Board certification is no guarantee of excellent patient care

When a doctor makes a mistake, it’s rarely out of ignorance.  We usually have the knowledge we need. Instead, most medical mistakes happen because we’re tired, distracted, hurried, or indifferent — or maybe some combination of those things.

Since physicians rarely publicize their personal frazzled-and-frenzied, pooped-out or burned-out quotients, health care consumers shopping for a doctor often consider Board certification as a kind of Good Housekeeping seal of approval. The “board” in “board certified” varies by specialty, but the largest is the American Board of Internal Medicine, which certifies doctors specializing in internal medicine (like me) and twenty different subspecialties such as cardiology, nephrology, gastroenterology, etc.

The American Board of Internal Medicine (ABIM) has been in some hot water lately. At issue is ABIM’s progressive expansion of what it requires for a physician to remain board certified. When the boards began in 1936, passing an exam after completing medical school meant you were certified for life. In the early 1990s, ABIM began mandating certification renewal every ten years, with additional maintenance of certification activities required just to be eligible to take the recertification exam. In 2014, ABIM announced a new set of maintenance-of-certification activities that were so complex and tedious that physician groups nominated colleagues to try and divine exactly how the new requirements were to be fulfilled.

Frustration with these changes led a group of prominent physicians to organize a nationwide petition against ABIMs mission creep. Later the group created the National Board of Physicians and Surgeons (NBPAS) as a more streamlined and inexpensive certification alternative to the ABIM.

In February of this year, ABIM apologized for its overreach and suspended some of its most recently added requirements. But a Newsweek article claiming that ABIM’s expansion was financially motivated, and had little to do with physician competence, only fanned the flames of the rebellion.

Physician controversies like this rarely garner much pathos in the lay press. To the general public, it’s like watching a BMW and a Lexus locking horns over a parking spot — who cares? But the controversy points to a much deeper issue in medicine: What does board certification really mean, and how can your doctor hurt you?

ABIM states, “Certification has meant that internists have demonstrated — to their peers and to the public — that they have the clinical judgment, skills and attitudes essential for the delivery of excellent patient care.”

That may be true in theory, but I can assure you that board certification is no guarantee that excellent patient care will actually be delivered to you. I understand how bacteria can be spread to and through hospitalized patients. But answering “D) Clostridium difficile” on the standard multiple choice board examination does not get me to slow down and wash my hands before I enter the room, and that’s what my patients need.

Most doctor mistakes are not about aptitude or lack of knowledge.  The list of most commonly missed diagnoses contains common ailments, not the quirky esoterica (known as “zebras”) that physicians complain are often overrepresented on board exams.

The New England Journal of Medicine presented a case of a woman who came to the hospital with a stroke that might have been prevented if the clinic doctor had recognized the diagnosis of atrial fibrillation on an EKG. Typically this is not a difficult EKG diagnosis, but the physician missed it on two occasions. Given that the patient presented twice with palpitations, and that atrial fibrillation is way up on the list of causes of palpitations (even medical students know this), many physicians might have reviewed the EKG with a colleague down the hall. But that takes time, an emotional investment in figuring things out, and a certain amount of humility. These qualities cannot be tested on a board exam.

The well-trained physician who missed a lethal case of Ebola virus in a Dallas ER admitted that he had received and read prior Ebola updates from the hospital. Indeed, everyone in America knew about the Ebola update: As the TV told us repeatedly, we were all going to die. But answering “B) Recent travel to Liberia” on a board exam is not the same as asking it in real life. (The RN who saw the patient first did indeed ask the question.)

I am not arguing against physicians being well informed. Indeed, we’re already required to complete a certain number of continuing medical education hours each year, and given the pace of advancing medical knowledge, self-education is an almost daily occurrence. But up-to-date, accurate, authoritative medical knowledge has never been more instantly accessible to physicians since Hippocrates started the first urgent care. Does it matter that your physician has committed it to memory, transiently at least, so as to pass a test?

What every sick person really needs is a doctor or health care provider who will enthusiastically engage in sorting through that person’s problems: Someone who will look up what they aren’t sure of, who has the time and the interest to double back on a diagnosis that doesn’t seem right, and who will rethink a treatment that isn’t working.

The answer is “B) If your doctor is hurried, distracted, indifferent, or just plain exhausted, his or her board certification probably isn’t worth the paper it’s printed on.”

Craig Bowron is an internal medicine physician and can be reached at his self-titled site, Craig Bowron, MD.

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