I retired from my rheumatology practice at the end of 2020. That is when my board certification expired. That is not a coincidence.
Some background information: I passed my Internal Medicine boards in 1986 and received lifetime certification. I completed my rheumatology fellowship in 1989, but the rheumatology boards were not offered that year. I had to wait until 1990. That was the year that ABIM decided that board certification would only be valid for ten years. Because of that one year delay, it became necessary for me to take a recertification exam every ten years. I passed the exam in 1990, 2000, and 2010 on the first try each time. However, when it came time for my recertification in 2020, I refused to genuflect to ABIM again.
Over the years, I have been at odds with ABIM regarding their maintenance of certification (MOC) program. I have repeatedly called to their attention the following problems with their ten-year recertification exam and their subsequent two-year Knowledge Check In:
- What does the exam measure? It is not clear what the recertification exam measures other than a physician’s knowledge at a given point in time. The exam does not assess their knowledge two weeks later or even their baseline knowledge. Most importantly, it does not determine a physician’s qualifications to practice. If we want to evaluate a physician’s competence, we need to assess their judgment and decision making, i.e. how they apply information. Knowing facts in and of itself is of limited value, especially when those facts are easily accessible via a hand-held computer they carry in their pocket. We do not judge a philanthropist by how much money they have in their wallet on a given day, especially when they can access their bank to get more. Instead, we look at how they spend it. The same concept applies to a physician’s knowledge.
- Lack of Relevance. The exam is not especially relevant to the day-to-day practice of medicine. Questions are often esoteric, and analogous to playing medical trivial pursuit. Much of the material learned in preparation for an exam is soon forgotten, because it is not used regularly. Rote memorization of which gene causes which syndrome or the different types of Ehlers-Danlos is not a particularly useful construct.
- Minimal educational value. Studying in advance for unknown questions is not as helpful as learning with a specific question in mind. Think about how we teach medical students. We advise them to read up on a disease, after they have seen a patient with that disease, and to then relate the information to that patient. That is a much better way to learn than reading up on diseases randomly. Information is better retained if there is a “specific hook to hang it onto.” I used to actually write the names of patients in my textbooks so I could connect a particular disease to a particular patient.
- MOC is expensive. An article in the Annals of Internal Medicine in 2015 cites an average cost of almost $24,000 for a general internist to do MOC activities and take the exam. That figure takes into account time spent away from the office. It does not include the additional costs of board certification courses that many physicians take, or the travel and hotel costs associated with these courses. Helping physicians prepare for the exam has become an entire cottage industry. There is also the added expense of retaking the exam if a physician should fail on the first try.
- High stakes/ stress. The exam is a punitive, high stakes endeavor. A key point here is that the exam is not voluntary, despite ABIM’s statements to the contrary. Most hospitals and insurance companies make board certification mandatory for their physicians, so failure to pass the exam can have significant job implications. Fifteen percent of physicians failed the American Board of Internal Medicine recertification exams offered between 2000 and 2014 on their first try. That means that according to the ABIM, about one in six physicians is not qualified to practice!
- Time. Physicians are busy with family issues, patient issues, practice and hospital issues etc. Preparing for an exam means significant time away from all of these activities, including patient care. Many physicians resent being forced to spend many hours on an endeavor not of their choosing that they perceive to be of limited value.
- Trust ABIM has made it clear that they do not trust physicians to stay current on their own, nor do they trust physicians to take an exam honestly. They have little confidence that physicians will use CME appropriately. Physicians have patients’ lives in their hands every day, yet ABIM does not trust them to maintain their skills without their oversight.
- Patients. The most important part of all of this is how it affects patients. MOC means time away from patient care and serves as a distraction for physicians. Furthermore, there has been no evidence that the recertification exam improves patient care. MOC does contribute to physician burnout and early retirements, both of which affect patients negatively.
For all of these reasons, many physicians feel that MOC is of minimal value and not worth the time, expense, and stress associated with it.
I personally have cajoled, coaxed and pleaded with ABIM on multiple occasions to make changes to their assessment process. More specifically, I have promoted the following changes based on the American College of Rheumatology educational program entitled CARE:
A. Create a new format where physicians have three months to answer 90 questions and can take the exam from home.
B. Allow physicians as much time as they want to answer each question.
C. Make questions relevant to what doctors do every day. Do not ask general internists about biologic agents for rheumatoid arthritis.
D. Make the exam entirely open book. In a patient encounter, physicians are free to use whatever information they want. Why should a recert exam be any different, especially when ABIM claims the exam should mimic real life scenarios?
E. Include resources i.e specific articles or general topic discussions with each question.
F. Provide the correct answer with the rationale for that answer immediately upon completion of a question.
Combined, these steps offer many advantages.
- This format would reduce the high stakes nature of the exam. Physicians would feel comfortable knowing that if they put in the time and effort, they would be unlikely to fail. No longer could car trouble, a fight with a spouse, or not feeling well on a given day affect a physician’s performance.
- The task at hand would be concrete rather than abstract, which would reduce stress as well. Physicians would not have to prepare for everything they MIGHT be asked. This would eliminate the need to spend several months preparing for the exam.
- The expense would be reduced as there would be no need for board review courses and the expenses associated with that (e.g. airfare, hotel, time away from practice).
- The learning experience would be improved, as physicians would be reading information related to a specific problem rather than reading information without a hook to hang it onto. Furthermore, providing the correct answers and their rationales, would also be a learning tool.
- The exam would measure due diligence on the part of physicians rather than knowledge at one point in time and would demonstrate to insurers, hospitals and patients that a physician is making the effort to stay current.
- ABIM’s reputation would change from that of enforcer to that of educator.
It has taken more than six years, but to their credit, ABIM has implemented many of these suggestions in their new longitudinal assessment, which will be available in 2022. However, they adamantly refuse to put item B above into place. ABIM insists on a four-minute time limit per question. This one critical issue defeats all the improvements they have made in other areas.
With a time limit in place, physicians will still need to spend extensive prep time in advance of the exam, thus maintaining MOC as a high stress proposition. Furthermore, the value of an open book is severely restricted with a time limit. Physicians will not have the time to read in depth on a subject. They will be more prone to read only as much as is necessary to answer the question. The goal here should be learning, not answering a question. A time limit favors the latter. Part of the assessment will be a physician’s time management skills. Is that what we ought to be measuring? ABIM has argued that this reflects the time limits physicians have in practice, but that is not realistic. I know that I have spent hours in the evening or on a weekend on multiple occasions researching a topic necessary to help a patient. ABIM’s time limit is arbitrarily imposed.
Eliminating the time limit for each question, would make a huge difference in physicians’ perception of MOC. ABIM, however, remains obstinate in their refusal to consider this idea, despite repeated entreaties. They continue to see their role in the medical profession as an enforcer rather than an educator. Meaningful change in MOC requires a paradigm shift in this dynamic. It is especially unfortunate, because the one small change of removing a time limit for each question could make a huge difference. Yet, ABIM will not yield. One can only speculate as to why.