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Wednesday, April 1, 2015

American Board of Internal Medicine Maintenance of Certification firestorm: what more to say?

About 2 years ago I finished the process of recertifying for the American Board of Internal Medicine. I had last done this in 1990 and had a time unlimited certification, but had heard that recertification, which included doing a certain amount of studying and then taking a long test, was a good idea. Specifically, one internal medicine physician had written an article about the process, which sounded a little like a medieval quest, complete with hardship and mortification. That sounded perversely attractive.

The process was expensive, about $1500 (now $1940) to sign up for the whole deal, which involved keeping track of the educational modules on the ABIM site, access to some educational material and completion of a Practice Improvement Module which was more disruptive than the rest of the process. I had several options, but chose to evaluate how well I was doing on preventive medicine, things like getting my patients to do mammograms and colonoscopies and screening blood tests and that sort of thing. There were before and after questionnaires for my patients to fill out which were tallied and available for me to see on the website. These told me how I was doing before and after instituting certain changes. I've always disliked being evaluated with a numerical scale in a disconnected manner, but it wasn't too awful and I did learn quite a bit about the current recommendations for preventive practice and the evidence behind them. I then took the long test, which was another fee, about half of the original fee, and waited maybe a month before being notified that I passed. In order to feel confident in my ability to pass the test, I attended a several day long preparatory set of lectures at a major medical school, which cost a few thousand dollars and took a couple of weeks off from work to prepare. I didn't resent it, because it felt like the process had fully updated my operating systems, but the cost ended up being somewhere between $10,000 and $20,000.

About a year later I learned that, in order to maintain my certification, the ABIM was asking that I complete ongoing approved Maintenance of Certification (MOC) activities, including the practice assessment modules which would be due every 2 years. This was a change, since the prior requirements were assessed every 10 years, culminating in the exam. I thought that I would go ahead and do this, since I had learned a good deal the previous go round. In my present practice as an itinerant hospitalist and sometime rural primary care physician, the practice assessment piece is really tricky, so I haven't gotten around to that yet. The requirement to do this is presently on hold by the ABIM.

Since the change in requirements for MOC, internists have been rebelling. Many of them have practice responsibilities that are more demanding than mine, so they really don't have time to do all of this. The scope of practice for internists is very diverse and many find that what they learn in the process is not that useful. The price is painfully high. Newsweek picked up the smell of blood in the water and wrote a nice inflammatory article that simplified the issues and opened them up to general scrutiny. The ABIM responded testily. Fur is flying everywhere. Much has been said by knowledgeable people on the many sides of the argument, and I will not attempt to cover their points. I have a few thoughts, though, that don't stand out in what I've read and have some bearing.

1. There is at least one other way to get certification as an internist. The American Board of Physician Specialties offers certification in Internal Medicine and various other specialties. It was initially started as a certifying agency for Osteopathic Physicians, but now includes MD's. The cost of certification is about the same as for the American Board of Medical Specialties, the parent organization for ABIM, and their recertification occurs at 8 year intervals. They do not require ongoing maintenance of certification activities, other than demonstrating involvement in continuing medical education for 50 hours a year. This might be a viable way to opt out of ABIM's requirements.

2. The concept of "Maintenance of Certification" didn't come from ABIM, but was adopted by the parent organization, the American Board of Medical Specialties in the year 2000. This board includes doctors of pretty much all varieties, including surgeons, anesthesiologists, radiologists and everyone I can think of. There are 24 member boards. I checked the boards of Family Medicine, Pediatrics and Emergency Medicine and all of them have MOC requirements that are ongoing in order to continue to have a board certification. There are at least a few of these doctors who write about their specific requirements, and it looks like they also find them onerous and of dubious value. The physicians who find the process to be just fine probably don't write about it. Most of those who are unhappy about the process are likely too busy to write about it and probably just growl quietly to anybody who asks.

3. It is very hard after finishing medical school and residency to keep up with the huge body of internal medicine, with its very active ongoing research on the pathogenesis of diseases and what therapies work and don't work. Having a process such as board certification and recertification that can provide a framework for relearning that body of knowledge as it changes is very important. Just achieving 50 hours of continuing medical education in the fields that most interest us is not enough to maintain competency. The process of learning what I needed to know to pass the ABIM test was valuable and I am a better physician for having done it.

4. Doctors don't want to be attached at the hip to their certifying boards. That goes for pediatricians, family practitioners, emergency physicians (and so on times 24) as well as internists. We already have to prove competency for maintenance of privileges at hospitals, state licensing agencies and even with insurance companies. Something about this recent MOC change was the last straw.

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