Friday, December 28, 2012

The Punative Evolution of Board Certification

Once upon a time, doctors looked forward to the opportunity to become “board certified” in their specialty of interest in medicine.  Time was plentiful.  In the lost days of Never-never Land, doctors would leave their office at lunch time while their secretaries manned the phones.   Patients still got their appointments while doctors had time to play golf on Wednesdays.  It was an idyllic time with plenty of time to read, brush up on the latest innovations in medicine, attend scientific conferences, and still be able to make a living.  Board certification was simple: study hard, take a test, and move on.  Patient care didn't suffer.

These days, Never-never Land no longer exists.  Time is the most valuable commodity for doctors now as they see more patients in less time than ever before.  Pushed to perform in an era of exploding health care costs, the days of leisurely lunches, unlimited patient appointments, and easy access to caregivers have given way to a frenetic pace of 7-minute appointments, decreased length of stays, productivity quotas, and cuts in ancillary personnel as costs are shaved.  At the same time, regulatory burdens have exploded.

With this explosion of regulatory bodies has evolved a network of licensure bodies so complex that doctors have a hard time keeping up with the numerous affilitations, acronyms and name changes for these bodies.  Worst of all, fewer have time to perform their requirements without impacting patient care.  

Since 2000 the American Board of Internal Medicine, citing the need to stay abreast of the many innovations in medicine, decided to limit the duration one could remain “board certified” to ten years.  That way, the logic was spun, doctors could be brought up to date on the lastest and greatest concepts of their field so they could “maintain” their certification by passing a maintenance of certification (MOC) process.  Of course, this “maintenance” never took into consideration the ten additional years of clinical experience, anxiety, legal risk that doctors were exposed to in the meantime.  The “maintenance” never took into consideration the ongoing CME requirements doctors are required to maintain for state licensure.  And the "maintenance" was ever clinically validated at having an effect on patient care.  And the cost varied from doctor to doctor specialty.

And so it has gone: certifying board after certifying board, entering the fray – each with their own self-interest (and financial solvency) in play to assure their particular form of “certification” and doctor education is the best in the eyes of regulators and "stakeholders" (i.e., the people controlling the money).   Even an unscrupulous self-proclaimed "reverend-doctor"  joined the fray, promising a “board certification” certificate for just $500 by completing a simple questionnaire and mailing it to a post office box - all for far less hassle and time spent away from patients.

This week’s New England Journal of Medicine has an excellent article reviewing the Maintenance of Certification process for “board certification” and reviews both the complexity and regulatory burdens imposed by the new collaboration between the ABIM’s MOC process and the Federation of State Licensure Boards (FSLB’s) maintenance of licensure (MOL) process.   Ironically, the article sites an earlier published fictitious vignette from 2010 involving a subspecialist who held time-unlimited ABIM certificates in both internal medicine and endocrinology.  In the vignette, the physician wrestled with whether he should enroll in the MOC program of the ABIM voluntarily to become recertified, and readers were invited to vote on the question.  Of 2512 votes case, 63% advised the doctor against enrolling in the MOC program.

My bet is the number of doctors who would advise against the process would be far greater now.  The process has grown so time-consuming, expensive, and arduous (without any proven clinical benefit) that doctors are feeling the effects on their practices, income, and patient care.  Time away from practices has become very expensive for BOTH doctors and their patients.  After all, patient appointments, already hard to come by, are necessarily taking a back seat to these board-certification-turned-licensure requirements.

Board certification should return to a personal goal, rather than a regulatory one.  More doctors would be likely to participate voluntarily as transparency to credentials increases.  As a result, patients would benefit and payers would benefit.   Let doctors complete these requirements on recommended schedules, not mandatory ones.  Credit for safe, effective care should serve as an even more valid substitute for certification compared to sitting for tests before a computer and performing chart reviews.

Unless regulators comprehend how their evolving punitive, time-consuming, and expensive board and licensure recertification process has become for doctors, they might miss how its increasingly compromizing patient care rather than improving it.


Disclosure: I am currently undergoing the MOC process for the third time because I don't live in Never-never Land.


Iglehart JK and Baron RB. Ensuring Physician Competence - Is Maintenance of Certification the Answer?   New Engl J Med 2012; 367:2543-2549 December 27, 2012.


Hal Dall, MD said...

Accurate post, DrWes.

Why do MDs with 7, 9, even 11 years of graduate and PG training need to play "Simon says" with the Boards while threatened with replacement by 2 year PAs if the doc declines?

Anonymous said...


You have brought up an important topic that is a sore point for many if not most practicing physicians. As you have noted, the re-certification process is an onerous burden that purports to assure clinical competence. I can tell you more precisely what it has accomplished quite well. It has transformed a once respectable institution (the ABMS) into one that is a glorified version of a pay to play "Who's who", while simultaneously stuffing the ABMS coffers.

I am about to enter my second round of MOC in my subspecialty (I am grandfathered in my specialty Boards). When I originally became Board certified, I wore them with pride. They represented a formal validation for years of training in my field and an accompanying mastery of its knowledge base. Coincident with those thoughts was the now antiquated notion that medicine was truly a "learned profession". As such, I accepted a responsibility to enter into a lifelong and in many ways autodidactic educational process.

Re-certification is just another manifestation of the deprofessionalization of medicine, from an intellectually capable expert to skilled technician. CME requirements apparently no longer suffice. I now view the entire certification process with contempt. I ascribe no personal or professional value to it, merely viewing it as another aspect of 'playing the game'. And play the game I will, disheartened and distracted, henceforth acquiring new knowledge on a 'need to know' basis. Fervently hoping it will be the last time I must go through this circus act.

marcsf said...

MOC should be voluntary. There is no data other than retrospective chart reviews by ABIM employees that MOC accomplishes any goal except padding ABIM bank account. Cassel, ABIM CEO draws a salary of nearly $900k which is a clear insult to diplomates forced into the MOC abyss. Time for MOC to go away and ABMS as well.