It’s time to look critically at the concept of board certification

In 1994 I was thrilled to become certified by the American Board of Emergency Medicine. I had worked very hard. I studied and read, I practiced oral board scenarios and even took an oral board preparatory course. It was, I believed, the pinnacle of my medical education. Indeed, if you counted the ACT, the MCAT, the three part board exams along the way and the in-service exams, it was my ultimate test. The one that I had been striving for throughout my higher education experience.

I am now disappointed to find that my certification was inadequate. In fact, all of us who worked so hard for our ABEM certification find ourselves facing ever more stringent rules to maintain that status. And it isn’t only emergency medicine. All medical specialties are facing the same crunch. Our certifying bodies expect more … and more … and more.

And the attitude is all predicated on the subtle but obvious assumption that those of us in practice are not competent to maintain our own knowledge base. Despite spending decades in education that we are not to be trusted. That we are not interested in learning. That we do not attempt to learn and that our practices are not, in fact, the endless learning experiences they actually are. They assume we need more supervision, despite demonstrating (by our continued practice) that we are willing to do hard work, in hard settings, and do the right thing.

Unfortunately, the rank and file is very unhappy. There is remarkable discontent, and considerable anger, among the lesser physicians. That is, the test takers, the physicians in practice subject to the new rules, the ones who have to add one more rule, one more activity, one more form, one more check to their already busy lives.

That discontent, that anger, that frustration on the part of practicing physicians is, in my opinion, very rational. It’s a tough time in medicine. Our regulatory burden grows by leaps and bounds every year. We are watched and harassed, by CMS, by JCAHO, by our state medical boards, by our insurers, by our hospital staff offices and now, most painfully, by our own specialties.

Of course, all of it comes in the context of falling reimbursements, a federal government licking its lips for any spurious allegation of fraud and a system in which EMTALA forces physicians of all specialties to see patients for free, even as government insurance programs pay less than the over-head to see their patients (and fulfill the regulatory guidelines required for the privilege of doing so).

In light of all of this, I have to ask ABEM and every other board certifying body, a simple question:

“What are you people thinking?”

Here’s the reality. Our certifying bodies should be our greatest, most passionate advocates. When the Institute of Medicine issued a report some years ago that said physicians were killing people on a scale consistent with the holocaust, ABEM should have looked at the data and refuted it. ABEM, and ABIM and all the others should have taken our fees, run out and found the best PR firm they could afford. “We stand by our physicians and we have serious questions with these research results and the way they are being interpreted.” That would have been a good use of my dues. That would have merited high salaries for everyone in every board that stepped up for its members.

Instead, at every step, ABEM seems to argue that “the public” wants us to be watched more closely and tested more frequently. Except, I’m not confident that’s true. The public never cares where you went to medical school. The public thinks most emergency physicians are interns hoping for a “real practice” someday. The public wants affordable, quality care. The public, in practical terms, doesn’t know the difference between a physician, a PA and a nurse practitioner, and often calls all of them “doctor.” The public, furthermore, tends to believe that mid-level providers are more attentive to their needs. (Despite their lack of board certification; shocking indeed!)

More poignantly, more ironically, our policy-makers and academics often say that public needs a European-style health-care system with better outcomes and lower costs. Whether that is ultimately true or not, the funny thing is that Canadian and European physicians don’t have to do ongoing board-certification activities. Hmmm.

More irony: medical practice is supposed to be evidence-based. So where’s the data that board certification makes a difference in patient outcomes? Maybe it does, maybe it doesn’t. But even if it does, we’ll need to break it down to see if ongoing certification matters, if repeat testing matters, who sponsored the study. etc. Our certifying bodies should be eager to see independent evaluations of the question. Or would that be a problem?

It might be a problem from a financial standpoint. Is ABEM, or ABP or ABS or the ABMS simply “too big to fail?” Do they employ too many people to cease to be relevant? Is there a financial imperative for them to continue doing what they do? With director salaries in the $200,000 to 800,000 range (depending on board), is there a potential hint of conflict of interest?

How is this different from the financial conflicts of big pharma? Their drugs help people, even if their techniques are shady. Is this an uncomfortable question for everyone to ask?

It’s a time of changing paradigms in the world at large. Print books are succumbing to electronic ones. The Internet is an unfettered land of free expression, uncontrollable by government entities or hospital administrators. People text more and talk less.

It may be time for us to look critically at the entire concept of board certification. It may be time for alternate boards to emerge. It’s certainly time for our boards to be our friends, our advocates, and thereby justify their cost. And it’s likely the future will not look like the present, when it comes to the way we certify physicians. In an era of impending physician shortages and fewer reasons to enter medicine as a whole, I hope that we can remove some obstacles and stand up for one another.

That’s a change I can get behind. And that’s a change that would make me much happier to write that check to ABEM when the time comes.

Edwin Leap is an emergency physician who blogs at edwinleap.com and is the author of The Practice Test.

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  • Anonymous

    Right on!  I know many family docs took up this issue a number of years back, only to lose to the ABFM.  I work with 2 internists who are “grandfathered” in their board certification and analysis of our patient outcomes are the same.  

  • Anonymous

    Agree.  This is not about testing to ensure avoidance of a dangerous knowledge gap.  This is about certification and education lobby pushing the bar up artificially so they can resell more certification to the same group who bought into the original board certification hype to begin with. 

    This is the same lobby who pushes for advanced degrees and doctorates for nurses in clinical practice when those pursuing those advanced credential do not advance clinical results.  

  • Anonymous

    While the Boards come up with new and improved chess games for us to play, they stand by while non-board certified people take our jobs and practice medicine. But I guess thats not their problem. As long as they get to cash in on the process, who cares about outcomes.

  • Anonymous

    and our so-called leadership is not helping us here either. aaem, in spite of having a good stance on a lot of issues, requires abem certification for one to be faaem.

    for me, the last straw is this bogus new APP requirement. i intend to ignore it, be designated board certified but “nonclinical” by abem, and continue practicing clinically along my merry way nonetheless. i doubt my employee will notice.

    also, though i’ve already cleared this hoop, the mandatory pilgrimage to chicago needs to be done away with.

  • Anonymous

    Agreed.  While specialty-specific continuing education is very important, and I can’t actually quibble with the quality of the educational materials from my Board, I’m honestly not sure what the value added by these certifying Boards are at the moment. Of course, the elephant in the room is that these certifying boards are FOR-PROFIT.  So as clinical reimbursement goes down, the powers that be running these boards have decided instead to cash in by creating arbitrary, confusing deadlines and then charging exorbitant late fees for missing them, charging members substantial fees so that members can do their own, unassisted chart reviews, or show knowledge of journal articles that are NOT EVEN PROVIDED to the members!  It’s a racket that’s hard to stomach, as eloquently stated above. 

    In the meantime, the fact that physicians are beholden to these very specific specialty boards instead of some larger organization representing physicians as a whole, any lobbying power or credibility in patient or physician advocacy is severely diluted.  Instead, we actually have quibbling between specialty societies getting media attention, which is frankly embarrassing, not to mention counterproductive to providing the best possible health care in the best possible environment.  I think somehow these specialty boards need to be brought together into a more unified front, so that they can do some good for the physicians that they certify, as well as be more accountable to the patients they supposedly protect.

  • http://www.facebook.com/julie.long777 Julie Carpenter Long

    Just FYI, most states require NP’s to be board certified in their specialty in order to practice. I don’t know of any practicing “mid-level providers” who are not board certified.

    • Anonymous

      There is no doubt about that. But what that amounts to is that if you don’t meet the qualification of one board, simply form another board and go meet those qualifications. Anything profession can be undermined using a “sub-profession” or alternative profession which renders having any standards meaningless. Mid level providers are subjected to the same thing and will ultimately be undermined as soon as the next wave of cheaper labor comes along.

      • http://www.facebook.com/julie.long777 Julie Carpenter Long

        NP’s are NOT striving to meet the qualifications of YOUR board. Advanced practice nursing is a separate and distinctly different profession than that of a MD. Why are you so unnecessarily threatened? It is not like it is an easy task to obtain certification to become a NP. In fact, it is quite difficult and rigorous. Only the brightest and best nurses make it through the NP program and are able to obtain certification. Admission standards and coursework are very demanding and difficult. There are many who can’t make it and end up obtaining a different advanced nursing degree. NP’s are very good at what they do (many studies have proven this), which is why the profession is taking off the way it is and we are in no way substandard. We certainly are not out to undermine or replace MD’s, in fact I wouldn’t be the provider I am today if not for the wonderful physicians I have worked with. We are here because there is a desperate need to increase access to health care for all, which should be everyone’s goal. I get the point the author is trying to make, but I don’t see the need to try and discredit midlevel providers or make misinformed or hostile comments such as yours. Don’t forget- we are all in the same fish bowl.

        • http://www.facebook.com/RebeccaCoelius Rebecca Coelius

          Great comment, I agree with everything you say and learn a ton from working with NPs and PAs (RNs too), as we all have a different focus to our training and skill sets developed over our careers. Though I would suggest that before you get too upset with the author, you consider some of the rhetoric coming out of the leaders in the NP movement. They ARE making claims that they can replace MDs, and provide the exact same care at the exact same quality despite vastly different training and clinical experience before becoming certified. This is especially demeaning for MDs working with medically and socially complex patient in primary care, where the majority of this rhetoric is aimed. (Though I do believe in team based care with NPs and PAs managing many of the less complex patients). We receive enough scapegoating from the rest of the medical industry despite how intellectually and emotionally challenging our jobs are, its not helpful to have NPs as our adversaries rather than partners in fixing this access problem.

  • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

    The frustration and anger is deep. It’s real. It exists across the board in all specialties.

    The Boards are turning into a racket. Nothing more, nothing less. It’s a moneymaking operation, and they exist to make more money for themselves. Look up guidestar.org and look at the financials of your specialty board.

    But you complain, all you get is condescension and arrogance. What can we do?

    • Anonymous

      One possible action … change medical staff bylaws.  Require board certification once only.

  • Anonymous

    The specialty boards, JCAH, NCQA, etc. are all classic protection rackets, demanding their take off the top. They send their goons around on a regular basis to collect their cut: if you don’t cough up, they take you out.

    • Anonymous

      Kind of like attorneys who write the laws and then require you to pay large sums to prove you haven’t broken them.

  • Anonymous

    Yup.

    I’m likely to recert one more time (for income purposes within the system in which I choose to work), then let it go.  If having been being board certified thrice is insufficient for the bean counters … oh well. 

    I number among those who grow uncomfortable with the metastatic encroachment of rules written for us by those not in clinical practice … especially rules written by non-clinicians.

    I try to sort out the role of my ego in this.  How much is merely a blindly prideful resistance to being told what to do by someone other than me?  There’s some role for that.

    But, then I hit the rules that just make no sense (they grow in number.)  Or I spend TIME (and more time) poring over confusing tapestries of rules that supposedly govern my clinical life.  What do they mean?  Wow, I didn’t even know THAT rule existed …, etc.  And then extra time/$$ are spent in compliance with these rules. 

    In private practice days my office staff used to call the Medicare intermediary 2 or 3 times with the same question.  We chose the answer we liked.  Even the rule makers can’t keep track of their own rules and make them fit appropriately into the reality they try to regulate.

    Regulating bureaucracies risk the fate of evolutionarily unsuccessful parasites … killing off their sustaining hosts.

    Or, in the case of the board recertifications … we can elect to stop being recertified, change our medical staff bylaws to reflect this, and move on.  The decision is still ours.

  • http://pulse.yahoo.com/_27HQZHWJS53LZ644AMBW2NRROQ Hockeyref1

    Here, Here!!! There are a few other important parts to this that really get me going. Let Me state that I am the Practice Manager Spouse, Husband of a hard working, very caring, solo Family Doc. So I come from that perspective.

    My wife is being literally Threatened and Strong Armed by both Hospital Commitees as well as our “Wonderful” 3rd party Insurance Carriers that if she does NOT keep her Board Certification, then she will be “Dropped” kicked-out, and CUT-OFF from her main source of Income. Do we really want to kick-out and cut-off our longest and most personal visit style solo practioners from both being able to visit or work with a patient in hospital, no less no longer allowing them to be “On-Panel” with most of the private third parties that presently contol the access and the purse strings of our industry and profession??? And as our author here touched upon, who says that any of these measures and new “Barriers” to ones own right to practice are even valid and significant? And if so, how much bang are we getting for this buck?

    But to me one of the most upsetting parts of all of this is the fact that just a few years ago, Board Certification was NOT a requirement to practice, it was completely Optional. It was the kind of thing that some, granted Many doctors did to help “differentiate” themselves for non-certified others. It was a badge to wear and an internal to the field, specialty kind of thing. Now today these other entities are Co-Opting this last and largest proof of Academic and Professional knowledge into and entrance exam to the financial pipeline, the cash flow, no less access to our own patients, customers of our own end services.

    So today one has NO CHOICE but to basically retain their board certification or risk being cast off, thrown off the economic cliff of American Medicine. The Optional part of this entire process is completely GONE! And that is a huge change in role for this process and our boards. And one can not help but consider, wonder, just how much their proven for profit intentions and selfishness really Like, Love, and will fight with all might to retain this new found leverage, control and influence. This means that no doctor who cares to be of staff at a hospital (and not always to actually practice and or do procedures there no less) or simply to be able to accept and process their patients’ increasingly crumby, cheap and painful insurance claims, prior auths, and referals, have NO CHOICE, no options left to them, but to Submit to the ALL POWERFUL board of their speciality.

    This is not supposed to be their role, to be the final barrier to professional practice. They were supposed to be and used to be a means of proving one’s superior level of knowledge and continued study in the field of practice to them be able to proudly display to patient consumers as well as potential employers and or academic places of higher learning, if one cared to do such. It was simply created to separate and show the difference between the average and the above average. But will our boards storm Washington D.C. in protest, and demand a federal law the takes away this all too far reaching and “Mob-Like” power, making it illegal for any academic institution, employer or insurance carrier to require and or mandate their Certification to be hired, on one of their panels, or be paid more or less of the fee schedule by such controlling entities??? Of course they won’t because they are drunk with their new found power and the revenue stream, from beated down, learned helpless, have no choice but to comply and pay up, Jump the Hoop or Barrier that this entire situation has created. This kind of access to proffesional practice used to be the domain of the State Licensing Authorities but today the various Medical Specialty Boards have in collusion with these other entities stolen and taken over this role and serverly increased the bribe money and efforts required, simply to get in, to simply reach “GO and Collect Our $200″….

    Lastly, Our boards are created from a broken “Old Boy Network” with no form of deriving their power from the people they claim to represent. There is NO voting of all licensed or residency graduated doctors in a speciality for Board Members… It is simply this person who is friends with a board member recommending another such person to then simply be voted upon for acceptance to the board by the present members already sitting and serving on that board!!! Yes, I confirmed this with a reasonably nice and somewhat accessable member of the Family Practice board not to long ago via the IMP list serve. If this is not a system ripe for abuse and full control of retaining power and direction, mindset, agenda, and political power and influence, to closed no outside feedback loop, all a group of potential Yes Men and Women then tell me what is???

    It is time to strip these boards of any and all power, for a mass defection, leaving them without the one thing they need the most to survive and that is Membership Dollars and actual support of Membership Numbers. It is time for docs to demand that such requirements be removed from all of the contracts with the insurance carriers and fight in their hosptial commitees to do likewise. The time has come to send these “Old Boys” packing, back to where they belong and to take back control from those that stole it without our permission and without valid standing to do such… Let’s keep talking.

    • Anonymous

      Subverting the Boards will take more than denial of income. There will have to be denial of relevance. This could be achieved by physicians directly negotiating with payors and hospitals and clearly demonstrating that the function of Board certification does not have anything to do with quality of care and increases the cost of health care for patients and providers. Hopefully, someday, what patients think, along with real outcomes, might begin to matter.

      • Anonymous

        A state struggling to recruit/retain physicians could choose to make a law stating board certification once is sufficient to meet any third party payer requirement within that state.

        And, medical staff bylaws could be amended by physicians to require board certification once only.

    • Anonymous

      Paul ~ I knew this was you!

  • http://twitter.com/middlegatemed MiddleGateMed

    Well stated…keeping up with ABEM’s requirements, and the omnipresent feeling that I was not trusted to remain competent without Big Brother watching me, was one of the reasons I chose to leave Emergency Medicine for business. 

  • Anonymous

    I’m a patient.  And I think the doctors here are aware that during the dilemma of selecting an unknown doctor from a list that the impressive sounding ‘board certified’ next to the doctor’s name often is the deciding factor for our choice.  I believe all the complaints expressed here, but to the other 99% of patients who don’t know the other side of the story, there isn’t much out there for guidance in choosing a
     ”good” doctor.

  • http://www.facebook.com/people/Yale-Lewis/100001648132529 Yale Lewis

    Board Certification does not mean you are a good doctor. It means you can pass a test or two after you cough up the money to tke the tests….again and again…..
    Not being board certified does not mean you are a bad doctor, it means you have not taken the tests, or you refuse to keep taking the tests and coughing up the money to pay for the tests…..

    • Anonymous

      I understand and accept what you say.  But the average patient hasn’t heard that explanation, so they will continue to be ‘impressed’ by the lofty sounding credential,until it’s challenged in more mainstream news sources.

  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    I took and passed the certfiication exam in geriatrics in 1992. It was expensive , it required time away from the practice to take the test in a city five hours away from home. Once I advertised that I was certified in geriatrics younger patients shied away. In 2002 when it was time to recertify I decided it was not worth it. I still read the geriatrics literature and take the practice exams but the negatives outweigh the positives. I have never been comfortable with the ABIM recertification program. I do not know why my generation was grandfathered in but I am glad and somewhat guilt ridden that we were. I read and complete the Medical Knowledge Self Assessment Program with each new edition and may actually retake the internal medicine boards for the challenge of it some day. Professionals stay current . Mandating repeated exams is inappropriate and is a cave in to bureaucrats, well meaning but naive legislators  and administrators in organized medicine who see it as an income generating cash cow.

  • Anonymous

    Agree with everyone here. Great topic Edwin. We’d rather be caring for patients than jumping through hoops. Need more direct physician leadership in the community. Time for DISINTERMEDIATION: Removing the middle man. 

  • http://www.facebook.com/people/Terence-Ivfmd-Lee/1523282856 Terence Ivfmd Lee

    I teach medical students, organize an informal Journal Club of 25+ physicians and I read a lot on my own, and yet I am FORCED to specifically read 30+ articles each year chosen by some committee in order to maintain my board certification. Also, I have to pay a fee. In about 6 more years, my understanding is that the rules change and I’ll have to fly to some other state and take a written test. At that time, I’ll be really really tempted to let my certification lapse.

  • Anonymous

    the funny thing is that Canadian and European physicians don’t have to do ongoing board-certification activities. Hmmm.

    This is not true, and I have no idea where you got this idea.  Both the Royal College of Physicians and Surgeons of Canada (specialist certification) and the Canadian College of Family Physicians have fairly
    stringent ongoing maintenance of certification [(FRCP(C), FRCS(S), CCFP] requirements.   For the matter, I believe the same is true for the specialty and general practice royal colleges in the UK and other Commonwealth countries.

    • http://www.facebook.com/beau.ellenbecker Beau Ellenbecker

      In Germany, the Docs have no maintenance of certification requirements and it shows.  Many of the older physicians are woefully behind the times.

  • http://www.facebook.com/RebeccaCoelius Rebecca Coelius

    I’d take this whole discussion a step further. Board (re)certification is a pain, but even more of a pain is having your scope of practice limited by local faculty or department politics, not outcomes data, such as with midwives and Fam Practice physicians doing OB, or PAs doing colonoscopies. Medicine puts people into ridiculous boxes not based on experience or actual skill set, but what you were boarded in decades ago or who can make the hospital the most money for the same intervention with the same outcome. What other industry puts such limits on its workers in their 30s? This goes for MDs in their various speciality areas, but also for the other caregivers that could be utilized on our teams. This sort of restriction made sense when all of medicine was intuitive and there was no real way of measuring outcomes, but this is no longer the case and our system needs to evolve. 

    Second, we really need to rethink how we train physicians. Does it make sense to have future ophthamologists or dermatologists delivering babies and learning all of internal medicine? I’d suggest no, it just makes that provider much more expensive when they finally do complete their training, with years of earning potential lost. I’m curious to see how NPs and PAs will start targeting subspecialist areas for this reason, its already happening in derm, anesthesia, and neonatal intensive care. 

  • Anonymous

    I agree but also bemoan the lack of knowledge of many out there.  Can’t we in primary care at least come up with a body of knowledge that we should know 90% of the time, instead of esoteria that are in our Boards and Maintenence procedures that we only need to score 70% on.  As a good guesser the system helps me, but we don’t have a good source of all the facts that I need to know 90% or better, and some of them I don’t know, and I know too many doctors who don’t even try to know.  And I don’t like Maintenance of Certification requirements that make me read several reviews on one disease and then quiz me on the one peice of esoteria that only made it into one of them, while caring less if I know anything about any other disease.

    Think about it, if you’re a patient do you want your doctor to know 10 basic facts about H1N1 in 2010, or nothing about it because they did their Maintenence last year on diabetes.  I worked with a pediatrician that year who didn’t know little kids should be a priority for the vaccine because they were dying.

  • http://arnonkrongrad.com Arnon Krongrad, MD

    America is the country that gave the world the profession known as “compliance officer.” It’s not about doctors. It’s about a modern culture that doesn’t trust anyone, including doctors. Maybe it’s time to look critically at the concept of “land of the free.”