Maintaining board certification: Stop with the patient surveys

It’s one thing to ask a doctor to stay current on his knowledge, it’s quite another to insist he survey his patients for a private enterprise, especially if that survey represents unvetted independent research.

Recently, a colleague of mine was attempting to maintain his board certification credential with the American Board of Internal Medicine (ABIM) and signed up for the ABIM’s requirement for a practice improvement module worth a required 20 points of 100 total required before he could sit for his specialty board re-certification examination.  For his module, he optimistically chose to offer a survey created by the ABIM to his patients, receive feedback on how he did on the survey, then repeat the survey to a later set of patients to show improvement of care.  In return for his considerable efforts, he would be granted his required points from the ABIM so he could quality to sit for his specialty recertification examination.

Here is an exact copy of the survey my colleague was sent in its entirety.   He received a packet of 70 of these surveys from the ABIM, neatly shrink-wrapped, to distribute to his patients.

What could go wrong?

First, imagine the time and work involved to distribute these surveys. Whether he provided the survey to his patients himself or he tasked others to do so, what lab result was not reviewed or phone call not answered as a result?  We can only speculate.

Second, informed consent about the true nature of this survey was not obtained from patients nor my colleague.  Rather, my colleague was coerced into purchasing the survey because he’s might not be able to continue practicing medicine unless he complies.  Informed consent would suggest that the doctor and his patients are informed of potential harms or risks involved with the collection of such survey data.

For the patient: What might their responses mean for their doctor’s ability to practice medicine?  How might the working relationship with their doctor be degraded or the trust he has in them be compromised?

For the doctor: How are the data collected on the non-secure website protected, how will they be used against him?  Will they be used for future health care policy development or sold to third parties?

I have no doubt that many will see this survey collection as a benign attempt to truly improve a physician’s practice or an opportunity to empower patients with an means of changing physician behavior.  But I suspect these same people never consider the potential negative consequences of such a survey.  The very idea that this survey is a destructive intrusion into the doctor-patient relationship is a foreign concept to its designers.  We can only imagine the moral outrage and disavowal that will arise in the halls of ABIM with such an assessment.  Yet like a bull in a china shop, the collection of anonymous survey data completely disrupts one of the most tenuous and vulnerable relationships in medicine.  It ignores the vulnerable, highly-charged and often emotional circumstances that accompany any visit to a doctor’s office while rendering valid concerns a patient might have about their experience into the muddied waters of anonymous data aggregation.

Also, this unscientific research survey contains a host of dependent variables like age, race and self-assessments of general health status and mental illness.  Self-assessments make a mockery of non-biased data collection, yet the destructive assumptions made throughout the survey are clear: Doctors should have unlimited time, provide unlimited access, and perfect manners toward patients without regard to forces (such as this ABIM survey) that increasingly pull them from what they yearn to do: care for their fellow man, woman or child.   This lack of concern with scientific validity and objectivity  leaves the end game of any particular individual or group findings only left to the imagination.

If we are going to investigate whether an individual doctor’s behavior reflects an age/education/gender/race bias toward their patients (see questions 42 through 46), this is a serious question, deserving of the doctor’s consent, and requiring scientific validity far past that of correlational survey data on an n of 70 patients. The possible end result or accusation is far too damning.  Or haven’t the ABIM committee members thought of that? But we shouldn’t worry: Patient bias/irrationality/emotionalism is controlled for by question 41 — where the patient provides us with an assessment of his overall mental health.

If doctor’s are subjecting themselves to this kind of scrutiny, shouldn’t they (and their patients) know how it will be used? Whether aggregated or individual data, this kind of helter-skelter approach is surely designed to lead to progressive quality initiatives to adjust doctor’s behavior whether findings are valid or not. We are participating in the first step of yet another new initiative in micro-managing and control of the already besieged doctor.

The intrusion of this survey into the sanctity of the doctor-patient relationship by an independent and non-accountable non-profit organization that ignores sound research and ethical principles should be stopped.  It’s negative consequences far outweigh any benefit to patients.

In a recent survey of their membership of over 4000 cardiologists nationwide, the American College of Cardiology found that nearly a third of their respondents indicated that the changes imposed by the ABIM’s subversive recertification process (that includes these patient surveys as one tool) will affect their future career plans and will likely accelerate their decisions, such as early retirement, part-time work, or transition to non-clinical work.  Approximately one-quarter of physicians in practice for 15 years or more specified that early retirement is a likely outcome.  Exactly how will such a survey help patients already struggling to access care?  Is ABIM responsible for the repercussions of their physician bullying?

I know this is a time of multiple instances of moral outrage and demoralization for physicians.  But I would ask that you take that outrage and forward this survey to colleagues.  I would also ask that you I contact your local professional subspecialty organizations, state licensure boards, and appropriate members of Congress to insist on an immediate moratorium to the American Board of Medical Specialties/American Board of Internal Medicine maintenance of certification process as it currently exists.

Believe me, this discussion is ongoing and far from over.

Wes Fisher is a cardiologist who blogs at Dr. Wes.

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