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If certification process is reformed in response to physician concerns, I’ll be the first to get in line to recertify
I confess it. I am not a “board-certified” physician.In fact, if you contact the American Board of Family Medicine (ABFM), they will claim to have “no record” of my certification—the same response that the American Board of Obstetrics and Gynecology gave to reporters about Mahendra Amin, a physician accused of performing unnecessary hysterectomies among ICE-detainees, and a fact that was quickly pounced on by the media.
Although the ABFM will be quick to tell you that I am not currently board-certified, they will be unlikely to explain that I completed my initial board certification immediately following my family medicine residency in 2002, scoring in the top 95th percentile on the examination. They won’t add that I recertified in 2009, again scoring among the top test-takers. And they certainly won’t tell you that I dropped my board certification in 2017 in protest of the exorbitant fees and mindless ‘practice improvement’ requirements, nor that I certified instead with a competing agency, the National Board of Physicians and Surgeons. They’ll simply say, “We have no record of Dr. Bernard being board-certified.” Hard stop.
I never wanted to drop my board-certification. I am proud of being a Family Physician, and like most practicing doctors, I consider continuing medical education to be an essential part of my job. Not a day goes by that I don’t double-check my diagnostic and treatment plans in the medical literature. I pay for subscriptions to UpToDate and Prescriber’s Letter to stay current. I read the journal American Family Physician as well as a variety of other medical journals cover-to-cover every month. I run cases by colleagues and analyze my practice data to look for gaps in care.
My epiphany came in 2016 when I logged into the ABMS system to start working on my next recertification cycle, which had just introduced a series of self-assessment modules—or “SAMS.” I had finally resigned myself to start the tedious process when I reached an impasse – the system wouldn’t allow me to even start working on the SAMs until I entered my credit card information and made a payment.
I blinked at the several-thousand-dollar figure in front of me. I could pay it all at once (the best deal, according to the ABFM), or I could make annual payments. If I couldn’t afford the expense, the ABFM kindly offered me “pay-as-you-go balloon financing,” which would allow me to pay less in the years before the exam, and then a “balloon” payment during the exam year. Candidates were warned that the total amount was not guaranteed and might increase in the intervening years, leaving me with an even bigger fee during my exam year.
As I contemplated this expense, I thought about my experience the year before when I sat for the Certificate of Added Qualification in Hospice and Palliative Medicine. I had paid $1200 to take the exam, traveled to Orlando where I also had to pay for a night in a hotel, and spent the day locked in a cubicle answering multiple-choice questions. I had been treated almost like a criminal - fingerprinted, photographed, and nearly patted down each time I entered or left the exam room – no extra sweaters, bottles of water, or tissues allowed.
I had also done a little reading about some of the controversies with the ABMS, in particular, the Internal Medicine Board, which was subjected to an expose by Newsweek writer Kurt Eichenwald in 2015. The investigative journalist uncovered “lavish” spending on CEO salaries and deferred compensation, as well as questionable behavior such as failing to report lobbying activity on IRS filings (a no-no for non-profit organizations). I had also read blogs by Westby Fisher, MD, a cardiologist and electrophysiologist, who noted the Board of Internal Medicine’s purchase of a $2.3 million luxury condominium, complete with chauffeur-driven BMW 7-series town car (which they sold in 2016 at an estimated $1.2 million loss).
These reports, along with studies showing that MOC does not improve patient outcomes and the ABMS’ belligerence in refusing to make meaningful change, led physician leaders of some of the nation’s most prestigious medical centers including Scripps Clinic, Mayo Clinic, Harvard, Dartmouth, Massachusetts General, and Colombia to create the National Board of Physicians and Surgeons (NBPAS) in March of 2015, as an alternative to the ABMS. Due to criticisms of the MOC process, many states, including Georgia, the state where Dr. Amin practices, have prohibited tying board certification to hospital credentialing. While an investigation into whether Dr. Amin engaged in any misconduct is necessary, a lack of continuing board-certification alone should not condemn any physician.
Board certification also demonstrates a double standard between physicians and nurse practitioners.Nurse practitioners are permitted to recertify every 5 years by simply attesting to a minimum of 1,000 hours of practice (which can include volunteer work) and 100 hours of continuing education. Meanwhile, as a physician, even though I have been board-certified twice and maintain an unrestricted medical license, the Florida Board of Medicine does not permit me to self-identify as “board-certified.” I can obtain hundreds of hours of continuing education, practice full-spectrum family medicine, and teach medical students and residents.But unless I pay thousands of dollars to the organization with the monopoly on certifying physicians in the state of Florida, none of that seems to matter. And if, like Dr. Amin, I was accused of wrong-doing, critics and reporters would be quick to weigh in. “What do you expect from a doctor who isn’t board-certified?”
While I hope this never happens, I’m aware of the risks. I am fortunate to be able to practice medicine in a direct care model, without any obligation to an insurance company or hospital to be board-certified for credentialing. Even so, I try my best to hold myself above reproach in the way I practice medicine. I’m honest with my patients about dropping my board certification, with a section of my website explaining that I am not conventionally board-certified, but rather, certified through the NBPAS, an alternate organization.
If one day the ABMS reforms their certification process in response to physician concerns, I’ll be the first to get in line to recertify. Until then, I’ll save my money and my effort for programs that I believe will help me be the best physician I can be.