Certified, but denied: the impact of board certification on patient care [PODCAST]

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In this episode, we’re joined by Emmanuel K. Konstantakos, an orthopedic surgeon, and Jeff Morris, an attorney and CEO of the American Board of Physician Specialties. They discuss the ongoing debate about physician board certifications and the role of monopolistic practices in limiting patient access to care. During the COVID-19 crisis, discriminatory hiring practices left many highly skilled, dual-board certified physicians unable to provide emergency and telemedicine services. The guests will explore the dangers of monopolies in health care, the reasons behind these practices, and the impact on patient safety and care. The guests will ask important questions about the true motives behind these practices and the need for change in how we approach physician board certifications.

Emmanuel K. Konstantakos is an orthopedic surgeon. Jeff Morris is an attorney and CEO, American Board of Physician Specialties.

They share their stories and discuss the KevinMD article, “Stop the ABMS monopoly.”

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Transcript

Kevin Pho: Hi, welcome to the show. Rate and review at KevinMD.com/rate. Subscribe at KevinMD.com/podcast. Today we welcome back on the show Manny Konstantakos and Jeff Morris. Manny’s an orthopedic surgeon. Jeff is the CEO of the American Board of Physician Specialties. I had them on the show in the summer of ’21. It’s been a long time since we last chatted. So both of you, welcome to the show.

Emmanuel K. Konstantakos: Thank you very much, Kevin.

Jeff Morris: Thank you.

Kevin Pho: And it’s unlikely that a lot of listeners have listened back to our first episode from about a year and a half ago. So just briefly introduce yourselves and share your journey to where you are today. So Manny, why don’t you go first?

Emmanuel K. Konstantakos: Sure. Well, thank you very much, Kevin. Yes, my name is Manny Konstantakos. I am a board-certified orthopedic surgeon. I went to both college and medical school at Case Western Reserve University. I did my orthopedics residency at Wright State, and I did a fellowship in sports medicine at the University of Chicago. I really enjoy practicing orthopedics. It’s a great field, and I’m very glad to be doing that.

Kevin Pho: Perfect. Manny, just take us through a typical day, the typical cases that you would see on a routine basis.

Emmanuel K. Konstantakos: My practice is mainly focused on sports medicine. I do take general orthopedics call, and a lot of it happens to be not just with athletes, even though my fellowship was centered on athletes. A lot of it is weekend warriors, or just people who are reaching behind the seat in a car, and then bam, they get some subacromial bursitis. With the day-to-day things, I think society thinks, “Oh, you’re dealing with the NFL, college athletes.” Very, very rarely do I even see that. Mainly it’s regular people who are putting in hard hours at work, whether it’s a sit-down job or people who do manual labor.

And my focus in all patient care is always to do what I can non-operatively first. I truly believe that the body has the ability to heal itself, just like the Greek philosopher Socrates said: “A healthy mind and a healthy body.” And we can’t really separate the mind, body, and spirit. So once that’s fully appreciated, then if surgery is done, that surgery is a last resort, except in cases of trauma surgery, like a car accident or something like that. So that’s really my approach, that the body can really heal itself, and that’s my main focus.

Kevin Pho: Sure. So I’m an internal medicine primary care doctor. So tell my audience one tip that would prevent me from sending patients to doctors like yourself.

Emmanuel K. Konstantakos: Well, some tips. First of all, it starts with a healthy attitude and healthy nutrition. So I think getting up in the morning and just drinking a glass of water really helps get the body going. Putting in a good amount of sleep at night, and having a good mattress, for example. Sometimes we sleep wrong and just put that pressure on the shoulder. Use one or two pillows, especially if you have bigger shoulders. You want to be at that sort of good angle, so you’re not doing this and causing pressure on your shoulder. Also, just try to keep your hands in front of your body. Sometimes when our hands, or especially our elbows, go out this way, we do cause impingement, and that’s more prevalent once we get to the age of 30. We start seeing more impingement then, and that’s also very prevalent.

Kevin Pho: All right. Jeff, you’re the CEO of the American Board of Physician Specialties. Tell us about your journey to where you are today.

Jeff Morris: Yeah, prior to law school, I ran campaigns for a living and was in the political world, and during law school, I met a couple of lobbyists and realized, wow, it kind of gives me the best of both worlds. I was looking for a governmental affairs job, and fortunately, being in Tampa, I came across a posting for the American Board of Physician Specialties. Over 12 years ago, I started as someone in their government affairs department. I have been with the organization for the last 12 years and have worked my way up, and now I’m CEO. I’ve been CEO for the last three years and was executive director for the three years prior to that.

Kevin Pho: All right. So you made that transition from the political world to the health care world, and you’ve been in the health care world for a while now. So what’s something about health care that you’ve learned that surprised you?

Jeff Morris: When I first started, I realized that there’s more politics in health care than there was in politics, which has been shocking to me. It’s kind of part of the reason why I like working at the organization I work at, because it’s great helping to be a voice for the little guy, helping to be a voice for physicians who are being discriminated against because of that political machine, which I always thought was in politics, not in medicine. But there’s politics everywhere.

Kevin Pho: All right. So we’re going to talk about Manny’s KevinMD article, “Stop the ABMS monopoly.” The ABMS is the American Board of Medical Specialties. So Manny, you wrote this article back in March of ’22. How did this article come together?

Emmanuel K. Konstantakos: Well, Kevin, how it came together was that during the most critical time in our country, with the COVID crisis, some of the hardest-hit ERs, specifically those in New York City and Detroit, and of course some other big cities, didn’t allow board-certified emergency medicine doctors to even step foot in those ERs because they’re board-certified by the ABPS, the American Board of Physician Specialties, and not the ABMS. You know, Kevin, what’s even crazier is that these hard-hit cities allowed third-year medical students, OK, and were even calling on retired physicians, who knows how long it’s been since they’ve seen a patient, to help them out instead of ABPS board-certified EM doctors, OK?

So when I heard about this, not just as an orthopedic surgeon, getting this word from another field of medicine, it was like, OK, something needs to be done about this. That’s really when I wrote the article. But I think it would be best for Jeff to explain the entire issue. Jeff, didn’t you testify before the New York State Legislature recently about this?

Jeff Morris: Yeah, I did. It was shocking when it first happened. Then, after COVID, the New York State Legislature had a combined session to hold a hearing to find out what lessons were learned from COVID, so they don’t happen again. And they saw what was going on in some of these hospital systems when they were begging for help, when they had the morgue trucks out there on the street, and people were trying to volunteer, but because they weren’t ABMS or ABEM docs, they weren’t viewed as good enough.

But some of these were leading physicians. Some of these physicians have been practicing for over 15 to 20 years. These physicians have been medical directors in some ERs. But they’re being told no, not because of how well they can practice, not because of anything about their education; it’s just because they chose to be board-certified by one organization over the other. And it was disconcerting to me because it was, as I said earlier, the politics of medicine. This wasn’t about politics. This wasn’t about anything. This was about patient care. This was about really treating those who needed to be treated and putting all your resources out there. And we were seeing this in some of the most affected areas, where they were allowing the politics of medicine and allowing the push for a monopoly to overpower patient care.

Kevin Pho: So Jeff, tell us more details. How did you hear about these cases? Did some of your members come to you and say, “We can’t practice because we’re not ABMS-certified”? So go into more detail. I’ll keep it anonymous, of course. Tell us some specific case studies to give us an idea of what you were hearing.

Jeff Morris: Yeah, first and foremost, we were hearing from our own diplomate doctors. We get this all the time, when people reach out to us when they’re applying to jobs. They’ll say, “Look, I’m applying for a job. I got all the way through the credentialing process. They like me. But then they found out I’m ABPS instead of ABMS, and they’re telling me that they only want an ABMS physician.” And then usually it’s an educational period, and it’s showing them how you can credential. This is a recognized choice and certification.

But during COVID, it was a little different. We had people who were volunteering. This is what’s amazing in this world: When bad things happen in bad places, people step up, and physicians and first responders are the heroes out there as well. They stood up, and they wanted to go into these areas to help these individuals, and they were being denied solely because this was a position where they wanted an ABMS-only physician. And then I started looking at the job boards, and we noticed recruiting listings in Detroit that were doing the same thing. And then the recruiter even called us and said, “Well, it’s not me, it’s my employer.” That was after an article was written on it by an investigative journalist. And we said, “Look, I know it’s your listing, and it’s your client, but it’s still a listing that is openly discriminating when you are needing physicians in an area.”

And this was something that was important to us to get out there, because it’s wrong. It’s not saying anything other than that it’s wrong. When you are in times of need, and, like Dr. Konstantakos said, you’re reaching out to residents to come get a license early, and you’ve got people who have been retired and you’re begging them to come back, when you have an actively licensed physician in the state of New York who is well qualified, who is an emergency physician, and who is being told no just because of his certification, it was wrong.

Kevin Pho: So Manny, as an orthopedic surgeon, you have different paths to certification. Tell me the questions that you asked yourself as you were going through that decision process. Why did you choose one route over the other?

Emmanuel K. Konstantakos: Well, Kevin, the reason I chose ABPS is because I wanted a choice in board certification. In residency, we’re only told about one board. Let me ask you, Kevin, did you hear of any other board in residency other than the ABMS?

Kevin Pho: Well, residency for me was 20, 25 years ago, but you know, it’s tough for me to recall.

Emmanuel K. Konstantakos: But the whole point is, chances are you didn’t. And the reason is because residency programs work hand in hand with the ACGME. The ACGME is the Accreditation Council for Graduate Medical Education. The ABMS co-founded them, OK? And therefore, their residency programs in all fields, not just surgical like mine, from medicine to all fields, don’t allow their residents to take a board other than the ABMS. They don’t even allow them to tell residents about other boards, such as the American Board of Physician Specialties. And let’s face it, these residents are always pushed, in fact required, all residents in America, to take the ABMS boards. And therefore, a monopoly is created.

And let’s face it, Kevin, when are monopolies ever good? Except for the guys who are in charge of the monopoly, I suppose. But you’ve got to have competition, OK? Especially with different board-certifying bodies. Because even taking health care aside, just for business purposes, for example, in business in America, competition improves innovation and decreases costs, OK? Monopolies do the exact opposite. A monopoly has been created by the American Board of Medical Specialties. So we need to tell our residents about having a choice. And that’s the reason why I went with the American Board of Physician Specialties. I wanted a choice in board certification. I’m very glad that I went with ABPS.

Kevin Pho: So Manny, when you were making that choice, when you were a resident or fellow, when you were still in training, why didn’t you go along with the crowd? Why didn’t you just say, “Everyone else is doing it; I’m getting board-certified like everyone else, using one group”? Why did you seek out an alternative choice?

Emmanuel K. Konstantakos: Well, thank you for asking me that, Kevin. In addition to spending all the hours in surgery, and learning and perfecting my technique, I would also be listening to other doctors complaining about the MOC, which is a direct result of the ABMS monopoly. MOC is maintenance of certification. These great attending physicians, 10-15 years in practice, were scared to death, because if they didn’t do the MOC, they were at risk of losing their certification.

I have an older brother who is a cardiothoracic surgeon, and he has to maintain his general surgery boards. OK, he hasn’t practiced general surgery in who knows how long, at his age, but anyway, he has to maintain his general surgery boards just to be a cardiothoracic surgeon. Kevin, he hasn’t practiced general surgery in decades. So it’s this monopoly that’s being created, and I said, “Look, I’m not going to be part of this run-of-the-mill type of thing,” where it just leads to misery that ultimately leads to bad patient care, because you’ll be so miserable and so focused on doing what the crowd is doing, maintaining this certification in a field you’re not even practicing anymore, like the example I just mentioned.

So to me, it’s all about patient care, and we have to ask ourselves: Why do we become physicians in the first place? For me, it was always putting patients first, above all else. Patients always come first, and that’s what the ABPS focuses on.

Kevin Pho: Now Manny, among your orthopedic surgery colleagues, in general, what proportion of them are certified by the American Board of Physician Specialties versus the ABMS pathway?

Emmanuel K. Konstantakos: Yeah, you know, Kevin, I don’t know the exact numbers for that. Probably Jeff might be able to provide you with those numbers. All I know is that I’m very, very happy, because ABPS is an all-volunteer, physician-based organization. We’re allowed to have a voice. None of our members are paid at all.

[Remark removed by the editor.] Conversely, let’s talk about the member boards of the ABPS, for example, the American Board of Integrative Medicine. Kevin, do you know how much the president of that board of the ABPS made that year?

Kevin Pho: Nope, go ahead.

Emmanuel K. Konstantakos: Zero. Zero dollars and zero cents, OK? So you tell me, for a not-for-profit entity, and you can figure that out: Who’s supposedly a not-for-profit, and who really is putting patient care first, above all else?

Kevin Pho: For those physicians in training who are considering these different pathways to board certification, contrast those two pathways for me: the ABMS, the traditional pathway, versus the American Board of Physician Specialties. Can you contrast those rules for those who are listening to this and are first hearing about this other pathway?

Jeff Morris: The pathways are pretty much very similar. At the end of the day, we’re a competitive, recognized choice. I know some people like to say an alternative choice or an alternative option. For us, it’s a competitive option. We do have some competitive boards, like orthopedic surgery, like radiology, and dermatology, and internal medicine, which has been growing ever since, as Dr. Konstantakos talked about, the MOC, as well as when the ABIM decided to say, “If you haven’t gotten board-certified within seven years of completing your residency, then you’re no longer eligible.” For us, internal medicine physicians are still eligible, and they have come to us to get certified. We look at this as recognizing you, your training, and demonstrating your knowledge.

I actually had a physician tell me, who has been practicing internal medicine for, I think, 15 years or more, that he didn’t have the need or the requirement to get certified, and then his hospital was updating, and they said, “Well, you have to get certified now; you’re the medical director.” He went to get certified, and the ABIM told him, well, maybe he should think about going back and doing a residency again, because that’s the only way he could be eligible to take the test. For me, again, talking about patient care and what’s best for that hospital, is it best for that person to quit their job to go back and do a residency, most likely an international residency, because he or she has been out for this long?

So that’s where we have the competitive options. What also makes us unique is that we have innovative options. It’s what happens when you have a monopoly and you only have ABMS: ABMS defines what is a specialty and what is not. We, as a competitive option, have developed some boards that they haven’t. We have the first disaster medicine certification, which I say should be every physician’s true second specialty. We also have what Dr. Konstantakos talked about earlier, the first integrative medicine board certification. What I always say is nice about this is that it really combines Eastern and Western medicine, and this is for those physicians who have completed an academic fellowship in integrative medicine. We only allow fellowships that have been recognized by the Academic Consortium for Integrative Medicine. These fellows are then able to demonstrate their knowledge and competency in integrative medicine, just like you did in internal medicine.

Integrative medicine is a new field; it’s a new specialty. Most recently, we were able to get a taxonomy code from the National Uniform Claim Committee, as a sponsor for integrative medicine, because it is a defining and newly developing specialty. We’re seeing hospitals develop departments. We’re seeing the Department of Veterans Affairs really getting into this because of the opioid crisis and things. So by having a choice and by having another organization, you’re able to have more than one option for certification, but you’re also able to have innovative options. If one board didn’t view this as money-making, or as one section of this, maybe this other board did, because they see the good in the specialty as well. And that creates options, and that’s all we’ve ever wanted.

We’re not trying to replace the ABMS. We’re not trying to be the only certifying body. What we’re trying to be is a competitive option, so physicians have a choice. And with that choice, it’ll make them look at the standards. It’ll make them look at the requirements. It’ll make them look at the cost. You’re internal medicine. Look at where the MOC started, I want to say almost four or five years ago, with the big anti-MOC movement from the internal medicine doctors. Look at what that push started to cause: a little change. Can you imagine if you had a Pepsi versus Coca-Cola, or a Ford and a Chevy, that gave true options in internal medicine, that were tied to ACGME residencies, that were tied to large hospital systems that the ABMS wasn’t able to just push their monopoly into and be the only option?

Kevin Pho: So for internal medicine recertification, I certainly know what I have to do from a maintenance of certification standpoint. So from an ABPS standpoint in internal medicine, what are the recertification pathway options?

Jeff Morris: Right now, we still have a recertification exam. We understand that the idea of longitudinal assessments and continuing certification is the future, and we’re looking at those options. But for us, as a physician-led and physician-run volunteer organization, we want to ensure that whatever we do is right for the physician. I always say the MOC was pushed out too quickly, especially in internal medicine, with the fallout they received.

So we have a specialty-specific CME requirement: You have to do so many CMEs and some self-assessment per year, and at the end of your eight-year period, you give your CMEs. You need to take 8 hours’ worth of ethics training, because to me, that’s also very important, and we’re the only certification that requires that. I’ve been to enough medical board hearings, as the lobbyist and the external affairs guy for the organization, to realize physicians aren’t getting in trouble because they’re bad doctors. They’re getting in trouble because they’re bad, unethical doctors. So having an 8-hour ethics training was important for us. And then we have a 100- to 150-question recertification exam that tests your clinical knowledge. So that’s the demonstration component.

We are looking at options for continuing certification, but it’s not going to be just CME. There has to be some demonstration component to it. So there may be some self-assessment tied to the CME, some form of this, but it’s not going to be an overly burdensome, very cost-heavy, module-based system. You’re internal medicine; you’ve seen the hand-washing module. So for us, we want to make sure we get it right. And until we have it right, we’re going to continue with the processes that we have, because it is a valid, recognized system. The exams are psychometrically sound, and it meets all the standards for certification and testing.

Kevin Pho: All right. Take-home messages. Manny, why don’t we start with you?

Emmanuel K. Konstantakos: Yeah. So Kevin, as we know, one of the most fundamental concepts of life, especially here in America, is freedom of choice, OK? And physicians have a choice for board certification. Residents have a choice for board certification, and residency programs need to inform the residents of these choices, specifically of the ABPS, so that residents can really decide for themselves. OK, so residency programs really need to inform the residents of the ABPS.

Kevin Pho: And Jeff, we’ll end with you. What are some of your take-home messages for the audience?

Jeff Morris: Just to echo what Dr. Konstantakos has talked about, there is a recognized choice. There’s a competitive option. Physicians need to know that. Hospitals need to get updated with what the current standard of board certification is. I always say, just because ABMS is the largest one doesn’t mean they’re the only one, and just because they’re the most popular brand doesn’t mean that’s what defines board certification. Make sure your bylaws are current if you’re a hospital.

And if you’re a physician, understand that you have a competitive choice. Even if you’re currently certified by ABMS, but you’re angry with the situation and you don’t feel like being a number, we will actually recertify ABMS physicians in the specialties we currently certify in. They have to go through the recertification process, so they can have a choice. They can have a say in their certification. They can participate in an organization and be part of it, and not just a number.

Kevin Pho: Manny and Jeff, thank you so much for sharing your time and insight. Thanks again for being on the show.

Emmanuel K. Konstantakos: Thank you.

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