How do doctors feel about the new ABIM board certification requirements?

I received an interesting email this week from the American College of Cardiology. The purpose of the note was to relay the results of a survey regarding member’s views and concerns of the new changes in board certification.

Before I tell you about the survey’s striking results and clear message, it’s worth reviewing the contentious debate over the proposed new changes for “board certification.”

In years past, being board certified meant passing a comprehensive exam given every 10 years by the American Board of Internal Medicine (ABIM). It was a hard test, one that required significant preparation. I have taken the cardiology and electrophysiology boards twice thus far in my career. I learned a lot preparing for these exams, and felt like it was a valuable exercise. (I’ve always liked tests though.)

For some reason, which isn’t entirely clear, those in power at the ABIM determined that an expensive comprehensive test wasn’t enough to ensure the quality of American physicians. We do so badly after all. So, in collaboration with professional medical societies and health policy regulators at the federal level (e.g. ACA writers) the ante for physician certification was upped.

Beginning this year, the ABIM implemented a more intense program for maintain of certification, or MOC. The most onerous and contentious part of the new process is the patient safety and patient survey modules, which the ABIM provocatively calls practice improvement modules. Just that name drips of arrogance. As in, policy wonks in cubicles, many of whom have not ever taken care of patients other than as a hobby, are implementing requirements of real-world clinicians who know only one thing—how to care for people.

Normally physicians roll over. We just sign the form, check the box and grin and bear it. This time it was different.

In March of this year, even I, a test-liker, wrote a post on theHeart.org calling for a timeout before implementing the new MOC. My reasoning was that the ABIM method of assuring quality physicians has not been validated through clinical testing. Though it is possible the ABIM brand of testing would improve outcomes, it’s also possible that an emphasis on patient satisfaction surveys, blind adherence to guidelines and preparing only for a test could impair doctoring and its outcomes. I also emphasized the profound financial conflicts of interests of the test givers and professional societies—who profit from selling prep materials.

My point in the post was not to dismiss the benefit of continuing education but to consider a less disruptive more nuanced approached to ensuring an ample supply of up-to-date humanistic caregivers. Just as I do in clinical practice, I advocated for evidence, not eminence, based decision-making.

It turns out that many other practicing docs had the same feelings about the new changes. Many thousands of real world doctors (17,452 to be exact) have signed a petition stating opposition to the MOC changes. The American College of Cardiology heard these voices and responded by conducting a survey of its members.

The ACC survey of physicians:

The results included responses from 4,406 cardiologists, me included. There was widespread opposition to the new requirements for maintenance of certification. Here were a few of the highlights (the link to the reference is at the end):

  • 87% of members opposed the new requirements;
  • 72% of members strongly opposed the new requirements;
  • 89% of members felt the costs are higher than expected;
  • 32% of members said the new requirements will affect their future practice plans;

Wow.

This is disruptive. I am sure the ACC would say its members are smart doctors. They would express confidence in American cardiology. Yet they now have to digest the fact that almost nine out of ten of its members oppose a process it has been integral in developing.

Despite its “collaborative and collegial relationship with ABIM,” is it possible for ACC leadership to dismiss the wisdom of 90% of its supposedly wise members?

We shall see. I don’t know what will happen.

I write about this topic because it has bottom-line effects on patient care. Consider these three questions:

If a third of cardiologists decrease their workload, is that important for heart care?

If cardiologists are forced to go through an unproven educational process, one that may or may not improve outcomes, is that important?

And then there is this biggy:

If the stunning overreach and hubris of medical leadership provides the catalyst for physicians to finally organize and speak as one, is this important?

JMM

My friend and colleague Dr Wes Fisher also commented on the survey.

Here is link to the ACC member survey

Comments

  1. says

    JOHN – I love how you keep us up-to-date with ALL aspects of what is going on in your field (and in Cardiology in general). As one who had been involved in education (and validating “competency” of family medicine residents and medical students) for the duration of my 3 decades in Academics (before retiring from this in 2010) – I sense what is evolving in your specialty is similar in concept to what evolved in mine a number of years ago (development of new “modules” aimed at getting at that “extra dimension” that goes beyond straight written exams). That said – trying to validate such testing AND to demonstrate improve outcome is far from an easy task (if possible at all). This is not to say that it is not worthwhile to try to expand beyond simple written testing – but only to acknowledge that optimizing the process with goal for optimizing care is far from a simple task. IF indeed this is met by close to 90% disagreement by those currently in cardiology practice, with potential for altering in negative manner availability of cardiology care on a national basis – then the reasonable approach would seem to be to reassess the process and think a few more times before implementing. Unfortunately – such “reassessment” might not occur due to “the powers that be” (as conflicting as interests by those powers might be …. ). In my opinion – that is a sad situation …

  2. pgyx says

    “If the stunning overreach and hubris of medical leadership provides the catalyst for physicians to finally organize and speak as one, is this important?”

    Yes!! If we want our profession to succeed then we cannot afford to repeatedly “roll over.” The ABIM requirements are onerous and will not improve quality of care. Thanks for sharing.

    I’m a recent residency grad in another specialty and just learned that not only do I have to pay a significant examination fee to recertify every 10 years (which is fine with me), I also have to pay a yearly fee for maintenance of certification. What is the logic behind the latter other than “because we say so” on the part of my certifying board?

  3. Stella B says

    I retired early and did not recertify. I would like to return to work part-time, but without a job I am unable to do the MOC in order to recertify. I have no objection to taking the board exam, but I feel like the MOC besides being stupid, is glaringly over-priced. Happily, I can afford to remain retired.

  4. says

    Perhaps more troubling is the climbing failure rate of the Maintenance of Certification program. We should ask ourselves why this is so. Is it because doctors really have less intellect now than five years ago? Or might this process be a way to covertly ration eligible practicing physicians favoring those who are younger and employed by hospital systems? We should understand the conflicts of interest that existed with the President of the ABIM who worked for CMS while also serving as a Board member of the ABIM before the new MOC process was enacted. We should understand the use of the MOC examination as a “quality” measure for doctor pay in 2015 when physicians shift from a fee-for-service CMS payment formula to a “value-based” concoction with MOC and uncontrolled surveys as part of the formula. We should see the vast salaries that our professional society board members, many of whom are no longer physicians, are paid.

    Only then will we how cronyism has fed this deeply flawed measure of physician “quality” that is now deeply embedded within our nation’s Social Security law, courtesy of the Affordable Care Act.

    I suspect many doctors will not comply with the ABIM’s demands and when actions are taken against them, many suits will follow or people will throw up their hands and just retire.

    How will this “quality” process look then?

  5. says

    Excellent Points! I signed up for this program even though I am grandfathered in for eternal Internal Medicine and Cardiovascular Board Certification. The only reason I will participate is if it somehow tied to payment by CMS or insurance companies. I don’t see it advancing my quality of care. I spend 7 hours/ week reading medical articles and researching patient-related issues and this is not factored in at all.
    I agree with Dr. John and Dr. Wes that it has been instituted without appropriate review and at excessive cost to docs. I’m going to do whatever I can to fight it. If the ACC does nothing to stop it I will resign my membership.
    Dr. Wes, your reply suggests “climbing failure rate” (of MOC) is a link but it seems dead.

  6. st says

    Patient satisfaction as a criterion!? My husband and I (lay persons) go to a “center of excellence” that is in the top five, nation-wide. The quality of the care is exceptional, and by all objective standards, the place is outstanding. Nonetheless, this institution garnered rock-bottom “patient satisfaction” numbers, year after year, for both the hospital facility and the physicians. We never had any complaints; the quality of care is superb.