Dr. Wachter reflects after completing his term at the ABIM

I recently completed my last day as chair of the ABIM, and ended my eight-year tenure on the Board. In this blog – a bookend to the one I wrote at the start of the year, which went near-viral – I’ll describe some of our accomplishments this year and a few of the challenges that I leave my talented successors to grapple with.

I had two very tangible tasks to accomplish during my chairmanship. First, after a decade-long tenure as CEO and president of ABIM, Chris Cassel announced her intention to step down. (Chris is now CEO of the National Quality Forum, which is increasingly crucial in a world looking for robust measures of quality, safety, and value.) After an extensive search, we selected Richard Baron to become ABIM’s new CEO, and Rich began earlier this month. Rich is one of the most impressive people I’ve met in healthcare, and a perfect choice to lead ABIM into the future. As someone who practiced general internal medicine for nearly three decades in a mid-sized Philadelphia office, he is a “doctor’s doctor.”

He is intimately familiar with the work of the Board, having served on the boards of both ABIM and the ABIM Foundation for over a decade (including a year as ABIM chair). He also has extensive policy experience, most recently as director for Seamless Care Models for the Center for Medicare & Medicaid Innovation (CMMI), where he was responsible for putting meat on the bones of concepts like the medical home and accountable care organization. Rich is wickedly smart, a superb communicator, and a great listener with impeccable values and an unerring ethical compass. He’ll be splendid.

The second area may be a bit more inside baseball, but will ultimately be just as important. A couple of years ago, we began a process to redesign the ABIM’s governance. Our 28-person board was both too large and had too much on its plate for effective decision making. In work that was superbly led by then-chair Catherine Lucey, assisted by a crack committee, staff and governance expert Jamie Orlikoff, we decided to transform our governance structure. As of tomorrow, the ABIM board shrinks to 15 members – chosen for their experiences and competencies rather than because they represent a given medical subspecialty – and a new group, the ABIM Council, is formed. ABIM’s work is now divided: the new board is charged with developing and carrying out our overarching strategy and holds fiduciary responsibility; the Council is responsible for the core work of the organization: the certification and MOC processes. This separation (accompanied by appropriate cross-links) is designed to give both groups the time and support they need to focus on their very large agendas. My thanks to Catherine, Jamie, the staff, and the Governance Task Force (particularly Governance Committee chair Pat Conolly and inaugural Council chair Lee Berkowitz) for breathing life into this structure, and to the entire board for a thoughtful deliberation and a very bold decision.

There were several other initiatives we started under my watch but which I’ll hand off to our able new chair, David Johnson, the Board, Council, and staff. We created a committee called Assessment 2020, led by Harlan Krumholz, whose job is to rethink how we assess physicians in the future. Here are merely some of the issues we’re grappling with:

  • In a world in which virtually every doctor is documenting his or her care in an electronic medical record system, how do we take advantage of these data, as seamlessly as possible, to assess the quality of care?
  • As more of our assessments are drawn from data created during care delivery, how do we ensure that we’re also measuring things that are harder to assess than care processes or even outcomes, such as diagnostic acumen and empathy?
  • Since we know that the quality of care delivered by individual doctors is profoundly influenced by their practice setting, how do we measure context and take it into account in our certification process?
  • In a world of ubiquitous and instantaneous access to online information, does a purely closed-book test make sense?
  • How do we integrate modern simulation techniques into our assessments?
  • How can we assure that individual physicians have the skills they’ll need to contribute most effectively to a rapidly changing healthcare landscape?

While our methods must remain consistent with modern thinking and technology, we can’t abandon scientifically valid tools and assessments for the latest fads. The Assessment 2020 committee is an eclectic and accomplished group that includes experts from healthcare, education, simulation, and a variety of other domains. I look forward to seeing what we come up with (I’ll continue on as a committee member).

This year we also sharpened our focus on two other challenging and hugely important issues: harmonization and transparency. We know that many physicians complain of being crushed by the burden of being measured by a variety of payers, healthcare systems, quality coalitions, as well as the Boards. We have worked hard to integrate MOC with these efforts – our goal is to allow (if the diplomate wishes) the same activities to “count” for Medicare and other insurers’ quality incentive or public reporting programs, Joint Commission practice assessments, state maintenance of licensure programs, meaningful use incentives, and more. We’ve made some headway on this, but it remains a work in progress – these are some very big cats to herd. We’ve also worked hard to keep our costs down. They are among the lowest of boards that make up the American Board of Medical Specialties(the umbrella organization for the major certifying boards). I am confident that future boards will remain committed to this path.

Moreover, we recognize that many physicians are now participating in robust QI programs within their own healthcare institutions. We have created a pathway by which such organizations can oversee their physicians’ quality work – so a group of doctors in a given hospital working on a diabetes or heart failure improvement project can all receive MOC credit, offered by their own institution, for this work. In our harmonization efforts, we have been encouraged by the response of others (particularly Medicare, under CMO Patrick Conway’s superb leadership), who appreciate that physicians themselves (this is, after all, what the Boards are – groups of physicians creating standards for their own specialties) will do a better job than payers or regulators. This too is a work in progress, but we have made real advances.

In addition, a personal passion of mine was to push the Board to become more transparent. I mean this in both senses of the word. First, how we do our business and make our decisions should be accessible to everyone who wants to know. We’ve taken strong steps in this direction, with even more to come next year.

Even more importantly, I believe that the Board should, ultimately, make more information available to patients and other interested parties than simply whether physicians are, or are not, board certified. But what type of information? Should it be levels of performance (for example, expert vs. competent), areas of specialization within a specialty (for example, an endocrinologist who has a particular expertise in thyroidology), or something else? We’ve begun a process to think through these very hard questions, with a lot of input, over the next few years. Of course, this issue is highly intertwined with our Assessment 2020 work.

Our efforts to modernize our certification programs and consider issues of transparency will be facilitated by more frequent touch points with our diplomates. All of the boards under the ABMS have been asked to transition to a more continuous process in which physicians participate in MOC more frequently than every ten years. In focus groups that we conducted in planning our MOC transformation, many physicians begged us to “just tell me what I need to do.” Our soon-to-be launched web portal will fill this need. This is an extraordinarily complex undertaking: a senior physician might be “grandfathered” in internal medicine, but have certain requirements for, say, her subspecialty of cardiology, and others for her sub-sub specialty of electrophysiology. The new web portal will represent a real advance.

It would be wildly unusual for an accreditor or standard setter to be universally loved, and ABIM is no exception. We sit at a delicate interface. Patients and patient representatives often ask us to do more: provide them more information about physicians to help them make choices and weed out “bad apples.” Yet many physicians – including a particularly vocal group of readers of this blog – clearly want us to do less. After my tenure on the Board, I remain convinced of the value of professional self-regulation and assessment, and utterly unpersuaded by the argument that MOC should just go away, that every physician can be counted on to keep up with advances in their field on their own, and that patients don’t deserve to know whether their physicians have met a set of scientifically-valid standards set by experts in their own specialty.

But can the process be improved? Sure. I’ve done my best to help ABIM, which is filled with talented and highly committed staff and board members, to do just that. As we do, it will be important to look unblinkingly at where our programs fall short, but also to base such efforts on real data, not some of the misinformation I’ve seen flying around the web. For example, between 1997 and 2012, the pass rate on the MOC exam has been 87% for first time takers, with an ultimate pass rate of 96%, not the far-lower rate being suggested in some posts (though rates on individual exam administrations do vary). Between 1990 and 2001, more than 72,000 physicians received time-limited certificates from ABIM; 92% of them enrolled in MOC at the appropriate time, and 84% completed the process successfully. Finally, we ask physicians to assess their experience with the testing component of certification and MOC. Eighty-three percent of physicians who participated in certification were satisfied with the experience, as were 78% engaged in MOC (3% and 5% were unsatisfied, respectively; the rest were neutral). Seventy-nine percent of those who participated in MOC would recommend it to a colleague.

As important as physicians’ attitudes are those of patients. In a 2003 Gallup survey, 90% of patients felt it was important or very important that physicians be reevaluated every few years; 87% thought it was important or very important that doctors periodically pass a written test. More than half stated that they would find another doctor if their own physician’s board certification lapsed. Patients want and deserve a fair and robust certification and MOC process.

I look forward to seeing what the future holds, and wish my colleagues the best of luck in pursuing this crucial agenda. I’ll continue as a Trustee of the ABIM Foundation, whose main focus over the past few years has been the highly influential Choosing Wisely® campaign.

And, of course, I’ll continue to maintain my certification, proudly.

Bob Wachter is professor of medicine, University of California, San Francisco. He coined the term “hospitalist” and is one of the nation’s leading experts in health care quality and patient safety. He is author ofUnderstanding Patient Safety, Second Edition, and blogs at Wachter’s World, where this post originally appeared.

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  • azmd

    After reading the comments made by the “particularly vocal group of readers” on your blog, it seems to me that they all made very thoughtful comments and it is perplexing that the ABIM is not taking them more seriously. I didn’t see any commenters suggesting, as you imply, that MOC “just go away.” I saw a number of what seemed to me to be excellent suggestions to streamline the MOC process to make it more clinically relevant, more concise, and less organized around QI documentation requirements that quite frankly are widely seen in the medical community as busywork. I also saw a good suggestion that the profession find a way to incorporate, as the airline industry does, self regulation and assessment activities into the actual workday of a physician.

    I find it discouraging that these sensible ideas, offered by actual practicing physicians who are clearly engaged and interested in the self-assessment process, are being dismissed so readily by medical leadership.

    • Guest

      I read them also and found none of them to be out of line. I think Bob and his ilk are likely threatened by the pleas to “make MOC cheaper” and to back up outrageous claims like “research suggests re-certified physicians are safer.”

      Bob even claims that his top 2 criteria for his own personal physicians are that they are board certified and have been re-certified. Yeah, right.

      Meanwhile the CEO of ABIM collects a hefty 800K annual salary and the board is likely not hurting either.

      My specialty has also gotten quite carried away with the MOC and re-certification process. Now, every 10 years outside of retaking the written exam we have to complete 350 CME credits AND take a simulator course (offered at a few sites around the country) for the low low cost of $2000. Mind you the $2000 is the cost of the course; examinees also need to take time off work, pay for transportation to the course and pay for the hotel.

      • azmd

        I guess if the ultimate goal is to drive intelligent and thoughtful people with a healthy level of self-respect out of medicine they are going in the right direction.

        • kjindal

          haha. never too late to get into some variation of finance, even at the level of learning how to invest for yourself. There are MANY MANY IDIOTS in this field making way more than a typical internist or pediatrician of FP doc, who could barely get 1000 on their SATs.

  • PrimaryCareDoc

    I just completed my MOC and recertification exam in April. I passed.

    The overall pass rate was 67%.

    I find this frightening. Apparently 37% of docs who previously passed the test no longer can. Why? Have they become drastically more stupid over the past 10 years? I doubt it.

    I think the exam was terrible. It covered a ton of inane minutiae. It was not at all applicable to real life practice.

    Again, this is not sour grapes. I passed, and my scores were in the upper decile. I got 100% correct on most sections. I still think it was a stupid test.

    • Guest

      So how much time and money did you invest in this stupid test? Just curious.

      • PrimaryCareDoc

        Thousands. $1600 and change to register for MOC and the exam. $600 for the MKSAP review books. $3000 for airfare, hotel and conference fee for the ACP review course.

        Time? About 2 hours a day for 6 months, plus even more as the test got closer, so probably over 400 hours.

        400 hours, taken away from my family, my patients, and my mental well being.

        • Guest

          Revolting.

        • kjindal

          i too went thru this inane process last summer & fall. I feel dummer (sp?) for it. Besides the above costs, for us self-employed folks who pay $20,000+ for our family’s health insurance, we are away from the office seeing patients – maybe we can bill the ABIM for the missed remuneration!

  • DavidBehar

    I strongly urge any one who has failed to sue you personally. I also demand an investigation by the Department of Justice into RICO activities by your organizations. Lastly, I demand to know your pass rate by race. Because your examination has no scientific validation, any racial disparity represents racial discrimination. A federal judge should enjoin your entire operation until you prove it meets minimal scientific standards.

    • Suzi Q 38

      Dr. Behar,
      You are so complex, I can not even follow what you are talking about.
      Are you calling for a lawsuit because you feel that the Internal medicine exam is unfair (racially)?
      I thought you hated courts, tort law, and lawyers.

      “It is time for doctors to attack back, at the sworn enemies of clinical care. As they give no quarter, so their destruction should be a goal. To deter.”

      Dr. Behar,
      You are the “Pablo Neruda” of physicians. Your statement is a series of beautifully crafted words, intended for doctors to deeply reflect upon.

      Please explain the above “poem.”

      Who is your enemy, and how are you to incite a “war” against those who are “attacking” your profession? What exactly do you propose physicians do at this time to unite?

      At times I agree, but no one seems to have any concrete and deployable plans or answers.

      Do you?

      • DavidBehar

        Suzi: I apologize for the density of the comment, done for the sake of brevity.

        Each is a legal point with 10 layers of consideration. I would be available to the lawyers of any doctor wishing to pursue a claim.

        I do not hate the legal profession. I love the legal profession and the rule of law. I want to help it improve because it is in utter failure across the board.

        Liability will shrink an entire enterprise and immunity will grow an entire enterprise. I can give you many historic experiments, some on-off, on-off twice. So this is a back door path to industrial planning without legislative investigation and deliberation. Although courts should not be doing industrial planning, because they are incompetent, they do. And I prefer to take advantage of it rather than just complain about it.

        The liability path is a very reliable method to shrink goverment and quasi-governmental organizations. Support greater liability of government in statutes. And sue the government as often as possible. It will rapidly shrink, even if the claim is dismissed on first pleading by the biased pro-government judges (as all are biased in favor of the writer of their paycheck, the government).

        The American Association of Physicians and Surgeons has recently filed a lawsuit in new Jersey, naming the Am. Bd of Med Specialties for restraint of trade. I will contact them and ask that they add a claim of racial discrimination.

        • Suzi Q 38

          Thanks for responding.
          good Dr. Behar.

          This is what I am talking about.
          Start with your idea of adding a claim of racial discrimination.

          Can you file a lawsuit on behalf of doctors in general? The past group of doctors failed.
          They were showcased here on this site. I think they were wanting more pay from medical and medicare, and insurance in general.

          Why didn’t doctors stand up and fight with them by donations to encourage them to appeal?

          If not, people like you have to be “American physician dissidents” and fight for physician rights.

          This is bigger that just any single physician.

          Each individual has to consider any ideas, think about them, decide if it is possible or feasible, then follow though in order to effect change.

          We are not living in China, where physicians would be jailed for dissenting.

          Laziness and apathy with not get our physicians anywhere. With Obama care looming, know that the time is now, or forget it.

  • buzzkillerjsmith

    Board certification in IM is mostly a way station to a subspecialty. But Bob takes it pretty seriously I guess.

    • Guest

      Gee…I wonder why.

  • Steven Reznick

    Clearly Dr Wachter is quite passionate about the need to meet the expectations of the insurance companies and the employers they hoodwinked and ultimately the patients ,over the years to insure them that they could define quality in health care, measure it and get them all ” more bang for the buck.” What in fact happened is that the US Congress rejected Hillary Clinton’s managed care initiative and the big insurers with the support of the pharmaceutical industry and large corporations implemented the version of managed care that returned the most profits to their pocket books. Along the way Dr Wachter recognized the need for the development of the hospitalist care specialty, capitalizing on Medicare’s requirement that academic attendings actually see and examine patients when supervising and write care notes not just sign charts in order for their institution to get paid. He parlayed that into destroying longitudinal care and with procedural subspecialty support destroyed general internal medicine. They have been less successful in destroying family medicine but the effort continues. Whether this was by design or it just happened is something I do not know . The ABIM’s continued efforts to shorten medical school, shorten residency training despite an explosion of knowledge and technology in addition to traditional training further undermines the future of comprehensively trained internists. The fact is that there is no way to measure compassion and caring and I am not even sure in Baby Boomer multiproblem patients that there is a great way to measure efficiency?

    I do applaud him for his service and participation even if I disagree with his polices. As a general internist in a small practice I frankly did not believe I had the time to take away from patient care to invest in policy making because if I did, based on the reimbursement levels for primary care the bills would have never gotten paid.

    Maintenance of Certification is certainly something that needs major tweeking. Somehow as practitioners we need to take the reins back and restore sanity and practicality to the process

  • drgh

    I think there was a recent article about hostile dependence written by an insightful cardiologist recently. I believe this article and issue with board certification has turned into the same hostile dependency problem. As an MD, we are told that you have to be Board Certified. It use to feel like a meaningful pursuit. But no longer.
    Clearly there is no autonomy in medicine. In the past, there was one exam for board certification. Now it has become like everything else, a money making capitalistic enterprise that has frankly become sadistic to physicians.
    It of course is under the guise of being helpful to physicians to keep up with their knowledge base. But in actuality, it has become an exercise in torture. I am at a point in my life where I no longer care about continuing board certification under these terms.

    • Guest

      It’s a means by which some crafty blowhards in our profession that were sleazy enough to get into the “society” make big bucks. Other than that, board certification is pointless. My older partners don’t have to do it, but I do. Offensive.

      • drgh

        Disgusting! At least lawyers once they pass the bar, they are done. Although, the down side of that is if they don’t pass the bar, they cannot practice at all. Whereas , of course in medicine, you can still practice medicine.

  • Guest

    Bob, now that you have stepped down, can you admit MOC is all about the money? We all know it is/was, but can you admit it?

  • Laup Nepm

    Yes, Bob, your blog went viral and by far the comments were anti MOC. However, your summary here is simply another free advertisement for a product only the ABMS wants and from which it is the only one who profits. Certainly no patient or insurance payer profiting-these are the financial sources of the ABMS’s boards cummulative $400 million net worth and yearly gross receipts.

  • rtpinfla

    I question the results of the Gallup poll. Although I am sure the numbers are accurate, I know that questions can always be asked in a way to get the answer you want. Additionally, in reality, look at what all those patient questionnaires and internet ratings sites concentrate on. I have never seen a comment about whether or not a doctor is board certified. Physicians are rated only on things like: Was the staff nice? Could you get an appointment when you wanted? Was the waiting room nice? Did the doctor listen to you? And so on. I honestly think most patients are completely unaware of their doctor’s board status.
    I could be dead wrong, but as long as I continue to provide appropriate medical care in a pleasant and timely manner, I don’t think any of my patients will leave to establish with another physician. If I let my certification lapse I still believe I would get a healthy flow of patients because I have a pretty good reputation, and many of my patients are actually referred to me by other patients. I’m sure there would be a few that screen me out, but I don’t think I’ll suddenly wonder where all the patients went.

    However, if I or my staff turns rude or my appointment wait times increase my once loyal patients will be walking and word will get out quickly to avoid me. It will not matter a whit if I get the super -duper–gold-star recertification with special honors. That’s reality.
    Over half of my panel suddenly walking if they discovered my board certification lapsed? That’s not reality- that seems to be more like some sort of scare tactic.

    • Guest

      No one but the boards and hospital administrators (read: bubbleheads) care if a physician is board certified. If he and his/her staff are courteous, competent and friendly, THAT’S what people will respond to.

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