Sunday, April 18, 2010

Does Board Certification Really Matter?

My patients have the confidence of knowing that I am a board certified gastroenterologist (GI). I haven’t disclosed this to them personally, but somehow resourceful and curious patients can now find out facts about me that heretofore would have required a government warrant. (In fact, for my entire medical career, I have never displayed a diploma or any professional certificate in my office, which annoys my mom.) Now, with a few keystrokes, patients can read about my suspension from the fifth grade after making an unwelcome comment about another student. Being from the northeast, my initial reaction to this transgression was, “Will this be on my college record?” Assuming that I successfully recertify in gastroenterology in the coming year, I will enjoy this prestigious designation for another decade. I hope I that I am still practicing then, since the health care reformists have promised us a medical nirvana in in the coming years. It would be a shame if I retired just before the nirvana tsunami struck our shores.

What does a board certified label mean for patients? Patients seem to be reassured when their physicians have received the American Board of Internal Medicine’s ‘Good Housekeeping Seal of Approval’, but do they really know what it means?

Here’s a short quiz for patients to gauge their knowledge of this issue. While each answer may seem reasonable, you are charged to choose the best answer. Don’t agonize over this. After all, this is not the SAT or the ACT, where a single incorrect response can determine one’s ultimate success in life. Indeed, we have taught our 5 kids since kindergarten that failure on important standardized tests is tantamount to failure in life. For this reason, since our kids were small, I placed a different ‘flash card’ under the toilet seat each morning, so that their gastrointestinal function could be combined with educational enhancement. Our kids wondered if this activity needed to be continued during their high school years, but I emphasized that knowledge acquisition is ongoing, and should not be prematurely flushed aside.

Here’s the quiz question.

Board certified gastroenterologists, in comparision to 'board eligible' GI wannabees are able to :

(1) Perform rectal exams with all 10 digits

(2) Complete a colonoscopy speedily before the sedation has taken effect

(3) Impress patients with fancy jargon like dyspepsia, instead of using common verbiage, such as stomach ache

(4) Profess ignorance of the cost of procedures since health has no price

(5) Order enemas routinely assuming that patients will enjoy the experience

(6) Make an involuntary donation every 10 years to the American Board of Internal Medicine (ABIM) so that hospitals and insurance companies won’t kick us off their rosters.

I am now deep in the recertification experience, which is known by the ABIM as MOC, or Maintenance of Certification. I have completed most of the required modules, which are home study sessions that can be retaken, if they are not successfully passed. Afterwards, I can proceed to the culminating experience of the entire recertification process – the all day test. Here's where I will likely have an opportunity to guess at answers that I could look up in a book or computer in real life. Physicians in private practice like me are always delighted to sacrifice a day’s income to serve the greater good. In this digital era (who knows more about digital than gastroenterologists?), would it not be possible to take this exam from my own computer on my own time? However, it is not for me, a simple blogger, to question the infinite wisdom of the ABIM who has commanded from a Philadelphia mountaintop:

 Thou shalt set aside a day of wages on the Altar of Knowledge after the check has cleared.

There’s a reason that so many physicians find the MOC to be an expensive hassle that doesn’t accomplish its mission to improve the quality of our care. While some argue that board certified physicians have superior clinical outcomes, this may be unrelated to the MOC process. These physicians may perform well because they are already skilled and knowledgeable practitioners. This is similar to concluding that high school students who score well on the exalted SAT examination will perform at a higher level in college. It’s the kid that determines the success, not the test score. Personally, I don’t think that the lengthy and expensive recertification process will improve my knowledge and performance. Like most physicians, I have developed my own educational strategies to remain current in my field, and I believe they are working well. It is clear, however, that the MOC delivers great benefit to the ABIM.  Not surprisingly, Christine Cassell, MD, president and CEO of the ABIM expresses on KevinMD that the current recertification process is worthwhile, although admits that reforms are needed

Would we physicians run this gauntlet if we didn’t have to? For many of us, the MOC is a Marriage of Coercion. Don’t look for my certificate on the wall.


Anonymous said...

In my field, I especially enjoy paying the application fee of $1000 just to be approved to pay the test fee of $1000.

The Notwithstanding Blog said...

What I'd be interested to see is how many board-eligible ACGME residency/fellowship graduates actually fail board certification exams, either initially or at the recert stage. If the number is low enough, then board certification probably doesn't convey any information about the physician than his/her GME completion does.

Peculiar Poster, MD said...

A cardiologist colleague of mine has decided to not let his internal medicine certification expire. To this end, he is pouring his heart and soul into learning all about dreadful things like TNF-alpha and its brethren (all due respect to the rheumatologist readers of your blog - he is a cardiologist after all, and has been for several years).

Despite jumping headlong into the pool of mind-numbing mumbo-jumbo, he readily states that he is happy for doing this. Just the other day, he almost looked excited when he said it was unbelievable how much medicine had changed since he was a resident.

I think he will be certifiable by the time the recertification is over!

Nicholas Fogelson, MD said...

Michael -

In my field board certification is pretty important, and I think it does serve as a marker of quality. About 85% of first time takes pass the OB/GYN oral boards, and in my experience the 15% that don't pass usually don't pass for a reason.

Our oral boards are very rigorous, and require a great deal of knowledge to get through. I think they serve as a pretty good sieve to lock out those who have not done the requisite work to become competent and knowledgeable.

Personally, I wish board certification (or lack thereof) were something that had to be advertised a bit more. Where I trained, there were a number of community practitioners that had failed their oral boards three times (the maximum number of attempts), and yet most of their patients had no idea. To a one, each of these physicians had very weak knowledge bases, in in most cases very suspect clinical judgement. The sad thing is that some smaller hospitals will still grant privileges to someone who had demonstrated an inability to pass their boards, if only because there are not other docs that want to work there.

Michael Kirsch, M.D. said...

Thanks, Nick, for your thoughtful comment. This is a murky issue. The 85% who pass on the first run are likely qualified physicians in the first place. In other words, they are not better qualified because they are board certified, but they pass the boards because they are more knowledgeable. I presume that nearly all of the remaining 15% will eventually pass. It is arguable whether the process that leads these latter physicians from board exam failure to passage makes them better physicians. The mechanisms that we use to measure physicians with board certification, pay for performance, etc. are problematic. Similarly, the skills and academic performance that I needed to gain admission to medical school are quite different from what I need and rely upon as a practicing gastroenterologist. Increasingly, we are measuring what doesn’t really matter.

Is the board certification exercise, which costs physicians money and time, really valuable if the vast majority of us pass on the first attempt? Of course, we physicians are obligated to engage in ongoing education. I am not certain, however, that the ABIM does better for us than we can and should do for ourselves.

Bruce said...

Dr. Kirsch, can you suggest the best way to finda qualified gastroenterologist to hopefully diagnose a pretty severe problem I have been having with a hiatal hernia since shortly after my heart surgery? The pain is incredible, almost daily, and closely mimics a heart attack - which I have already had 3 of. My current method to relive pain is to take sublingual nitroglycerin tablets - but the long term effects of this scare me. The last 2 gastroenterologists I saw had NO idea what was causing my symptoms and instead recommended a colonoscopy! I just don't know how to find a really competent specialist.

Anonymous said...

I agree that recertification is not a good measure of a quality physician. Why do we let the ABIM and ACP (in my case) do this to us?

Michael Kirsch, M.D. said...

We let them do it to us because we have to.

Anonymous said...

I agree with you, Dr. Kirsh, that those who fail, fail for a reason and that's probably reassuring. I suspect most of them eventually pass though. I don't believe that the converse is true however, that those who pass the boards are necessarily qualified. I can attest to the many physicians I have met who are board certified, who are quite scary, who I would not even send my enemies to.

Michael Kirsch, M.D. said...

To the above anonymous commenter, I agree that board certification is not tantamount to possessing medical excellence. Sorry to hear that you have enemies!

Anonymous said...

I have just passed my recertification in Gastroenterology. The Moc system has changed somewhat. (this is my second recert). The MOC modules have a new educational bend. The turn around time is now one day on line, and they provide answers and a rational for the answers with references. Some of the rationals are not written well and are tantamount to "it is because it is well known," but it is the first time I have seen the ABIM actually demonstrate any interest in educating whatsoever. The tests are now administered by a third party. The test room I was sent to was crowded and very noisy, with test takers taking other examinations such as typing speed tests, EMT tests, and other essay related tests. The staff make you empty your pockets,remove your watch and jewelry, and leave your wallet in a basket like a common criminal. You are fingerprinted going in and out of the room to make sure you have not gotten someone else to take your test for you. Bathroom breaks are permitted with a penalty that the clock continues. If one is foolish enough to use the bathroom, then one is penalized for the time it teaks for someone to deactivate your computer, escort you to the control room, scan you, walk down the hall to the bathroom, use the bathroom, return, go to the control room, get your id out of the locker, go to the receptionist, be escorted to the test room, be rescanned, and have your computer restarted.
I felt like a criminal who had been convicted of some crime. The room was so noisy it was difficult to concentrate. The experience was truly torture. If they are trying to make us angry they have succeeded. If they are trying to create an educational experience they have failed.

Anonymous said...

I lost a really good job on December 31, 2010 which I could have retired from if given the chance. I lost this job because I chose not to participate in the MOC process for either or both IM and GI. GI board certification expired on the above date.

I have written the President of the U.S.A; ABIM President, several major news organizations (the medical correspondents), BCBS of MT to explain why MOC should not be used in anyway to the practice of medicine. Admittedly this letter was about 300 pages, which included suggestions to try and keep up with changes in the "art and practice of medicine". I wrote the above because I did not know who to turn to after failing to negotiate with my employer. Unfortunately the majority of apathetic colleagues are not of any help either (just take the test, suck it up, etc).

If anyone is interested in reading the main part of this letter I will be more than happy to send this via e-mail or hard copy.

stubones said...

I have not passed my boards. I cannot find any guidance about what to do, only derisive commentary on how I failed for a 'reason.' The presumption being that I'm a moron. What would, in essence, be a valid reason for not passing? Maybe having my oldest (16 years old) son die three weeks before boards? Taking boards on the anniversary of burying my oldest son? Realizing that I was losing my physical ability to perform that duties of my chosen specialty?

The nuts of this comment is that I am alone! I am an outcast who has spent years of life working diligently to achieve a noble profession, and in the 11th hour I failed to finish the deal. Now that I can't pass boards for reasons of physical nature, what should I do? Where can I turn for help? Certainly not to the dispassionate naysayers who feel that I shouldn't be a doctor anyway.

Man, I feel lonely, bereft and worried. What am I gonna do now? Anybody?

Anonymous said...

I am deeply troubled by the fact that the internal medicine boards are a for profit corporation.

Why should a private, for profit, company be in charge of a certification that is so important to the careers of internists?

Whether or not I can recall the chromosomal abnormality of Tay Sachs disease on a closed book has little bearing on whether I am a good doctor.

And leaving something as important as certifying internists to a for profit company just seems very, very wrong.

Anonymous said...

I failed the initial cert GI boards three times. Have no idea what I am doing wrong. I don't think the test is a marker of how I am as a gastroenterologist but I just don't take tests well. Any suggestions?

Michael Kirsch, M.D. said...

I think the converse may also be true. Outstanding test performers may be less outstanding as clinicians.

Anonymous said...

Not passing your board is an agonizing feeling. It brings your self confidence to an all time low. Our profession and society make the board certification to be the ultimate seal of approval. Unfortunately, there does not seem to be much out there to help those of us who spent 11 years pursuing our dream of becoming a physician but do not succeed on the board exam. Obviously, there is a psychological aspect to this. Some of us are just not good standardized test takers.Only if I had realized that 11 years ago!!!

Anonymous said...

I have seen many so called Board Certified doctors who are extremely bad clinicians. Board Certification is just big business to collect our money and fool the general public that the certified physician is the best. If it were really a fair exam all the ABMS specialties should have the same format. All candidates given the same questions on the same day although the order of questions be changed. Why give the result pass or fail in percentile? Give pass or fail raw score then and there after the computer test administration.It is a common knowledge that if you fail the board exam once then you get harder and harder tests each time you take the test again. Why have the oral boards ,? Are they trying to check the face and color of skin of the applicant to decide who to pass? A lot of people get nervous on oral exams does that mean they are idiots and have no knowledge of the subject? Nervousness on oral exam does not necessarily translate to nervousness in imparting clinical care.Why not have doctors of each race and color on the examining board panel to check that the exam is fair for all candidates? I feel any exam based on percentile results is a way to limit who to pass and who to not to pass? Why do boards have to ask how much did you study during the last year before you take the test- I mean there are questions on computer based test asking the candidate for this information.Are they going to decide pass / fail on this question? Why ask for residency evaluation scores before you fill the application for taking the boards.So if for example the program punished a candidate due to various racial or other reasons and had bad evaluations he cannot expect to pass the boards because board has this predetermined knowledge that this candidate is bad and they can fail him with no questions asked. Until unless the boards become honest in their dealings with not charging exorbitant exam fees for profit and become fair in exam process I feel board certification is a not a fair exam.It is a common knowledge that all the boards are sitting on piles of cash which they use for lobbying the legislatures to pass laws favoring theim in myriad ways.

Anonymous said...

I am a non- board certified internal medicine / pediatrician. I practiced in an urban clinic with 5 other board- certified practitioners for 15 years. I also served as the Hospitalist for the practice as no one else wanted to do hospital rounds. I had to find my own coverage for medicine & Peds when I went on vacation or wanted a free weekend. In the office, the "board certified" docs all came to me with questions. In some specialized fields, it may (or may not) mean something. In primary care, the patients all wanted to see me after I took care of them in the hospital. I have since left the group, and went into private practice. I have taken a huge majority of the patients with me, without soliciting, they sought me ou and found me. As a boss, if a physician wants to work 9-5 and not care for their patients when they are at their sickest & hospitalized, you bet, I will insist on boards. If they're a "real doc" and follow their patients, won't really matter; I will base their employment on the interview. I find most docs in primary care today are really 'business tycoons' who work a few hours per week and din't really "care" for their patients. Mine have my cell number, they know I'm always available for them, they referr family and friends, and after 20 years of practice, I've never had a law suit. I am respected by the consulting physicians in my area and receive referrals from them all the time. Just wanted to give another view. I love being a physician (board certified or not) and would never trade it for anything. I and my patients know, I am a real doc!

Anonymous said...

There are a lot of IDIOTS who are BAD DOCTORS who pass boards.

MOCsux said...

It is clear maintenance of certification exists only to raise revenue for the ABIM and ABMS. The only study that could show it matters is by comparing age-matched clinicians who do and do not participate in MOC.....and that study has not and will never be done. All the "research" quoted by the ABIM is essentially opinion written by ABIM lackeys.

I disagree, Dr. Kirsch, that we have to let the ABIM do it to us. Oppostion to the expensive, unproven MOC process is becoming increasingly accepted and acceptable. Do not participate in MOC and spread the word to others that the process in unacceptable in its current form at its current price. Opposition is growing exponentially!!!!

Michael Kirsch, M.D. said...

Would protesting against the exalted ABIM be worth surrendering hospital privileges?

Anonymous said...

Deeply sorry for your loss. I fully understand, having lost my son, too. Not many get it.

Anonymous said...

I had active Internal Medicine boards from 1994-2004 and active Academy of Hospice and Palliative Medicine boards from 2004-2011 from the only organization that offered the specialty exam during this time. In 2008 and 2010 I petitioned the ABIM to "allow" me to sit for their version of the Specialty boards prior to the expiration of my already existing specialty certification. Despite 10 plus
years of direct patient care,service as a medical director of a large hospice, letters of recommendations from national leaders in the field, and medical directorship of residency training program as well as completion of 100 hours and the quality improvement program the ABIM turned down my application based on the fact that I had not re certified in my primary (internal medicine) Almost 100% of those taking the exam had either certified in medicine prior to 1990 (18-32) years ago) or recently graduated from fellowship programs. Those of us who were more recently certified in internal medicine( 1994 not 1980) but were busy practicing our specialty for 12 years were banned. Go figure the logic. I found the treatment I received from the ABIM to be cold, bureaucratic and uninterested. The most a low level person could say is "that is the way it is" after my petition was denied. I actually petitioned on behalf of the group at large and not just selfishly on my own behalf by asking them to reexamine their biased policy. Someone in middle management did confide that they have numerous complaints from the middle generation who have been in sub specialty work but that there is no interest in the ABIM board to relook at the grandfather clause and reconsider how they classify once certified candidates.
My recommendation and that which I propose is the following:
All original certifications should be listed as of the date the person was certified. Their should be no expiration date for anyone.
All completion of modules if done should be listed as further evidence of an individuals commitment to ongoing learning
All successful moc exam should be listed if the individual chooses to take the exam.
This and only this will level the playing field.
The public is very confused and I am one of the resentful folk that have been treated differently as though I never passed the original exam when compared to my same age or older colleagues who never retook the exam either.
Am interested in responses:

Anonymous said...

It's great to read your blog! Let me start by saying I am a specialist physician and my work is my passion. My patients give me the feedback that I'm one of the best diagnosticians they have ever come across. I love figuring out differential diagnoses, and over the 10 years i've been in practice with more experience, I have become even more interested in solving difficult cases. Many of my colleagues in town refer their tough cases to me. That said, I am NOT board certified, nor did I ever plan to be. Despite studying my a$$ off I averaged in the 19th percentile in the mock boards every year of my 4 year residency. I decided it was not worth the money to get certified especially since I could start a practise anyway. If a patient ever asks, I tell them that my residency certificate/dipoloma is my proof of specialty training and that board certification is not a requirement to practise. Not one patient has ever had a problem with this. I even busted a few stereotypes that a couple of patients had when they had told me I had figured out their problems unlike any other doc they'd seen in the past. So my point is that I see board certification as a crude filter of sorts. Sure, it filters out those who didn't attend residency or didn't learn any facts in residency, but it is also a way to filter out those like myself who cannot think in black-white multiple-choice format, which is irrelevant to clinical skill. I am contracted with several insurances, no problem. One insurance did turn me down, however even they later contacted me to apply again, apparently partly due to several complaints they'd received from patients of mine with that insurance!!

S. Frembgen, DO said...

Its me, the proudly non board cert'd doc again. I don't know why I made the comment "anonymous"! Habit I guess !!

David said...

Dr. Kirsch, thanks for your blog post. I am a newly board-certified psychiatrist who has reluctantly complied with the system so far in hopes that certification will increase my opportunities, as my goal is enter academics as an educator. There are a number of reasons that I dislike the system of board certification as it stands now, but at this point I've decided that opposing the system on principle is too likely to adversely impact my career since I am just starting out.

One of the main reasons I disagree with the current system is that the boards claim to set a standard for practicing physicians, yet many of the test questions are on minutiae that realistically no practitioner needs to know to treat patients. For instance, it does not help my practice to know what chromosome the gene for Huntington's disease is on, yet it is a common question for the psychiatry boards. My opinion, which I not-so-humbly state is actually pretty common-sensical, is that the questions should deal with the issues that we as docs NEED to know. Otherwise, some docs will fail based on missing questions that would never have impacted their care of patients anyway.

Another issue I have with the psych boards specifically is that the failure rate is absurdly high. Interestingly, the pass rate for recertification is approximately a rather astonishing 99%, and the ABPN (the psych and neuro board) publishes this on its website. However, the pass rate for initial certification is not published on the ABPN's site - only the number of certifications that have been granted. From multiple sources I have read, that pass rate hovers around 65-70%, and I wonder what other motivations the ABPN is fulfilling by failing about a third of examinees. I haven't mentioned until now that the psych boards cost $2700 to attempt, among the most expensive of all specialties.

Finally, I dislike medical standardized tests in general because they do not emphasize thought, but speed. Anyone reading this who has taken the USMLE steps knows that an examinee cannot spend much time at all thinking about each case vignette when a typical question has about 5-10 lines of text, 5 answer choices (or more in the case of USMLE Steps 1 and 2) and there is little more than 1 minute to decide on an answer. I don't mind having a doctor who processes information quickly, but I'd rather my doc not take shortcuts with my care.

Anyway, those are a few of my reasons for disliking the system, but as a recent residency graduate, I don't feel like I'm in quite the position yet to concretely change it. I'm glad to be vocal about it in the meantime and maybe a cogent argument or two will reach the right ears.

Keep the posts coming, please.

HS said...

I failed my Rheumatology recertifying exam twice and not sure what to do. I don't label myself as a bad doctor or one with less knowledge. I guess I don't have good test taking skills. I am not sure what to do?
I need help.
Any suggestions?

Michael Kirsch, M.D. said...

To David, the psychiatrist, excellent comments. Though you're new at the game, you're ahead of schedule. Hope this blog is on your reading list.

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