ABIM monopoly hurts osteopathic physicians overseeing residency, fellowship programs, lawsuit says

The American Board of Internal Medicine (ABIM) is a monopoly that freezes osteopathic physicians (DOs) out of program directorships in medical education, according to the American Osteopathic Association (AOA).

The allegation is part of a class action lawsuit that AOA filed this month to stop what it claims is anticompetitive behavior that hurts residents and fellows studying internal medicine, and their patients. ABIM requires residency and fellowship program directors to be ABIM certified — and won’t honor attestations of completion from program directors certified by the American Osteopathic Board of Internal Medicine (AOBIM), according to the complaint filed in the U.S. District Court of the Northern District of Illinois.

“When DOs are excluded, patients lose,” AOA President Robert G.G. Piccinini, DO, D.FACN, said in a news release. “This policy removes skilled program directors from leadership, disrupts career paths and limits mentorship for young physicians.

“At a time when the nation faces a growing physician shortage, ABIM’s actions close essential training pathways that ultimately hurt patient care,” he said. “We will continue to defend osteopathic physicians and stand up for a medical education system that recognizes excellence.”

The complaint seeks a court ruling that the ABIM policy violates the Sherman Antitrust Act and an order that ABIM must accept attestations from AOBIM-certified program directors.

The legal action was not the first choice for AOA.

“Legal action was our last resort. We filed this lawsuit only after exhaustive efforts to resolve the issue collaboratively,” said AOA CEO Kathleen S. Creason, MBA. “Our goal is to ensure fairness, protect our members, and preserve the integrity of graduate medical education.”

Osteopathic growth

Currently, ABIM and AOBIM are the two boards that certify internal medicine physicians in the United States. AOA says ABIM has monopoly power, certifying 95% of the nation’s internal medicine physicians.

The complaint recounted some of the history of osteopathic medicine, including some 20^th century efforts by allopathic physicians (MDs) to hinder or limit practice by DOs. Even so, osteopathic medical care and education have grown to become a significant part of U.S. health care, with DOs certified and licensed to practice in all civilian and military settings in all 50 states.

Starting in 2015, the Accreditation Council for Graduate Medical Education (ACGME) integrated a single system for residency and fellowship training for students of allopathic medicine and osteopathic medicine. Under that system, physicians could serve as program directors if they were certified by allopathic or osteopathic medical specialty boards, according to the lawsuit.

An anticompetitive requirement

Now, ABIM has a policy requiring and ABIM-certified program directors to attest residents or fellows have completed their programs, or the budding physician may not sit for an ABIM board certification examination.

“In other words, ABIM will not accept an attestation from an AOBIM-certified program director before a resident or fellow may sit for the ABIM examination, even though the resident or fellow is otherwise completely qualified to sit for the exam,” the lawsuit said, with the emphasis in the original text. “As a result, ABIM destroyed the ability of AOBIM-certified physicians to compete for program director roles and has steered medical school graduates that would otherwise pursue AOBIM certification to ABIM certification for fear of losing access to program director positions that are critical to the pursuit of a career in academic medicine.”

The policy is stifling ACGME’s goals of procompetitive integration, and hospital autonomy to pick the best and most qualified doctors to run residencies and fellowships, the complaint said.

“ABIM’s unlawful policy does nothing to improve the quality or effectiveness of medical training,” the AOA lawsuit said. “Instead, it is a way of gatekeeping, and unfairly profiting from, a critically important (and often final) step before entering the practice of internal medicine.”

'A fair path to certification'

The American College of Osteopathic Internists (ACOI), another named plaintiff in the case, stated the organization believes internal medicine residents deserve fair, evidence-based pathways to board certification. When program directors are pushed aside for reasons unrelated to competence, patients lose access to the physicians they need, the college’s statement said.

“We did not arrive at this decision lightly,” ACOI President Damon Baker, DO, MACOI, said in the news release. “We joined this lawsuit because the current policy creates unnecessary barriers for program directors and residents alike. We believe in a collaborative approach to graduate medical education — one that values all qualified physicians and maintains a fair path to certification.”

Physicians lose out

The AOA lawsuit said the position of program director is a prestigious one in medicine and may serve as a launching point to even greater duties for doctors in medical and administrative leadership. The lawsuit included physicians named as plaintiffs and descriptions of how the ABIM policy has affected their career decisions because ABIM would not recognize their attestations:

• Nancy Law, DO, MPH, transitioned from director to associate director, then co-director, of the infectious diseases fellowship program at the University of California San Diego School of Medicine. ABIM would not let her attest to her fellows’ successful completion of that fellowship.
• Maria “Lily” Asprilla, DO, took a demotion from director to assistant program director for the hospice and palliative medicine fellowship at John Peter Smith Hospital in Fort Worth, Texas. The move has hurt the hospital’s ability to recruit for that fellowship and a related one in geriatric medicine.
• Emily Hurst, DO, was a founding director of the first residency program at a federally qualified health canter serving low-income patients through the Detroit Wayne County Health Authority in Michigan. She stepped down from the post and has focused her career away from medical education.
• Erin Huston, DO, CMD, was program director of the geriatric medicine fellowship for Atrium Health Carolinas Medical Center. She passed the ABIM examination for family medicine in 2024, but would need another year of training to qualify for ABIM’s geriatric certification exam, which was not feasible. Huston has since returned as program director but must limit program recruitment to allopathic internal medicine candidates.
• Matthew Hardee, DO, is program director of the internal medicine residency program at MercyOne North Iowa. MercyOne required Hardee to obtain ABIM certification, and he was forced to step down as director for two years while working full-time with patients and the program, training and family obligations. He now maintains two internal medicine board certifications, costing money and time.
• Seger Morris, DO, was recruited to start an internal medicine residency for Baptist Memorial Hospital in Oxford, Mississippi. He got the program running in 15 months, but had to step down as founding director and eventually took another full-time job. The hospital’s resident satisfaction surveys have declined.

The cost of certifications

Meanwhile, physician certifications are a big business for ABIM, which generates approximately $100 million a year, according to the complaint.

“ABIM has been accused of financially exploiting its diplomates in ways that do not relate to the quality of services that it provides, a hallmark trait of a monopolist without sufficient competitive checks,” the lawsuit said. “Not only that, but ABIM has been expressly called a monopolist in the popular press and by other industry organizations such as the National Board of Physicians and Surgeons.”