Efforts to ease requirements for maintaining board certification have not quelled internists’ complaints about the time and costs the maintenance process demands. Still, the president of the American Board of Internal Medicine—the body that oversees certification for internists and many other subspecialties—remains convinced that maintaining certification is important for physicians, and that the board’s path for doing so is the best one.
“Putting out a credential that speaks to whether doctors are staying current in knowledge and practice, I think overwhelming numbers of doctors want to have a way to reassure themselves that they’re doing that,” says ABIM president Richard Baron, MD, MACP. “And they want a way to communicate to their patients and colleagues and institutions that they’re doing it.”
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Even so, the ABIM has been trimming many of the changes it made to the maintenance of certification (MOC) process in 2014 and that led to the outcry among physicians. Last year, for example, the board invited practicing internists to review the outline—or “blueprint”—of the assessment exam and rate the topics it covers for their relative frequency and importance to everyday practice.
Then earlier this year the board announced plans to introduce a shorter assessment test in 2018, one that doctors can take on their own computers rather than in a central testing location. Doctors who do well on these assessments can “test out” of the current assessment, which is required every 10 years.
Baron’s comments were part of a wide-ranging interview with Medical Economics regarding MOC and other issues facing the ABIM that took place during the American College of Physicians scientific meeting in May. The full transcript follows:
Medical Economics: One of the complaints we hear about MOC is that the process has very little relation to the kinds of problems most practices face on a day-to day basis. Do you anticipate that the changes you outline in the announcement are going to address that complaint?
Richard Baron, MD: I would say that a number of changes we’ve already made have taken important steps to address that. We’ve been engaged in what we call a blueprint review process where we invited practicing doctors, all board-certified doctors in a discipline, to give us feedback on what’s called the blueprint, which is the design specification for putting together the exam. We did it in IM in the MOC exam in the fall of 2015 and had very positive reviews from doctors that it was more relevant and moving in the right direction.
So crowd-sourcing in how to put the exam together has helped a fair amount in the relevance area and we’re rolling that out across all our disciplines. So I think we’ve taken a number of important steps there and will continue to.
The changes we made with ACCME [the Accrediting Council for Continuing Medical Education], creating a way for more CME programs that met ABIM standards to seamlessly generate MOC recognition is something we also think was in the direction of saying this is a program that gives people credit for the work they are doing that is sustentative, valuable educational work.
ME: Can you point to any specific changes in the blueprint that you feel are making it more relevant to everyday practice?
RB: I’d have to say it’s too numerous to count. In other words, the blueprint review is pretty technical. It not only gets into different diseases but it gets into is it important to be able to diagnose this, to treat this? Is it important to understand the disease mechanisms? Those are all things that exam questions might test. So some of the things we’re asking doctors is, how important is this?
So for example a disease that you don’t see very often, that is very rare, but if you missed it the consequences for the patients are dire. That is something we want to keep on our exam, because missing that is really a problem even if it’s not something you see every day. So getting a crowd-sourced opinion on that of people helping us think through well how important is this really? And OK, I mean I (don't) carry around in my brain what antibiotics to treat meningitis, but I better understand meningitis when it happens, and I better understand the test I need to do when a patient shows up with a fever and a headache.
So that kind of thing, it was just a bunch of calibration across a very large exam.
ME: Another complaint we often hear from readers is the requirement to have to board in each subspecialty in which the physician practices as well as in IM, and that the ABIM doesn’t advocate strongly enough on behalf of its members with hospitals that require this for admitting privileges. They want to feel that the ABIM is going to bat for them. Any response to that?
RB: Well, I think how people use ABIM credentials is very geographic and market-specific. When I finished my training in New York the first practice I did was in the NHS Corps in rural Tennessee. It was a community hospital with an ICU and CCU and no medical subspecialists. There were nine internists in the community. So when I had a patient with a heart attack I admitted them and took care of them in the CCU.
Three years later, when I moved to Philadelphia, I got admitting privileges in an academic health center. I admitted my first heart attack on a Thursday night, I was in the CCU writing orders and the nurse asked what cardiologist are you going to consult? I said will they come in tonight? The nurse said no, why would they need to? And I said well why would I need to consult a cardiologist? And the answer was you don’t have admitting privileges in our CCU because you’re not a board-certified cardiologist.
So it’s very market-dependent. Institutions are looking to maximize the quality opportunities they can get, and they want the best-trained doctors in their communities providing care in their institutions. We don’t tell anybody how to use the credential. We explain what the credential is. That’s our responsibility is for the credential to mean something and say what it means. But how it gets used is not something we decide.
ME: But why not try to advocate more strongly and say, ‘this is a real burden for our members to get certification in an area they clearly already have competence in.’ Wouldn’t that help them?
RB: When you say they clearly already have competence in, that’s where things get sticky. Over time knowledge decays, over time people don’t know what they don’t know, treatment expectations change, treatment options change. I’d love to say that every licensed doctor in America always keeps up with that stuff, but that’s not how the world works. And putting out a credential that speaks to whether people are staying current in knowledge and practice, I think overwhelming numbers of doctors want to know that they’re doing that, want to have a way to reassure themselves that they’re doing that, and want a way to communicate to their patients and colleagues and institutions that they’re doing that. That’s what we do.
ME: Despite the cost and time commitment required for that?
RB: The bulk of the time commitment is staying current in a rapidly-changing field. If we went out of business tomorrow, doctors would still need to spend a ton of uncompensated time reading journals, coming to meetings like this, studying. We don’t make people do that. We recognize that they have, and give them a way to acknowledge that they’ve done what they needed to do.
ME : That’s a good segue to my next question, which is that doctors say that between requirements for CME and the easy access to information on the internet, that more than keeps them abreast of developments in their field, so why certify at all?
RB: First of all, the wide availability of the internet, the patients have that too. Yet there’s a significant difference in what we expect from patients with regard to knowledge and ability and what we expect from physicians with regard to knowledge and ability. So doctors know stuff that patients don’t know. And when they’re seeing patients—and I was in practice for many years—if you had to look up everything on every patient you see you’d never get through the day.
So everyone’s doing the time-lookup balance, so the more you know the sager you’re going to be in managing that tension. So the first thing I’d say is the availability of the internet doesn’t mean that knowledge doesn’t matter.
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The second thing is everyone agrees CME varies enormously in quality and effectiveness. Everyone knows about courses you can go to on the cruise or at the ski resort and may or may not be getting any knowledge. And it’s important not just that your seat was in the seat, but that you actually know what you need to know to do what we do. And what we do is pretty important and it changes pretty rapidly and people are not good at assessing what they don’t know. People assume that what they know is the right thing, but as one of my colleagues said some years ago, 30 years of practice doing it the wrong way doesn’t make it right. And how you keep up and learn with changes is an important thing all of us care about.
And one more comment with respect to the internet. There are now credentials available on the internet too. My son’s getting married this month by somebody who went on the internet and clicked “become an ordained minister for free.” And he got that credential, and he’ll marry my son with legal authority in the state of New York. It’s OK with me that he’s marrying my son, it wouldn’t be OK if he was providing healthcare to my son. And I think most of us really are proud of having a credential that distinguishes us in a world where what’s behind that credential really makes it valuable.
ME: But of course, that’s not the same thing as getting licensed to practice medicine. There is a lot more that’s required of you to do that.
RB: That’s true, but once you are licensed, first of all, only 81% of doctors are board-certified, 19% are not. So one in five doctors in this country is a licensed doctor who’s not board-certified, and I assume most of them are working.
Board certification has always been a standard that is higher than licensure, and people who hold it are proud to hold it because it’s higher than licensure. They could have gone out after one year of training in most states to independent practice, and most of them didn’t, because they wanted to learn more and be able to say they had acquired a set of skills.
It used to be that lifetime certification was a great way to do that. But with knowledge changing as fast as it does, it becomes pretty important to know who’s staying current.
ME: What about the cutoff date? That’s not going to change at all under this announcement you made today?
RB: When a certificate is issued, we make commitments that we keep. So when we issued certificates before 1989 we said those would be lifetime certificates, and they are.
When we issued certificates after 1990 we said they would not be lifetime certificates, and they’re not. Part of what we started to do in 2014—and this was also something we heard a lot from younger doctors—was, ‘Wait a minute, how can anyone tell the difference between me, with this time-limited certificate, and this person who got a certificate in 1980, and for all you now hasn’t done anything?’
So we still report those people as certified, but we report separately whether they are participating in the maintenance of certification program, and we do that for precisely that reason. A number of so-called grandfathered doctors have signed up for the maintenance of certification program, because they want to have a way of saying to their patients, ‘I’m staying current. I’m at the top of my game, I’m practicing today’s medicine.’ We don’t make them do that to still report them as certified, so that’s not changing.
ME: Is there any evidence that certification, or lack of certification matters to patients?
RB: Absolutely. I think patients are desperate for high-quality information about doctors and who they’re seeing. Lots of doctors say to me, ‘no patient has ever asked me whether I’m board-certified.’ Well first of all, lots of patients I talk to say ‘I go on the internet or I look at the directory, and if that doctor’s not board-certified I don’t go.’ Lots of people tell me that. They’re not asking the doctor because they already know before they came.
So yeah, I think patients do care about it. I think patients don’t look too deeply the way doctors do at what’s behind the credential. But I think they respect it a lot more deeply than they do Yelp reviews.
ME: It kind of makes you wonder how the 20% of doctors who aren’t certified are staying in business?
RB: Well as I say, I think it’s very market-dependent, And there are places where people are practicing and situations where people are practicing where they are filling a need. And someone says ‘I may not be as pushy here as I otherwise might have been.’
ME: How would you characterize the ABIM’s relationship with the National Board of Physicians and Surgeons [an organization founded last year to offer doctors an alternative route to maintaining certification]? I assume you saw their announcement in the last couple of days about their agreement with the osteopathic association?
RB: To be honest, I didn’t actually see that announcement, and Dr. Teirstein [Paul Teirstein, MD, NBPAS founder and president] and I have spoken on a number of occasions.
I think it’s pretty clear what the difference is. Again, for NBPAS as I understand their requirements, it’s ‘send us copies of your CME certificates and a check and we’ll send you a certificate as long as you were originally ABMS board-certified in any ABMS discipline.’
There’ve always been boards like that. Rand Paul created his own ophthalmology board 25 years ago or so. And it hung around for a few years in Kentucky and then he stopped doing it. But there have always been boards out there. The difference between us and them is the standards. We have a set of standards, and when you asked earlier why we aren’t moving faster, why don’t we just have an answer to this, it’s because having meaningful standards that are real is very difficult to do and it takes a lot of work. We make that investment. And NBPAS, as far as I can tell, has not made that investment.
Now, they’ve been around a year and a half. The last I saw on their website they say they have 3,100 doctors who’ve signed up. There’s 900,000 doctors in the country. We have 200,000 doctors. I think that people are staying with us because we issue something that means something, as opposed to, if all you’re doing is the same think you had to do for licensure anyway, what’s the value added? And I think people have been angry at us and they wanted to say, ‘we want an alternative.’ But I haven’t seen a lot of large reputable organizations get on that train, because they care about standards too.
ME: So you’re not concerned that what NBPAS does may make what ABIM does irrelevant?
RB: I’m not concerned at all, I think if anything they make it more relevant, because they highlight the fact that we actually have a performance standard in the middle of our program.
ME: Another big concern we hear is how ABIM spends its money. And today’s announcement didn’t really touch on finances at all. Are you concerned about the anger that’s out there about ABIM’s finances?
RB: A lot of people have raised issues about that. We are fully transparent about that. Go to our website, abim.org/finances and you’ll see a graphic that shows you where we spend our money and how we spend our money. You’ll see an audited financial statement posted on our website, which very few nonprofits do.
People have raised questions about compensation practices. We have a compensation committee that follows best practice standards, gets comparable figures on what people in senior executive positions get paid, which is how nonprofits set salaries.
To put it more bluntly, if I were trying to hire a cardiologist, and I said I’m going to pay you a general internist’s salary, I couldn’t hire a cardiologist on a general internist’s salary. And you can’t hire a chief operating officer of a $56 million-a-year company on the salary that you hire somebody to manage a one-doctor medical practice.
So we’re in a competitive market for talent. Our salaries are competitive, they are reviewed by an executive compensation committee, there’s an independent consultant that provides competitive data in the marketplace. So we have nothing to apologize for in our finances, That’s why we put it all out there.
We understand that every dollar we get we need to spend carefully. And we understand that doctors are concerned about the fees. And as we think about re-creating the program we will be looking at ways to restructure fees. But what I pay in fees to ABIM is less than what I pay the Commonwealth of Pennsylvania for being licensed, less than what I’m paying the federal government for having privileges to prescribe narcotics.