring more frequent participation in MOC of all board-certified physicians,” the lawsuit noted.
MOC Draws Fire from Docs
Physician concerns about MOC expense and the time-consuming process involved were noted in a December 2012 New England Journal of Medicine health policy report.
Robert Baron, MD, medical professor at the University of California, San Francisco, and journalist John Iglehart noted the low number of “grandfathered” specialists — those certified before 1990 and granted time-unlimited credentials — as evidence.
Only 1% of nearly 67,000 such physicians holding only time-unlimited certificates from the American Board of Internal Medicine have been re-certified through MOC, they said in the December piece.
MOC fees charged by boards over a 10-year period range from $4,820 from the American Board of Plastic Surgery to $1,250 from the American Board of Surgery, the authors noted.
ABMS said its fees average roughly $300 per year.
The MOC recertification process is complicated, and Baron and Iglehart note that if it went away it could be replaced by a more burdensome system to assure physicians competency.
“If that is indeed the case, the ABMS and its boards must actively (and transparently) respond to the MOC concerns of all physicians, young and old alike, and accelerate its collaborative efforts with external organizations as they strive to navigate a complex system that melds professionalism, government regulation, and market forces,” Baron and Iglehart wrote.
This week’s action against ABMS isn’t the first dramatic step taken by AAPS, which was formed in 1943 to preserve the private practice of medicine, according to its website. The organization was one of the first to file a lawsuit against the Affordable Care Act in March 2010, claiming it was unconstitutional, and also sued then-First Lady Hillary Clinton in 1993 over her handling of the Clinton administration’s health reform task force. It also broke stance with other medical organizations to support the patent protection of isolated genes in recent Supreme Court oral arguments.
It’s time for MOC to end
Publish date: OCT 25, 2013 Print
If the new president of the American Board of Internal Medicine wants to be a game-changing advocate for the practicing physician, he should be challenged to dismantle Maintenance of Certification (MOC) and defuse all attempts to tie it to Maintenance of State Licensure (MOL). (“MOC: Debate intensifies as Medicare penalties loom,” June 25, 2013.) Neither has any place in the life of practicing physicians.
We’ve had an effective system in place for decades, one that is the equivalent of MOC and MOL: keeping up to date through our continuing medical education and remaining in good standing to maintain state licensing. There is absolutely no need or justification for MOC/MOL and its imposed burdens.
Keeping up-to-date is essential to practicing medicine, but the existing MOC process neither qualifies physicians nor protects patients. MOC’s requirements have not been shown to be fair, accurate, or predictive indicators of a physician’s skills or competency. All licensed professions have continuing-education requirements, but those imposed on physicians by MOC are simply egregious.
In light of the boards’ unchecked power to regulate physicians, what we propose is fair and in the best interests of our patients and our profession. Our goals remain clear:
1. MOC should not be associated with hospital privileges.
2. MOC should not be associated with insurance reimbursements or network participation.
3. MOC should not be required for MOL.
4. MOC should not be mandatory.
5. All board certificates must be converted to lifetime status; only then will MOC be voluntary.
If these cannot be achieved, then mass MOC noncompliance is the only rational and logical means to reclaiming control of our practices.
During these changing times of healthcare reform, our Boards sit on nearly a half-billion dollars in assets while hard-working physicians get less and less in reimbursements and many Americans remain without healthcare coverage.
Beyond restrictive rules for doctors and their own enormous salaries and fees, what do our “nonprofit” boards actually provide? They do not represent us successfully in government matters, and certainly have no understanding of practicing physicians’ interests. It’s time for all of us to get involved and for MOC to end.
Ron Benbassat, MD
Beverly Hills, California
– See more at: http://medicaleconomics.modernmedicine.com/medical-economics/news/it-s-time-moc-end#sthash.G8aWJb6P.dpuf
Only a real tool would bring politics into the discussion. Wachter?