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On Being a Doctor |

The Professional Testing Center

Rebecca D. Elon, MD, MPH
[+] Article, Author, and Disclosure Information

From Johns Hopkins University School of Medicine, Baltimore, MD 21205.

Requests for Single Reprints: Rebecca D. Elon, MD, MPH, Erickson Health Medical Group, 6334 Cedar Lane, Suite 103, Columbia, MD 21044; e-mail, Rebecca.Elon@Erickson.com.

Ann Intern Med. 2009;150(5):357. doi:10.7326/0003-4819-150-5-200903030-00016
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17 November 2008





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Does the ABMS promote professionalism or perfectionism?
Posted on March 10, 2009
Edward J. Volpintesta
No Affiliation
Conflict of Interest: None Declared

I agree with the author's displeasure over the excessive security measures taken at the professional center where she sat for her recertification boards in geriatric medicine. But the recertification boards, especially in family medicine and general internal medicine are deserving of criticism in many other areas as well.

Clearly they are disconnected and out of sync with the real world of medicine, particularly with how most primary care doctors tailor their practices according to their strengths and the needs of their medical communities. I didn't take any board review exams because that would have made me a hypocrite. Besides, those who take the board reviews disadvantage those who don't and make the final results almost meaningless when it comes to measuring a doctor's total professional competence.

Recertification should be taken only to uncover areas of weakness with recommendations for remedial study. They should not have a pass/fail approach.

There is a principle at stake here. Physicians have the wisdom and the integrity to maintain their own professional competence. That's what professionals do. The boards however have usurped that role by maintaining a dogmatic and inflexible approach to physicians' continuing medical education (CME). Indeed, they have become the definers of physicians' professionalism. Even worse, by the inordinate and illegitimate power they have over doctors' lives they actually shape their practices by creating standards that are more befitting academicians than practicing physicians.

The power held by the ABMS over physicians' professionalism has great potential for abuse. The ABMS is a monolithic organization whose presence supports many CME programs including the board review programs.

In spring of 2008 I presented a resolution to the House of Delegates of the Connecticut State Medical Society addressing the many inconsistencies and defects of the current board exams. I have included the resolution here in its entirety.

The resolution is still a work in progress. I include it here for the consideration of those who may believe that the recertification process needs to change.

Resolution to Improve the Recertification Process

Whereas board recertification by the American Board of Medical Specialties (ABMS) is being increasingly used as a criterion of physician competence, and whereas, in a recent article "What do Certification Examinations Tell Us About Quality?" (Archives of Internal Medicine, July 14, 2008) written by Bruce Landon, MD, MBA, MSc of the Department of Health Care, Harvard Medical School, the author stated that [regarding credentialing exams] " "¦it is not clear to what extent performance on such examinations can predict clinical skill and quality of daily practice"¦[and that] the meaning of specific knowledge deficits on examinations is unclear, because, in practice, many physicians have available professional colleagues and consultants as well as additional information sources that they can use in real time to help them evaluate patients and formulate treatment plans. Therefore, knowledge deficits in the artificial setting of an examination do not imply that physicians will make mistakes in caring for patients.", and

The ABMS's dogmatic approach to recertification is considered by some experts to be an over-reaction to the Institute of Medicine's (IOM) 1999 report To Err is Human. The report was based on two studies (1) "Incidence of Adverse Events and Negligence In Hospitalized Patients" by Troyen A. Brennan MD and associates, published in 1991 in the Feb. 7 issue of the New England Journal of Medicine. It used information based on adverse events and negligent care occurring in New York State in1984 (2) "Incidence and Types of Adverse Events and Negligent Care In Utah and Colorado" published in Medical Care March, reporting on similar events in occurring in 1992. The studies implied that as many as 44,000 deaths occurred due to negligence in Utah and Colorado and as many as 98,000 in New York. The IOM extrapolated these numbers to the entire US and declared that as many as 98,000 deaths occurred in hospitals yearly because of negligence. This sent a shock to the public and policy makers who promptly initiated a medical safety policy rampage that affected all doctors, even though the report focused on in-hospital care and found that the errors which occurred were "systems errors" not errors due to doctors' lack of knowledg.

Another study by Rodney Hayward MD published in the July 25, 2001 Journal of the American Medical Association "Estimating Hospital Deaths Due to Medical Errors: preventability is in the eye of the reviewer" found that the number of deaths because of medical errors was between 5,000 and 15,000, substantially less than the IOM report, and never received any publicity to counteract the unnecessary fear caused by they IOM report, and whereas, at the June 2008 meeting of the American Medical Association's HOD meeting the Young Physicians Section (YPS) presented a resolution (Resolution 323"”Improvements to the maintenance of certification process) asking our AMA to write a letter to the ABMS asking among other things for the ABMS to ensure that the demands of maintenance of certification (MOC) also known as recertification are reasonable, to solicit physician input and feedback on MOC implementation, and to make recertification related costs transparent, which resolution was accepted by the HOD.

The boards fail to take into account important personal qualities such as honesty, ability to connect and form therapeutic relationships with patients, ability to work as a team member, participation in hospital affairs, participation in local and state medical societies, contributions to the medical literature, activity in educating the public and any other qualities which are not measurable by multiple choice tests.

Whereas, the president of the ABMS recently was quoted in the Los Angeles Times (May 19, 2008) as saying that doctors should not be rated like products or other service providers because the doctor-patient relationship is very personalized and that patients want doctors who are not only technically competent but who can communicate and who have an understanding of the human dimensions of health care that extend beyond technical expertise.

In addition to the resolution presented by the Young Physicians Section at the AMA HOD in June, 2008 another resolution also aimed at improving the recertification process was presented at the Organized Medical Staff Section of the AMA by a member of our Connecticut State Medical Society which was favorably received by that body and will be re-discussed at the interim meeting of the AMA in November.

The recertification process is time-consuming, costly, and requires time away from the office. The pass/fail approach used by the ABMS is an insult and affront to practicing physicians, who by their training and professionalism are committed to life-long learning in the specialty that they practice.

The recertification process is out of sync with what many doctors actually need to know, forcing some to take expensive and time-consuming board reviews to assimilate knowledge merely for the sake of passing the recertification exam. Some board review programs actually guarantee a passing grade, raising suspicions about the profit motives underlying the recertification process (and continuing medical education in general). The ABMS has unilaterally and expanded its role, now offering certificates in hypertension, diabetes, and sleep disorders, to name just a few, adding further pressure on physicians to prove themselves competent and adding further financial pressures, time demands, and psychological stress to their professional lives.

The ABMS has inappropriately and unilaterally assumed a disciplinary role, offering on the internet information on how to register a complaint against a doctor. The ABMS enjoys a monopoly status in the certification business, allowing it to enforce a dogmatic and inflexible philosophy. The boards are said to be voluntary, however, the pressure on physicians to protect their livelihoods and reputations makes them anything but voluntary, therefore be it resolved that our CSMS support all efforts of our AMA to assure that the recertification process is as helpful to physicians as possible by bringing it into sync with what doctors are actually doing in their individual offices.

Our CSMS support the motion presented by one of its members which will be re-examined at the AMA interim meeting asking our AMA to request the ABMS to eliminate the pass/fail approach in its recertification exams. our CSMS ask our AMA to request the ABMS to remove its offer of how to register a complaint against a doctor on its web site. Our CSMS should ask our AMA to request the ABMS how many examinees take board preparation tests, and what, if any, commercial affiliations the ABMS has, how it determines its testing techniques, what evidence it has that supports the validity and usefulness of its testing methods, and an explanation of why it offers information on how to register a complaint against a doctor on its web site.

Our CSMS should ask our AMA to keep surveillance on the activities of the ABMS since it is clear that their plans for expansion go far beyond their role of a voluntary examining body, and they may be motivated by concerns other than those germane to testing.

Our CMS should present these issues at the next meeting of the New England Delegation to the AMA

Conflict of Interest:

None declared

Exam Experience
Posted on March 27, 2009
Christine K. Cassel
President & CEO, American Board of Internal Medicine
Conflict of Interest: None Declared

Two letters in the March 2009 issue of Annals (March 2009; 150:357) highlight two very different testing experiences for ABIM certification.

Like Dr. Elon, I remember taking my pencil and paper recertification exam. Taking the exam with my colleagues was a collective and reinforcing experience. We could support each other during breaks, tell jokes to cut the tension and make new acquaintances who shared my area of specialization.

But many of the security concerns and measures of today existed then as well. When I took my geriatrics exam proctors walked up and down the aisles of the center and we had to follow a specific schedule for completion of each section and for breaks "“ you could not complete the exam at your own pace. We had to raise our hands to go to the bathroom and be escorted not out of the test room to the rest room and then back. We signed the same pledge of honesty we agree to when we register for an exam today.

Twenty years later the exam experience has changed, but not the need for the security measures. The shift to computer based testing provides an opportunity for physicians to take the exam at their own pace and allows ABIM to offer the exam at many more locations. Pearson VUE has more than 200 testing centers across the United States and in 23 countries "“ including Iraq where despite some logistical challenges Dr. Bedgood was able to successfully complete his certification exam in gastroenterology. In the old days of paper and pencil there were only 50 testing centers and administration of an exam in Iraq would have been impossible. The computer based testing environment also allows for different testing elements (like video, audio) not available in the old model.

The professionalism and integrity of most examinees is unquestioned. But improper behavior from one examinee would compromise the results for an entire group. Pearson VUE's security procedures are designed to help maintain examination integrity "“ but they come with tradeoffs, many highlighted by Dr. Elon. We hear from physicians who prefer the new computer approach and we hear from others that preferred the old pencil and paper model. Overall a large majority of candidates believe that the security procedures are appropriate.

The exam taking environment is not perfect and we are committed to improving the testing experience of all our diplomates and appreciate the insights of Drs. Elon and Bedgood.

Conflict of Interest:

Author is President and CEO of the American Board of Internal Medicine

Board Experience or Board Exasperation?
Posted on March 27, 2009
Edward J. Volpintesta
No Affiliation
Conflict of Interest: None Declared

It is gratifying to read Dr. Christine K. Cassel, president and CEO of the ABIM state in her March 27 rapid response "Exam Experience" that her organization is "committed to improving the testing experience of all" their diplomates. As a primary care doctor I have never taken the ABIM's recertifying exam but, until recently, I have recertified with the American Board of Family Medicine several times during my career. I had done so because I was worried about being dropped by insurers' panels if I were not certified.

With each recertification exam that I took however, I became more convinced of how out --of-- sync the ABFM was with what I actually did in my practice. Over time I tailored my practice and although I no longer took care of hospital or nursing home patients; and did not do gynecology or pediatrics, still a considerable portion of the exam was dedicated to these areas. There are many board review programs that prepare physicians for the recertification exams. One actually guarantees a passing grade. But engorging myself on knowledge that I didn't use seemed absurd and hypocritical. So I decided not to continue recertifying.

But the point is that many of the shortcomings that I see with the ABFP boards seem to apply to the ABIM as well. At least that is my impression after speaking to physicians who had recertified with both boards.

For example, both boards cover knowledge in many areas that individual physicians do not use in their practices. One doctor who recently recertified told me that had he not taken a board review exam, he would not have passed. He described how he learned strategies to maximize his chances of passing and how a lot of the medical information he learned was not material he needed in his practice. What does this say about the value of the recertification process?

A few important points need to be made here. If the boards for non- academic primary care and family physicians do not take into account how both groups tailor their practices over time and test them based on a generic model, how can they be helpful?

And don't doctors who take the board review courses have an advantage over those who don't?

Based on the above, it doesn't make sense; in fact it is insulting to grade doctors as passing or failing after they have already received initial certification by a board. The board should uncover areas of weakness in a particular doctor's knowledge base and suggest remedial study.

Many doctors feel that board recertification and CME in general have become cottage industries, more concerned with profits than actually helping doctors. Our leadership must make every effort to assure that testing and board organizations do not devolve into bureaucracies that have no concerns for the human consequences of their actions.

Criticizing medical education is difficult. It is easy to offend when no offense is meant. I am sure the boards and the board review programs are well-intentioned but some doctors' needs are not being met by either.

I hope Dr.Cassell appreciates my insights as much as she did those of Drs. Elon and Bedgood. I tender them in the same spirit of collegiality.

Conflict of Interest:

None declared

Re:Board Experience or Board Exasperation?
Posted on April 5, 2010
No Affiliation
Conflict of Interest: None Declared

Very well spoken. Unfortunately, the ABIM and ABMS have money coming out their ears and can't hear you. At this point, like many other things in the US today, this is driven by money. Only by all of us following Dr. Elon's example and not recertifying, thereby decreasing their income, will anything be changed. They will otherwise have no reason to change anything. As long as we pay them, they will take our money and do things as they please.

Conflict of Interest:

None declared

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