You have options when it comes to board certification [PODCAST]

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“Remember, board certification is supposed to be an option and not a requirement. Unfortunately, finding and keeping your dream job if you’re not board certified will add unwanted stress for you and your family.

And in case you’re wondering, I don’t work for or have anything to gain from informing you about any other board. I want you to know that you have other valid options for taking your boards, regardless of what you’re made to believe during residency.

So at this point, you may be asking yourself, why hasn’t an article like this ever been written before?

Well, the answer is quite simple: It’s called monopoly.”

Emmanuel K. Konstantakos is an orthopedic surgeon. Jeff Morris is chief executive officer, American Board of Physician Specialties.

They share their stories and discuss the KevinMD article, “You have options when it comes to board certification.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Manny Konstantakos, and we have Jeff Morris. Manny is an orthopedic surgeon. Jeff is chief executive officer of the American Board of Physician Specialties. Manny wrote the KevinMD article “You have options when it comes to board certification.” Manny and Jeff, welcome to the show.

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

Jeff Morris: Thank you very much for having us.

Kevin Pho: So, Manny, we’ll get into your article in a little bit. We’re going to ask each of you to share your story and journey to where you are today. Manny, why don’t you go first?

Emmanuel K. Konstantakos: Well, thank you very much, Kevin. Yes, my name is Manny Konstantakos. I’m 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. Orthopedic surgery was always a great fit for me. I was always an athlete as a kid, even all the way up to college, so it was a great fit. I love practicing orthopedic surgery. It’s a great field.

Kevin Pho: So, Manny, tell me, what would you say are some of the biggest challenges facing the field today?

Emmanuel K. Konstantakos: I think pretty much, and it’s what I’ll be talking about in the article, I think there has been a monopoly created by the American Board of Medical Specialties, not just with the MOC but with what they’ve created. And I think that adds to basically the whole burden of physicians. And remember, in the end, it’s all about patient care, and we have to ask ourselves, why do we become doctors in the first place?

Kevin Pho: And we’ll get into your article a little bit, but first off, Jeff, would you share your story and journey to where you are today?

Jeff Morris: I’ve been with the American Board of Physician Specialties for a little over 10, 11 years now. I came in right after law school. I was doing a lot of lobbying work and came in to run their government affairs and a lot of their external affairs efforts. After being there for a while, and the current CEO at the time retiring, the board of directors brought me on to be the CEO for the last, about, five years.

Kevin Pho: So how did you get interested in this whole field of board certification?

Jeff Morris: I’m kind of glad I did. Like most people out there, we really didn’t. Not many people know of the difference of what this is. And as the non-physician lawyer of the group, we have our own beliefs of what certification was, when things are run differently. I was fortunate. When I was looking for government affairs jobs, living here in Tampa, having a family, having children, and not wanting to move to either Tallahassee or D.C. or other places, this opportunity came about, and it’s really been an eye-opening one to see.

It’s funny, because in politics, I’ve always laughed and told physicians the politics of medicine, I think, is worse than politics. I used to run campaigns for a living and do a lot of things before law school, and I really noticed how the 1 percent, I would say the 1 percent of medicine, is making the decision for 99 percent of medicine. And board certification is really that main part of where you’re seeing a lot of the politics making decisions that are affecting patient care and affecting areas that might not be part of that top percent.

Kevin Pho: All right, and we’re going to talk more about those issues. Manny, you wrote this KevinMD article titled “You have options when it comes to board certification.” So for those who didn’t get a chance to read that article, Manny, can you just walk my audience through it and share the story of why you decided to write it?

Emmanuel K. Konstantakos: Absolutely, Kevin. Absolutely. So before I get into the specifics of the article, I think people need to know about exactly how board certification came to be. Back in the 1930s, a group of academic physicians got together and created a board known today as the American Board of Medical Specialties, the ABMS. It was really a way for these academic physicians to demonstrate their mastery of the specialty in which they were practicing, basically. So that’s really how it was created. It was really done in academia for academic purposes.

A few years later, the American Osteopathic Association, the AOA, went ahead and did the same to certify their osteopathic residents. But in the 1950s, several osteopathic surgeons who did their residencies in allopathic MD programs tried getting board-certified by their own AOA, their own, since they were DOs. And the AOA told them, “Well, guys, even though you’re osteopaths, you did your residencies in allopathic MD programs. You should go ahead and talk to the ABMS, because we’re not going to board-certify you.” So these guys said, “OK,” and they went over to the ABMS. The ABMS looked at them, laughed, and said, “Really? You guys aren’t even real doctors. You’re just a bunch of DOs. Go take a hike.”

So these guys got together, these osteopathic surgeons got together, and created a nondiscriminatory, volunteer-based board that places patient safety first, above all else, and access to physician care at its forefront. And that board is known today as the American Board of Physician Specialties, the ABPS, and they were the first board to certify both MDs and DOs.

Kevin Pho: So, Manny, from an orthopedic surgery standpoint, how does board certification differ from the American Board of Physician Specialties?

Emmanuel K. Konstantakos: Through the ABMS, what’s happening is that the ABMS has basically created a board that essentially is a Goliath. Basically, the more I’ve been in practice, they’ve been in charge of just about everything. People always complain about the MOC, and the MOC this, and you will see that, well, the MOC isn’t the monopoly, but in and of itself, the MOC is a result, a direct result, of the ABMS monopoly. So the ABMS is the Goliath, and the ABPS is David.

Kevin Pho: I know certainly what to do from an internal medicine standpoint. So traditionally, what are the MOC requirements for orthopedic surgery, according to the ABMS?

Emmanuel K. Konstantakos: In general, those things, and probably Jeff could talk more about that than I could, but it’s one of those things that is a burden for physicians every year. Basically, the ABMS, the ABOS in this case, and that’s important to mention, because any board that starts with “the American Board of,” whether it’s orthopedic surgery, internal medicine, the American Board of Radiology, dermatology, except for the American Board of Physician Specialties, falls underneath the American Board of Medical Specialties. OK, so that’s important to know.

So the ABMS comes up with these new rules, or the ABOS, whichever one, and you must abide by them. You must do it, or else you’re not going to keep your board certification. And that’s, in a nutshell, what’s going on.

Kevin Pho: And Jeff, can you contrast the board certification requirements from the American Board of Physician Specialties to the ABOS and the ABMS?

Jeff Morris: Yeah, there’s really not much of a difference. We’re recognized competing boards. We always like to say we’re a choice in certification. The American Board of Medical Specialties has done really well at putting themselves out as the only option of certification. When you look at how you define board certification, instead of looking at what board certification is and what makes up a valid certifying body, they like to put “being board-certified by the American Board of Medical Specialties.”

So requirements-wise, everything is extremely similar. We have boards that directly compete, like orthopedic surgery, internal medicine, family medicine, dermatology, radiology, what ABMS has, and like other boards that are individual certifying bodies or other things. We always say having a choice in certification is a good thing because having competition creates innovation. We have innovative boards that ABMS doesn’t offer. We have the first and only board certification in disaster medicine, which we always say should be every physician’s second specialty. We have the first integrative medicine board certification, which is a specialty in its own, which is growing and really changing how physicians practice medicine.

All of these boards have strict requirements for eligibility. They have residency requirements, or residency with fellowship requirements. As secondary boards, not many offer residencies in the specialties themselves. So we have requirements that are equivalent to ABMS boards on the competing boards. All of our exams meet the psychometric standards for testing.

And that’s what I always like to try to explain and push to people: Just because you’re not the largest doesn’t mean you shouldn’t exist, and there needs to be a defined guideline or defined standards so other certifying bodies out there can demonstrate the knowledge and specialties. Because if it’s just ABMS as the monopoly, they’re the ones picking what is a specialty and what’s not, and that’s not fair to innovation in the practice of medicine.

Kevin Pho: So, Jeff, one of the questions I often get asked about competing boards is that some hospitals and insurance companies may not recognize these competing boards. So I was wondering if you could comment on that.

Jeff Morris: Yeah, we’ve got physicians practicing in all 50 states. We’ve got physicians listed on all insurance networks out there. Are there areas of, you want to call it, discrimination? Yes. I relate it to, if you look at where the DOs were in the early ’70s in defining physicians, and some practice groups or hospitals really didn’t want someone else if they were a DO. We’ve seen this in some areas, in hospitals. We’ve seen this in some areas, and I call it lazy credentialing. Instead of going to the primary source for verifying the certification, if it’s not in the drop-down box in their database, which is tied directly to an ABMS database, we’ll see that.

But we work really hard in educating individuals. We work really hard in showing people that board certification, just as an ABMS. And usually, once they see and learn and are educated, a lot of these things change, and it’s just updating a lot of older bylaws to ensure that all physicians are represented equally.

Kevin Pho: So, Jeff, I’m an internal medicine physician, and I’m fairly sure of what I need to do from an ABMS standpoint. So can you contrast the ABMS pathway for recertification with what the American Board of Physician Specialties offers?

Jeff Morris: Yeah, what’s unique and different is we believe in recertification. We believe that there needs to be some demonstration component for maintaining your medical knowledge. The MOC, is it the right answer? Probably not. I’ve heard people define it as a bridge too far. Or you’ve got other groups out there that go a bridge too short when defining lesser requirements, saying you only have to do CME. Well, we as a certifying body have to validate to the public that you’ve demonstrated the knowledge. If you’ve only taken CME courses and you’re not demonstrating that you learned anything or actually did, is that too short?

So we believe there is a change in, is standardized testing the answer? I’m not sure if it is or if it’s not. But right now, we have a CME requirement throughout your eight-year certification cycle, and then we still offer a recertification exam, because we believe in that. The modules and what they’re doing on an ongoing basis, is that a little too much? And being an internist yourself and looking at what’s going on in internal medicine, the physicians have spoken. It’s showing. We believe in, if this is true, show us the proof. Show us the validity to these statements. We are evolving our process and trying to find that answer, but until we find the best choice, we’re not going to change that choice.

What’s unique about us is we are a 100 percent physician volunteer-run organization. Our board members are not paid board members. Our item writers, our subject matter experts, are our physicians. Our exams are clinically based. Our oral exam, a lot of our physicians like it, because if you are a practicing physician and you have maintained your clinical knowledge, the recertification exam is one that they enjoy for demonstrating their knowledge, where it’s not overly burdensome, having to memorize archaic things from a review course.

Kevin Pho: We’re talking to Manny Konstantakos and Jeff Morris. Manny’s an orthopedic surgeon. Jeff is chief executive officer of the American Board of Physician Specialties. Manny wrote the KevinMD article “You have options when it comes to board certification.” So, Manny, if you’re a newly graduated physician or a fellow and you’re due to take a board certification exam, how can you push back against what most people are doing?

Emmanuel K. Konstantakos: Well, Kevin, this was actually the biggest surprise, and that’s really the point of my article: When people don’t know, you don’t know. OK? I mean, let me ask you, Kevin, did you hear of any other board when you were an internal medicine resident, other than the ABMS?

Kevin Pho: No.

Emmanuel K. Konstantakos: And so the reason is, and this is actually something I found out after I wrote my article on your KevinMD website, afterwards I found out the biggest surprise, here we go, is that the ABMS co-founded the ACGME, OK, which is the Accreditation Council for Graduate Medical Education. They’re the board that oversees all the residency programs in America. The ABMS co-founded them. OK? I mean, if that doesn’t spell collusion, or at least conflict of interest, I really don’t know what does. The residents are told, just funneled right into an ABMS exam, the split second they graduate. So of course the ABMS is going to be huge. OK? I mean, how can they not be, in terms of numbers? So the ABMS has created a feeder program directly from residents, and this goes right into it.

And here’s everything. Surprisingly, the ACGME even created a program called the CLER program, C-L-E-R, that outlines the pathway to becoming a residency program director in all fields, not just surgical like mine. In all fields, any residency program director must first be certified by the ABMS in order to become a residency program director. The ABMS has to give their nod of approval. OK? That was my biggest surprise in finding out all this, that their control is through the fear of our residents. OK? I mean, that is how deep their control goes. And I find that a huge issue, because you can’t blame the residents. They’re just being told what to do. And like you said, Kevin, did you hear of any other board when you were a resident in internal medicine?

Jeff Morris: Just to add on a little bit to it, and to open it up some more, it’s what I talked about earlier, the politics of medicine, where you have the top 5 to 1 percent make the decision. It’s a big word, collusion, but if you look at where they are working together, the ACGME made a deal with the AOA to become the single accrediting body for residency accreditation. That’s at least got a lot of government funding behind it, so you could say there’s a little bit of oversight, where the ACGME can’t run rampant on requirements and costs and make more money by being the only option. But what most people don’t look at is they’re also working with the ABMS to become the single, I want to call it, accrediting body for board certification.

And in doing that, what most people don’t realize is, and Manny put a little bit of it together, in a lot of their CLER program, and you want to call it their MOC for residencies, for maintaining your accreditation, they have milestones. And in those milestones, for a residency program to maintain their ACGME accreditation, it’s also based on your first-time passage rate of your ABMS boards only. So no residency out there is going to tell their best and their brightest, “Do you know there’s competition, or there’s choices in certification?” because that’s going to mess with their maintaining their accreditation. They have requirements in place that the only people that can teach the residents should be ABMS doctors, or else, if you have other people, you can lose your accreditation that way.

Those are things that in legal worlds we like to call regulatory capture. They’re creating ways of creating rules that stifle competition, that stifle choices. And if ABMS and board certification were part of some overseeing, regulating body that had rules and requirements and had things in place, that would be fine. But without competition, you then get a single entity that basically says, “If you don’t pay the money that I charge you, and you don’t do the requirements that I tell you to do, well, then don’t be certified. We’re not forcing you to do that.” And it’s kind of why they keep winning a lot of these lawsuits, because they’re not forced to do this. But we all know in the world of medicine today, physicians can’t practice without their board certification, can’t take those next steps.

And we’re not here trying to say we want to be the only one. We just want choices, and we want competition, because that’s what’s best for the physicians, that’s what’s best for patient care, that’s what’s best for those urban and rural areas that a lot of ABMS doctors don’t want to go out to. The large academic centers and these ACGME towers aren’t thinking about people in small towns, people in urban areas. And by creating choices and competition in certification, you’re not only helping regulate the requirements for physicians, you’re not only controlling the cost of certification for physicians, but you’re also giving people in other areas the ability to be seen by board-certified doctors, and physicians maintaining their knowledge and demonstrating their mastery in the specialty we’re practicing. We don’t see that as a bad thing. We see that as a good thing.

Kevin Pho: Ask each of you your take-home messages to the KevinMD audience. Manny, we’ll start with you.

Emmanuel K. Konstantakos: One of the most fundamental concepts of life, especially here in America, is freedom of choice. OK? And think: We have choices, the ABMS, the Goliath, or the ABPS, David. OK? And residents have this choice for their initial exams, and that’s just important. This starts in residency, and that’s the take-home message here.

So to the viewers out there, look, don’t just take our word for this. Feel free to look all this up yourselves. Verify all this. Do your due diligence. OK? Because especially now, it’s July, and people are going from fellowship to their practice, or starting their residencies, finishing up their residencies, whatever. The young guys may not think this topic’s that big of a deal, but when they go out and practice in the real world, they’re going to find out this becomes a very big deal, this topic. OK? It’s going to affect their careers, their livelihood, their families, everything. So whatever they do, just don’t let this topic drop.

Kevin Pho: And Jeff, how can people reach you guys?

Jeff Morris: Yeah, hi. The best place is to go to our website, the American, it’s abpsus.org. You can just Google the American Board of Physician Specialties. There’s a lot of information on all of our boards on there. You’ll also see the application for people looking.

And just to follow up real quick, like Manny said, the main purpose for us is we’re here to make sure physicians know that they have a choice, that there are options in certification for residents. We also have options for physicians that have lost that eligibility status because the American Board of Internal Medicine closed that window for those physicians. We’ve actually had physicians call us that have been practicing for 15 years but opted not to get certified, and now they’re being forced to get certified, and ABIM is telling them that they have to go international to go find and take another residency because they’re no longer eligible for that exam. Come to ABPS. We recognize your training. We recognize your eligibility and want you to demonstrate your knowledge, because you deserve that right.

And we also offer that pathway through recertification for any current ABMS-certified physician. So if you’re ABIM-boarded, if you are American Board of Orthopaedic Surgery-boarded, or any other ABMS board, and you’re upset with the process that you’re going through right now, we offer a pathway that you can go through, a recertification pathway, and give you that option to actually become certified by us through recertification and not have to go through the initial application and initial certification process.

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

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