Doctors are reporting an alarming rate of dissatisfaction and burnout, with some leaving the practice of medicine altogether. Administrators and insurance companies are often blamed; however, our own professional organizations impose a significant portion of the problem.
Several years ago, Danielle Ofri wrote an op-ed in the New York Times about how doctors’ precious time was being wasted on recertification exams. That year (2014), I took my first certification exam in addiction medicine, which was administered by the American Board of Addiction Medicine (ABAM). Addiction medicine was not yet recognized by the American Board of Medical Specialties (ABMS). I understood that we would be “grandfathered” when the specialty was formally recognized, meaning we would not have to take a new exam.
Board certification in addiction medicine required certification in a primary specialty, so I needed to maintain my family medicine. I would be due for recertification in family medicine in 2016. At that time, since the addiction medicine exam was only offered every other year, if I didn’t take it in 2014, I would have been faced with taking two certification exams in 2016.
For some reason, the ABAM exam decided to offer an exam in 2015, the same year addiction medicine was recognized by the ABMS as a subspecialty of preventive medicine. This meant that the American Board of Preventive Medicine would now administer the addiction medicine exam. To my greatest surprise, we were informed that those of us already certified by ABAM would have to take a new exam, except if we had been certified in 2015!
Never mind that the 2015 exam wasn’t even a definitive option at the time I was preparing for the 2014 exam!
I wrote a letter of protest and the response read, in part: “Based on your 2014 ABAM certification, at the very latest you would need to take an ADM ‘recertification’ exam by 2024. You have until 2021 to take the ABPM ADM exam, so essentially if you wait for this 2021 exam you would be just three years early in taking your otherwise next ADM cognitive exam …”
While I appreciated their efforts at trying to make me feel better, I did not find the suggestion that I could wait till 2021 particularly helpful, nor did I think it was a practical solution, so I took the new exam at the first opportunity – in 2017.
In 2018, as program director of an addiction medicine fellowship, I was informed by a trainee that while attempting to register, he had been notified of his ineligibility for the certification exam. This was because even though he was certified by the osteopathic (DO) family medicine board, he had not taken the allopathic (MD) certification exam and had therefore not been certified by an ABMS board. We later found out that the American Board of Family Medicine (the allopathic board) had a provision that would allow him to take their exam, successful completion of which would make him eligible for the ABPM addiction medicine exam. What a waste of time and resources! So, instead of preparing for the addiction medicine exam, he had to take another family medicine exam first, despite the fact that he was already certified in family medicine.
The cost of these exams goes far beyond the thousands of dollars spent on review courses and the registration process. The mental and emotional toll on physicians, in addition to time away from patient care is significant. The lack of evidence that these exams affect patient outcomes is another reason to abolish them. While some specialty boards are making changes such as introducing longitudinal assessment options, we still have a long way to go.
Mark Lopatin wrote about his frustrations with the recertification process, stating that it was no coincidence that he retired in 2020, the year his board certification was set to expire. His essay details how the certification exam in rheumatology was not offered in 1989, the year he graduated. The earliest he could take the exam was 1990, when the specialty board decided that certifications would only be valid for ten years. After going through the recertification process a number of times, when 2020 came around, he decided that enough was enough and retired.
If those who certified prior to 1990 when the new requirements for recertification took effect were “grandfathered” for life, why should any physician have to recertify?
I write this as someone who is currently a member of an exam board. I do not suggest that we do away with certification exams altogether, and I still believe there is a place for initial certification exams. However, the current process of maintenance of certification is contributing to the problem of physician burnout, in addition to taking doctors away from patient care and needs to be overhauled.
The National Board of Medical Examiners (NBME) has made significant changes to the United States Medical Licensing Examination (USMLE), namely switching the scoring to Pass/Fail rather than numerical values for Step 1 and also getting rid of the Clinical Skills portion of Step 2.
As medical students already heavily in debt, we had to pay $1,000 to register for the Clinical Skills exam, not to mention the associated travel costs. Now the NBME has decided that the exam is no longer necessary.
If such drastic changes are being made at the undergraduate medical education level, the specialty boards can certainly make changes to the requirements for practicing physicians. Medical knowledge is constantly changing, which brings into question the emphasis on exams that test knowledge at a given point in time. The reliance on day-long tests of memory, aptly described as the “height of anachronistic ridiculousness”, by Danielle Ofri, is hard to justify.
It’s time to do away with unnecessary and burdensome requirements and exams that do not reflect the daily practice of medicine and allow doctors to be doctors. This is necessary to address the various factors contributing to physician burnout.
Olapeju Simoyan is an addiction medicine specialist.
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