Tuesday, October 08, 2013

What Board Recertification Is Failing to Teach Doctors

I continue to study for my third ABIM re-certifications in both cardiovascular disease and cardiac electrophysiology. In preparation for the examinations, I purchased the review materials offered by the American College of Cardiology called ACCSAP-8 and took the surprisingly expensive Cardiac Electrophysiology Board Review course held in Chicago recently. I find I have little time to study all of this material while delivering patient care, so I've been getting up at 4:30-5:00 am each day when by brain is rested to review the material. Needless to say, the material is so plentiful and dense that I feel like I'm reading through the Encyclopedia Britanica.

After studying for these boards for the third time, I have come to the realization that there's a million ways the ABIM could write test questions to pimp those of us required to re-take these exams. I can only hope that the few items I've learned as a consequence of answering the accompanying questions at the end of each section of the materials gets me by in a test whose curve is set by some statistical method that no one really understands. But what if I don't pass, God forbid? What would it mean for me professionally? While doctors are reassurred they can re-take the examination (for a fee, of course), does the ABIM's "scarlet letter" affect my ability to practice medicine? Should doctors be educated on the implications of non-certification and what it might mean to a doctor professionally rather than just touting the benefits of this process? Since the implications of not passing re-certification boards may have large financial and emotional implications to physicians, what ethical and legal responsibility does the ABIM and American Board of Medical Specialties hold to their members? I really don't know.

But my point in this post is not to re-hash my concerns about the non-objective and money-making nature of this recertification process, but rather to identify other problematic areas that the ABIM and professional societies like the American College of Cardiology and Heart Rhythm Society are missing in this re-certification process.

First of all, cardiology practice has changed. Cardiology specialists and subspecialists are now increasingly employees of huge health care systems as a result of the health care reform efforts underway. Increasingly, our subspecialties of cardiovascular medicine and cardiac electrophysiology are divided and continue to diverge clincially as knowledge and discovery expands at an unprecedented pace in both fields. As a result of these realities, there is little need any longer for electropysiologists to understand the nuanced differences between various glycoprotein GIIa/IIIb inhibitors, for instance. EPs just need to know that all of these drugs make patients' pacemaker pockets bleed more after surgery. Likewise, do electrophysiologists really need to know the differences between multi-detector CT and SPECT scanning protocols for the diagnostic evaluation of coronary disease in our new subspecialized world of medicine that remains far too litiginous? Electrophysiologists would be foolhardy to recommend a particular scan or the proper antiplatelet agent after a drug-eluting stent given these realities. Instead, doctors of varying skill areas need each other more than ever to provide quality care, not try to harbor every factoid in textbooks between our earlobes. To think any EP or cardiologist should (or could) know the ropes of the other specialty is unrealistic. As such, I continue to wonder why the added expense of cardiovascular medicine board recertification must be added on top of electrophysiology board recertification for tomorrow's doctors, especially in this era of Uptodate and Google. No matter that your view is of these arduous re-certification processes, we need to leverage technology to improve patient care and physician knowledge rather than pretend we don't need it. Force-feeding busy clnical doctors with more facts than they can ever hope to recall is frustrating, unnecessarily time-consuming, and may even have the unintended consequence of detracting from actual patient care delivery.

Secondly, ABIM re-certification test-writers fail to teach doctors how new CMS coding and billing requirements can adversely affect their colleagues and patients. For instance, no where is this more evident than the confusion that surrounds classification of patients coming to a hospital for "observation" or "inpatient" admission. As any skilled clinical doctor understands, what is billed and paid to the patient, doctor and hospital system rests heavily on this definition. Does the ABIM teach doctors this? No. Yet the financial and quality of care implications of this definition to both patients and doctors are very significant depending on how a patient stay in the hospital is defined by payers. (If you don't know this, dear doctor, you should.)

Thirdly, clinical physicians can even teach the more academic ABIM members a thing or two. For instance, maybe doctors who actually care for patients could insist that ABIM members teach doctors how to use vascular ultrasound devices to improve the safety of vascular access for our patients. Why isn't such a skill taught by our board reviewers who claim they are interested in improved patient outcomes? Might it be because it requires each of us to actually touch and care for a patient, something we get pretty good at after thirty years of providing care? Requiring academic discussions of obscure genetic disorders might make for good test fodder, but such obscure instruction completely misses important aspects of physician competency and patient safety.

This is not to say that all academic learning in medicine is without utility. On the contrary, learning by physicians will always remain an essential aspect of caring for our patients. I know that the many excellent doctors that have written modules for board certification preparation purposes have made every effort to make the re-certification process as meaningful as possible for doctors. But we should acknowledge that all doctors already have to "prove" that we participate in learning when we have to submit "certified" CME certificates to maintain licensure. Every doctor in America constantly has to "prove" we don't hurt people to our quality assurance committees and to the legal community. To force additional expensive and unproven training that is out of touch in so many ways with the way medical care is being delivered now may be having significant unintended negative consequences, too. We should start asking if the ABIM could be causing more harm than good as doctors become increasingly frustrated by the many bureaucratic and administrative hoops that increasingly detract from patient care.

After all, it's the lack of time left in the day to care for our patients that's most likely to harm them, not whether we pass a test or not.



Unknown said...

I find myself nodding in agreement at some of these comments as I chuckle the entire time about an EP and an interventional cardiologist or general cardiologist complaining that they have a tough time keeping up with each others specialties I'm an ER doc.

DrWes said...

I can't imagine...

G Sunil MD said...

Dr Wes,
Well said. As an endocrinologist who gives talks to other specialists, I have questioned the need for recertification myself, and have not done so for the past 10 years. As a result, no employers want to hire me; but I am thankful I have a private practice and I tell my patients that I am not board certified. My only peeve is that while there are people who passed the boards a year senior to me who are 'grandfathered' into a system where they are permanently certified, why should there be a dichotomy when it comes to certification? I am a person with no tolerance towards sitting in front of a computer for long; why can't there be an interactive system where we can have viva? I will gladly volunteer for being an examiner, pro bono if chosen. But, you know what, ABIM makes way too much money from this, and so do the 'board review' people; so I doubt it if the authorities will do something to change the way things are.

jeff Olson said...

The anesthesiology boards, one of the few which have an oral portion to the exam, are even more astounding and elusory in my opinion. Absolutely no feedback or insight into examinee's performance is offered months afterward for this far from realistic mock patient interaction.

Anonymous said...

Thank you for a very important blog! Physicians should be aware that, in April 2013, the Association of American Physicians & Surgeons (AAPS) filed a lawsuit in federal court against the American Board of Medical Specialties (ABMS) seeking to stop the MOC (Maintenance of Certification) program. The AMA agrees, and has filed resolutions opposing mandatory specialty board recertification programs and discrimination by hospitals against physicians who don’t recertify.
Medical staff membership in hospitals, participation on insurance panels, etc. often require board-certification. If physicians fail to pass the examination and numerous other requirements for MOC and to maintain their board-certification status, their medical staff privileges are revoked and their participation on insurance panels are terminated.
Please tell your colleagues.http://www.aapsonline.org/index.php/article/action_alert_stop_moc_mol_in_new_york_state/

Anonymous said...

Maintenance of Certification requirements fail to improve the quality of medical care while placing unnecessary burdens on physicians. The American Association of American Physicians and Surgeons (AAPS) filed an important lawsuit against the American Board of Medical Specialities (ABMS) in federal court in Trenton, NJ, docket number 3:13-cv-02609-MLC-LHG, for restraining trade and causing a reduction in access by patients to their physicians.
To find out more, google 'AAPS vs ABMS'.
The actual legal complaint can be found here: https://ia601704.us.archive.org/33/items/gov.uscourts.njd.288693/gov.uscourts.njd.288693.1.0.pdf
This information needs to be spread far and wide among physicians.

Anonymous said...

I am a gas-passer so please account for my biases. Since my field is implicitly in competition with CRNAs I always have to ask how is it physicians are differentiating themselves from nurses (this same argument can be extended to Internists and FPs). Should we require more education and/or Fellowship equivalents? Do we create value-added certifications that expand/extend our abilities? Or do we just sit down for a good ol' book learnin' test every 10 (or so) years? Does this test make us more marketable or better physicians--or is this just another money-making scam?