Recertification doesn’t help doctors improve patient care

I’m due to recertify in Internal Medicine soon, so a recent perspective from the New England Journal of Medicine caught my eye.

Of the many criticisms of the Maintenance of Certification Exam, one that stands out is whether the format and questions were relevant to modern clinical practice.

It’s not.

Two contrasting opinions were written, and I’m inclined to agree with the dissenting commentary. There is little data correlating those who recertify and improved medical outcomes.

The major reason is that the format of the exam is antiquated, consisting of hundreds of multiple choice questions that relies on a physician’s recall of obscure facts, largely irrelevant to clinical practice.

As the authors of the commentary write, “The one-size-fits-all secure examination, which requires many hours of preparation and the review of volumes of material, much of which may be irrelevant to one’s daily practice, is a key component of the Maintenance of Certification program. If you fail the examination, you fail to become recertified.”

With the emphasis on reducing medical mistakes and sticking with current clinical guidelines, an exam based on factual recall goes against this trend.

Today’s physician is expected to look things up if he doesn’t know the correct answer, but the “continued overreliance on factual recall runs the risk that physicians will be inappropriately encouraged to trust their ‘recertified memories’ rather than reminded that they should always consult easily accessible, authoritative resources to make sure they are doing the right thing.”

What’s the answer? It’s simple — make the exam “open-book,” or give doctors access to an UpToDate-like source during the exam. Rely less on simple memorization of facts. After all, doctors today don’t practice medicine in a bubble bereft of medical information. Most carry smartphones or PDAs containing extensive resources at their fingertips.

The recertification exam should more accurately replicate this more realistic environment.

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  • GlassHospital

    Your post hits home. I, too, am due to recertify this year.

    Not only do I find the ABIM’s system a price gouge (what else is new?), I think there are way too many hoops to jump through that aren’t very logical to accomplish the task.

    The whole thing creates unnecessary anxiety, since all of the different parts of recertifying add up to a set of not-very-clear directions. Maybe our august ABIM likes to induce a little anxiety.

    -Dr. John

  • Dr. Mary Johnson

    Gentlemen, like everything else this, is not about improving patient care, but money – and power.

    OF COURSE, once you get past your initial, immediately-S/P-training uber-expensive, hell-on-earth-for-some-people (like those of us with adult ADD) specialty certification, the recerts SHOULD be computerized, less expensive, at-your-leisure-in-what-little-free-time-you-have, and OPEN BOOK.

    In short, a lot like my life at the hospital now – when I don’t have a lot of free time to make like I’m in high school.

    Things are just getting stupid.

    The Academy of Pediatrics has made the process so complicated. and changed it so many times that I’m trying to figure out ways to retire early – before I get to pretend I’m starting-from-nothing . . . go on a higher dose of BP meds for the sheer anxiety-that-nearly-killed-me originally . . . take two or three days off from my busy schedule . . . and go “prove” to the nameless/faceless-powers-that-be-in-the-ivory-towers-of-Pediatrics that I am what I’ve already trained&studied&previously proved I could be . . . by taking a closed-book test that will be probably so dumbed-down in the end that the person-the-Academy-thinks-we-might-hire-to-impersonate-ourselves-on-the-computer could pass it without opening the book.

    I would like to see someone in the ivory towers make things easier on the front lines than exponentially harder and more complicated . . .

    . . . especially in the wake of healthcare “reform”.

    I guess here’s where we cue somebody from the AMA to tell us it’s all good for us. Someone else knows best.

    It’s like they’re trying to drive people out/away from the profession just for the giggles.

  • twaw

    Why “fix” a corrupt system? Is there any evidence that recertification (no matter how the testing is done) improve outcomes? Any evidence that CME requirements for licensure improve outcomes? Why is evidence based medicine only a concept for patients? The ABFP has been requiring recerts (q7-10 years) since its inception in the 1970′s. Sometimes our most widely held convictions are the most suspect.

  • Doc99

    Follow the money.

  • ZMD

    I recently took my recertification examination in anesthesiology, and passed. Did I recall scientific minutiae packed away in my brain long away after residency? Yes. Did it change my mode of practice? No. The proof that recertification does not improve physician practices can be seen every day with old timer docs who were grandfathered in before recerts were required. Their practice is not any more dangerous to the patient or likely to be sued than doctors who have recertified.

  • Mary Bee

    Couldn’t manditory re-testing for driver’s license renewal or airline pilot recertification also be challenged with the same logic?

    • ninguem

      Mary Bee – Couldn’t manditory re-testing for driver’s license renewal or airline pilot recertification also be challenged with the same logic?

      It is.

      • Dr. Mary Johnson

        Mary Bee, my “little” brother is an airline pilot with thousands of flying hours under his belt.

        A BIG difference between his “continuing education” and mine is that when he goes for his routine re-certs, he’s on-the-clock and gets PAID for it.

        We doctors, who all are required by our licensing boards (50 “industries” and of themselves) to complete a certain number of continuing medical education hours every few years (yet another multi-million dollar industry that flourishes on our shoulders), have to PAY for ours.

        On top of that, we have to recertify our specialitie over and over again – in an increasingly complicated, expen$ive, stressful and troublesome fashion.

        It’s absurd.

        • ninguem

          And the pilots have, in fact, protested certain policies of their own re-licensure process, especially the evaluation of older pilots, use of SSRI antidepressants, just thinking of a couple.

          Advocacy groups for the elderly complain about being asked to re-test just because of age.

          I’d say the better analogy would be pilots complaining about a new testing policy requiring them to know about how to run a train.

          • jo

            I totally agree about non-sensical questions that aren’t applied in real life. Just goes to show you that those who write the questions do not practice in the real world or keep up to date with changes in medicine, take for instance the hospitalists vs the priamcy care private practice-still yet both are required to keep up with both worlds of medicine which are very different.

            Solution: Only questions that have been addressed in that field of medicine over the past year by that particular specialty can be a part of the test and all board members that vote to approve the final test have to be practicing physicians, half in hospital/large clinic settings and half in out patient 1-5 physicians practices. If the specialty has not faced the problems that physicians are supposed to remember then the quesiton should not be on the test. They could throw in a few bonus questions that are not relevant for some stimulus money to the physician at the end of the test, but not make it part of the recertification.

  • ninguem

    The ABFM (family medicine) really went over the edge. I last recertified in 2003, and the stuff they were proposing then, so outraged the family docs, they backed off quite a bit.

    Still……I agree completely.

    Sometimes, I wonder if the American Osteopathic Association should find ways to certify MD’s and non-AOA-trained DO’s. Not to mention the American Association of Physician Specialists. If they did something more reasonable……and cheaper……I’d be glad to switch.

  • ninguem

    Among the family docs, there has been mandatory recertification of family docs for as long as there has been a Board of Family Medicine. No one was grandfathered in. Recertification was every seven years historically, as I recall. This has been the case for decades.

    What you’re seeing is new changes, widely considered onerous, un-necessary, not related to day-to-day primary care practice…………and too expensive.

  • jsmith

    I recertified last summer in Fam Med, and, as it turns out, I finished my first Maintenance of Certification module (for this year) yesterday. It was on asthma. What a joke. 15 hours of CME credit for 2 hours of work. Pitched at such a ridiculously simple level that I learned nothing. $235 to the ABFM. This is a money generator, pure and simple. Actually, I take that back. It also exists to fool the public.

  • mark

    If recertifying was about safety and keeping up to date, there would be no grandfathering allowed. In fact, the very physicians who are grandfathered, are likely the least up to date and could be described as the most in need of recertifying. Indeed, this is all about power and money as said above. $3500 for specialty recertification, not including the primary specialty. I agree with many of the posters. This should be open-book, internet-accessed testing. There should be standardization among all specialties.

  • BobBapaso

    We should remember that the practice of medicine is a physical sport as well as an intellectual exercise. Like tennis. To do a good job you need to pay attention to your foot work, your smile, relevant social constraints, diplomacy —and if you do all these well you may win without knowing many facts.

    The solution is, stop getting certified—everyone.

    If you want to measure practitioner quality, you must measure outcomes. Any other methodology is not an honest effort.

  • Dr. PJ

    Here’s my recent encounter with a subspecialty re-certification exam: Although I had my initial certification in this subspecialty in 1994, and had subsequent successful re-certifications since then, I was faced with having to again re-certify in 2008. At that point my small private practice where I did primary and subspecialty care for adolescents and young adults was encountering such problems getting paid from major insurance companies (right before the last Presidential election when healthcare reform was in the news) so that our cash flow was suffering; I had little to no time to review for the exam because of the financial worries and working every day without time off to generate enough to cover overhead expenses; my attorney had just advised me to close the practice and file Chapter 7; and the distractions at the testing site were so bad for my own anxiety-ridden, ADD brain that I could not even finish the exam! When I received my score, I had missed a passing score by only TWO POINTS. Needless to say, the Board executives encouraged me to re-take the exam (which costs over $1,000), but after filing Chapter 7 I did not even have a credit card with a high enough amount on it to pay for another exam, if I’d wanted to. I asked if I could pay with a check if and when I had generated enough extra income at a different job to pay for the exam, and guess what?? The only way to pay for this exam was with a credit card!! The woman I spoke with said, “Well, sometimes you can get a credit card with just enough on it to pay for the exam.” Hmmm…I wondered if she had ever had to file Chapter 7 because of insurance companies’ holding back or unjustly denying payment for claims?? And then tried to convince a bank to issue her a new credit card with her ruined credit score?? I doubt it. Anyway, I wrote a long letter to the director of the Board, asking how my passing the re-certification exam would translate into a higher income or improved reimbursements from insurance companies, and guess what? I received no reply. (By the way, I am now seeing patients part-time in a salaried position and operating a different, limited-scope private practice part-time where I will NEVER file insurance again.) Right now, re-certification is something I may do in the future; then again, I may just opt for an entirely different, non-medical career and spend that money for better things.

  • Dr. Mary Johnson

    Just another example of these Boards not living in the real world. And PJ, you are far from alone as a lot of disgusted, put-upon people re-consider their options.

    I’m supposed to re-cert (for the second time) this year. I’ve not registered for the ABP’s “Maintenance of Certification” program yet (I have until the end of the year), and I’m already starting to get the “you’ll be sorry” e-mails from the Amercian Board of Pediatrics.

    I wonder what would happen if all of their Diplomates told these Boards to go blow (or better yet, if a doctor or group of doctors with ADD decided to sue them for what amounts to undue hardship and/or discrimination) – since they cannot seem to come up with a user-friendly system of doing something we’ve already sweat and bled and PAID for?

    I mean, I know several doctors who are practicing Pediatrics right now who are not board-certified (and never were). They didn’t even care enough to be grand-fathered in.

    And they’re good doctors.

    So you have to wonder. What IS the point?

  • Mary Bee

    BobBapaso said:
    “If you want to measure practitioner quality, you must measure outcomes.”

    How does the patient measure the quality of the doctor’s outcomes? There’s no way we can verify from his other patients if they were satisfied, or their condition improved or cured? It would be impertinent to just ask ‘are you a good doctor?’ Where does the patient go for some sort of assurance that they are in good hands?

    (and don’t suggest friends for references. I have one that goes to a particular doctor only because he’s close to her workplace, and another because the doctor’s “cute”.)

    • BobBapaso

      Patients can’t measure outcomes. We need a scientifically oriented organization, and some way to keep it from devolving as boards had done.

      Until then, the fact that the doctor locates himself conveniently and cares for his appearance is a good sign.

  • Dr. PJ

    I understand that it’s honorable to be Board-certified, and I don’t mind reviewing for exams when I feel they are beneficial and I can do so without major distractions. However, given my circumstances at that particualr time in my life (as I’ve mentioned above), my priorities were to take care of my patients, pay my employees and other necessary overhead expenses, and to keep my practice running. Since I was unable to do that (because I wasn’t being PAID for my work–a circumstance entirely out of my control), I began to feel a certain “Who cares?” emotion when I was being urged to re-take the recertification exam by the ABP. When physicians get a huge dose of reality, as many of us in private practice have been hit with in this economy, we have to weigh our priorities against our level of burnout. We also begin to consider what the MOST important uses of our money may be–and if it means paying a house payment or buying groceries vs. paying for an exam that won’t benefit me all that much, guess what will win over the other?!

  • DrSheri

    Boy, am I glad to see that I”m not the only one struggling to afford recertification, let alone complete it! My ABP recert 3 yrs ago wasn’t difficult, culminating in a pretty easy 2.5 hr exam, but was expensive. I went solo 2 yrs ago and haven’t had the money to continue my ACP membership OR sign up for ABIM recertification, which is up this year.

  • Marc S Frager

    We may need a scientifically based organization to certify quality, but the ABMS/ABIM sure isn’t it. Since recertification has been around since the 1970′s, those organizations have have nearly 40 years to prove their worth…but as of yet, no data. When the ABIM recognizes that physicians are not sheep and responds to the problems of overcharging for irrelevant exams and exaggerating their own importance, they will have made a mjor step forward in establishing their own credibility

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