By ROBERT WACHTER, MD
What’s up with the ABIM?” “I just got a note about an alternative board. Should I join it?” “Aren’t you glad to be off the Board?”
These days, I get these questions from friends and colleagues regularly. When I first joined the board of directors of the American Board of Internal Medicine (ABIM) in 2004, the organization was a well-respected pillar of American medicine. Today the organization finds itself in a fight for its life, being painted as everything from out of touch to money-hungry to, more recently, corrupt.
I just completed my decade-long service to the ABIM and, more recently, the ABIM Foundation. I’ve waited until now to write this because I wanted to be clear that I am not speaking for ABIM or its leadership. I am also well aware that there is a vocal group of critics who feel passionately about this matter, whose minds are made up, and who are approaching this fight with a take-no-prisoners zeal. By adding my voice, I am likely to become a target for their anger.
So be it. With the help of social media and a journalist who has turned this matter into a cause célèbre with an unfortunate mixture of half-truths and innuendo, the critics have managed to control the debate, and people who believe in the values of the Board have been cowed into silence. It feels vaguely McCarthyish, and there comes a time when silence is immoral. This feels like such a time.
This is not to say that the Board has made perfect choices – it hasn’t, and ABIM’s CEO, Dr. Rich Baron, courageously admitted as much in a February statement of apology, in which he announced the suspension of certain parts of the program. But these were mistakes born of trying to do good but challenging work for the right reason: to ensure to our patients that their physicians are competent. Painting the organization – and particularly Rich, one of the finest people I know – as corrupt and nefarious is wrong.
Here’s what’s at stake: we physicians are granted an extraordinary amount of autonomy by the public and the government. We ask people to disrobe in our presence; we prescribe medications that can kill; we perform procedures that would be labeled as assault if done by the non-credentialed. If we prove ourselves incapable of self-governance, we are violating this trust, and society will – and should – step into the breach with standards and regulations that will be more onerous, more politically driven, and less informed by science. That is the road we may be headed down. It is why this fight matters.
Let’s start with a little history on how we got to where we are today, and then I’ll turn to and address the criticisms of the Board.
A Brief History of Board Certification and MOC
As Rich Baron recently described in JAMA, the board movement launched around the time of the Civil War, when the AMA began grappling with the question of how to determine whether a doctor was competent to call him or herself a specialist in a given field. After some fits and starts, the specialty boards were established in the 1920s and 30s to address this question. Importantly and, to my mind, correctly, the boards were created as independent entities – arms of neither the specialty societies (i.e., the ABIM is a completely different organization than the American College of Physicians or the subspecialty societies in fields like cardiology and oncology) nor the government. Why was this the right choice? Because credentialing organizations inevitably have to make tough decisions, including setting high standards, and thus need to be insulated from the politics of government or the advocacy of dues-funded membership organizations.
The ABIM was established in 1936, and things were fairly calm for the organization’s first 60 years. When I took the ABIM certifying exam after finishing my internal medicine training in 1986, I was 29 years old. The Board issued me a lifetime certificate, basically deeming me a competent internist until I retired. My expectation – correct at the time – was that receiving my certificate of passing was the last interaction I’d ever have with the ABIM.
Around 1990, the idea of lifetime certification had become increasingly troubling to patients, payers, and even some physicians. In retrospect, of course, it is indefensible. So the Board launched a program now known as Maintenance of Certification, thus planting the seeds of the current controversy.
MOC created a lifetime relationship between the boards (ABIM and all the other specialty boards, such as surgery, family medicine, and pediatrics; together, all the boards operate under an umbrella organization called the American Board of Medical Specialties, ABMS) and their diplomates. But this was a troubled marriage from the start. Physicians were now faced with taking a test every 10 years or so to prove their ongoing competence. Many didn’t like it one bit.
Moreover, the launch of MOC coincided with the growing recognition that the competent physician possesses an array of skills – patient communication, quality improvement, teamwork, patient safety, and more – that extend far beyond raw medical knowledge. This recognition challenged the boards with the task of figuring out how to assess these “softer” skills.
Finally, the boards realized that an assessment of a physician’s competence should not just include how she did on a test, but how she was performing in day-to-day practice. Thus came the push for MOC to include some demonstration of the skills of self-assessment and “practice-based learning.” This, too, was new territory for the boards… and everyone else.
Even if all the Board did was administer its “secure exam” to assess knowledge and clinical decision-making, that would be hard enough. ABIM employs a team of psychometricians to ensure the validity of its questions, and its test writing committees include well-respected members of each specialty, who craft questions designed to fairly test core knowledge in each specialty. Questions are thoroughly vetted to ensure validity; poorly performing questions (for example, questions that folks who did well on the overall examination had trouble with) are reviewed and often discarded, as are dated questions. It is an exacting, labor-intensive process, and experts in the testing field consider the board’s approach to be state of the art.
While testing core knowledge is hard, it pales next to the challenges of assessing the “softer” competencies. How to assess communication skills other than asking patients themselves? Quality improvement skills – how else but ask physicians to submit data on, let’s say, their diabetics or asthmatics, along with a plan for self-review and improvement? While these are reasonable approaches, asking busy physicians to provide such data created more unhappiness, as many found the process onerous and not particularly meaningful, particularly in light of all of the other entities asking for similar data.
The launch of MOC in the 1990s generated substantial controversy, but things eventually settled down. Many practicing physicians didn’t love MOC (and many objected, quite reasonably, to the fact that older doctors had been grandfathered out of the requirement because the Board chose to honor their “lifetime” certifications), but surveys of diplomates completing MOC generally showed that most found the process to be fair and even useful.
Although I was “a grandfather” myself, when I joined the Board I was required to complete MOC (all Board members must do this, grandfathered or not), and I did so about five years ago. I thought the test (I took the general internal medicine exam; this was before a hospitalist-specific test was available) was reasonable and that studying for it improved my skills. The self-education modules, mostly open-book tests, were also useful, even fun. On the other hand, the parts of the process that required that I measure my own practice were unwieldy, and the tools made available to support this work were relatively user-unfriendly. My colleagues and I on the Board pushed the staff to improve these tools, and over time they did, although they remained well behind the kinds of sophisticated web-based tools we’ve become accustomed to in our non-medical lives.
The Change to “Continuous” MOC
The heat increased a couple of years ago, driven by changes in the MOC process. Around 2012, the ABMS decided that MOC should become more “continuous.” This didn’t strike me as unreasonable, particularly since teachers, pilots, and others in high-stake professions need to demonstrate their ongoing competence every few years. The new MOC standards required that physicians accumulate some points (the completion of a self-improvement module, or a patient survey, or a review of their own practice data) every couple of years, although the high-stakes exam remained an every-10-year affair. Even more bothersome to some, while grandfathers’ lifetime certifications would not be challenged, grandfathers not participating in MOC would now be listed on the boards’ websites as “not meeting MOC requirements.”
While I can’t speak for the other ABMS boards, I participated in the ABIM discussions of these issues from the start, and they were thoughtful and nuanced. Because the boards have no way of funding themselves other than through fees to diplomates, there was a constant underlying tension about how to keep fees reasonable while building the infrastructure needed to support and improve the programs. We tried our best to develop standards and tools that were supported by science, would be acceptable to the physician community, and – most importantly – represented our best thinking on how to demonstrate that a physician was competent. We also worked with the professional societies to build modules for specialists in their fields, and many did so.
Any kind of certification or accreditation process will generate critics – witness the furor over testing in public schools to see another sphere in which this is playing out. For growing numbers of physicians, the new MOC requirements not only felt onerous, they felt like betrayal – since the requirements were being created by fellow physicians in their own field. “I can understand why [Medicare/Aetna/Epic… fill in the blank] is making my life miserable,” some doctors thought. “But the boards are made up of my own colleagues. How can they do this to me?”
The boards are voluntary organizations. Many physicians are licensed by their state but are not board certified – either because they trained outside of the U.S. (the pathway to certification for international graduates is challenging), because they chose to avoid the process, or because they failed it (about 5 percent of people ultimately are not able to pass the Boards, either in their initial certification process or in MOC, despite multiple attempts to do so). For these uncertified doctors, the “voluntary” nature of the process is little consolation, since many payers and hospitals now insist on board certification. Given the stakes, it’s not surprising that MOC has aroused so much passion.
The Battle Goes Public, and Gets Nasty
There is a well-known challenge in the world of certification known as the “race to the bottom”: unless everyone (payers, hospitals, etc.) insists on a rigorous certification process, easier processes are likely to emerge, which some individuals will find preferable. While there have always been non-ABMS boards that have tried to recruit physicians to their camps, the more rigorous ABMS pathway (including the ABIM’s) has been considered by most institutions to be the gold standard, and so upstart boards – usually promising certification to doctors who paid a fee, participated in continuing medical education (CME) programs, and had unblemished licenses – gained only limited traction. If hospitals, insurers, and other key players insisted that physicians go through the traditional (ABMS) board process, most physicians did so.
In 2012, when I began my one-year term as chair of the ABIM, I wrote a blog describing where the organization was going and what I hoped to achieve in my time as chair. I thought it was a relatively benign piece, one that highlighted the rationale for the changes to MOC and made clear that this would be a work-in-progress that we were committed to getting right. My usual blogs receive about 10 to 20 comments; this received well over 200. It was clear that there was a passionate group of individuals who were committed not just to slowing down or stopping the initiative to make MOC more continuous, but to eliminating the entire MOC requirement. Frankly, we were surprised by the anger, though perhaps we shouldn’t have been.
Part of what surprised us was the breadth of the anti-board movement. While some of the early critics came from a libertarian fringe, there were more mainstream arguments advanced by respected leaders in medicine. These included several editorials in the New England Journal of Medicine, including one by NEJM editor Jeff Drazen and another by my early mentor, Lee Goldman, now the dean of Columbia’s medical school. In a January 2015 NEJM piece cleverly titled “Boarded to Death,”a Scripps Clinic cardiologist named Paul Teirstein argued that the MOC process should be replaced. “We all support lifelong learning,” Teirstein wrote, “but an excellent alternative to MOC already exists: continuing medical education (CME).”
The anti-MOC troops gained followers in the social media world as well, and an on-line anti-MOC petition received more than 20,000 signatures. Physicians began pressing their specialty societies, including the ACP, to fight MOC, such as by threatening to withhold their dues; a few societies began to consider establishing their own certification processes. Teirstein and colleagues launched a new board, the National Board of Physicians and Surgeons (NBPAS), and sent letters to thousands of physicians asking them to pressure their hospitals to change the bylaws to accept NBPAS certification as meeting any board certification requirement.
From where I sit, all of this is uncomfortable, but natural and probably even healthy. The boards have occupied an enviable position as the unquestioned leader in physician accreditation for nearly 100 years. It would be surprising if they had not become a bit insular, or resistant to change. Some competitive pressure was probably necessary to ensure that the boards’ process delivers the most value to physicians, to patients, and to other stakeholders.
During my term as ABIM chair, my colleagues and I tried to be responsive to these pressures. In 2013, at the end of Dr. Chris Cassel’s 10-year tenure as CEO, we recruited a new leader, Rich Baron, an unusual choice in that he is not an academic with a book-length CV. Rather, Rich spent nearly three decades practicing general internal medicine and geriatrics in a small Philadelphia office, while also amassing a terrific track record as an organizational leader, both at the ABIM (he served as a Board member and ultimately rose to chair) and later at Medicare’s Innovation Center (CMMI).
We also launched an interdisciplinary task force, “Assessment 2020,” charged with taking a hard look at our testing processes and considering fundamental changes to it. Some of the questions we asked of the 2020 Task Force: Is an every-ten-year year test still a good idea? Should part of the test now be open book? Should we include simulation? The Task Force, working under the chairmanship of Yale’sHarlan Krumholz, has just presented its final report to the ABIM Board for its consideration. The recommendations are ambitious and potentially game changing.
Over the last couple of years, the Board also completed a full makeover of its governance structure, cutting the size of the Board of Directors from nearly 30 to about 12, to make it more nimble. It also broadened its representation, including adding non-physician public members for the first time. To complement the smaller Board, we created a new “ABIM Council” to oversee the Board’s products, including the examination, and to strengthen our connection to the specialty societies. Also over the past few years, the ABIM Foundation launched the Choosing Wisely program, one of the most influential campaigns in recent medical history. Choosing Wisely has been hailed both nationally and internationally as the most important effort to date in engaging physicians in thoughtful waste-reduction efforts.
While my colleagues and I took these criticisms seriously, I felt that as long as we admitted our missteps, weren’t resting on our laurels, and constantly tried to do the right thing, we would be okay. After all, even though it might be attractive to some physicians to water down board certification, it seemed inconceivable to me that our profession – or the public – would accept the argument that participation in CME should be enough to demonstrate lifelong competence. I like CME, I think good CME is valuable, I run a CME course that I’m very proud of – one in which people are engaged for three days learning, not on the beach or the golf course. But I would find it hard to keep a straight face while making the argument that such attendance alone is sufficient to demonstrate competence. I believed that the ABIM – by insisting on a more rigorous process – would always retain the moral high ground.
But I underestimated the opposition. There was a way for them to seize the moral high ground: by painting the Board as scandalously profligate and corrupt. And so that’s what they set out to do.
The Allegations Against the Board
Having sat through every meeting of the ABIM Board for nine years (and, more recently, those of the ABIM Foundation), I can tell you that the depiction of the Board as aloof, money grubbing, and corrupt is entirely off target. That certainly doesn’t mean that all our decisions were good ones, or were politically astute. But our motives were always to do the best we could to live up to the Board’s motto: to be “of the profession, for the public.”
Here is where the critics are mistaken, often taking matters out of context to bolster their points. Unfortunately, in the world of social media, these half-truths and distortions make for good sound bites, and the casual observer can be forgiven for believing them.
Let’s take a few of the more egregious allegations:
“The Board is All About the Money”
The ABIM is a not-for-profit entity, meaning there are no shareholders. But it does need a positive bottom line to stay in business and to do its work. As Board members, we constantly struggled with balancing our fiduciary responsibility to the organization (including to pay the salaries and the costs of doing the Board’s current work and innovating) with the burden to the diplomates. ABIM’s MOC process currently costs physicians about $200-$400 per year (the low end for the internal medicine certificate only; the higher range is for those maintaining multiple certificates, like IM/cardiology/interventional cardiology). These costs are consistent with the fees of other ABMS boards. The argument that this represents an impossible expense to the vast majority of practicing physicians is hogwash.
“The Board Established a Foundation to Serve as a Big Piggy Bank”
The ABIM accrued surpluses over the course of its nearly 100 years of existence. Between 1990 and 2008, the Board took the bulk of its reserves (about $55 million, when all the contributions are added up) and placed them in a Foundation, whose charge was to support the Board’s work and serve the broader medical community. This is a standard practice for most large societies and accrediting organizations. The accounting involved is completely legitimate and has been vetted by yearly audits conducted by national accounting firms.
As per usual accounting rules, the Foundation spins off about 5 percent of its corpus for yearly investments – currently this amounts to $3-4 million each year. Over the past decade, the Foundation has focused on professionalism as its main theme, and, beginning with its 2002 “Physician Charter,”has succeeded (well beyond my expectations) in putting this concept on the map.
More recently, the Foundation’s Choosing Wisely campaign has attracted worldwide attention, with more than 65 societies developing lists of activities in their fields that add no value. The impact of the Foundation’s work is enormous – many people have looked at Choosing Wisely as a model for the medical profession actually tackling the issue of costs in a positive way. Indeed, its recommendations have been implemented by several leading health systems, including Cedars-Sinai, the Fred Hutchinson Cancer Center, and Intermountain Healthcare. The campaign has also been adopted in a number of other countries. These days, nearly every discussion about improving value or reducing waste, whether it’s in the lay or professional media, references Choosing Wisely. For a small foundation, that’s one hell of a good investment – I’ve spoken to representations of foundations several times the size of the ABIMF who are using Choosing Wisely as a case study in leveraging a relatively small amount of money to great effect.
The Foundation also supports research that helps advance the ABIM’s mission – for example, on developing new simulator tools that can be used in physician assessment. It is free to provide money to ABIM for research and development, and it frequently does this, on top of its work promoting professionalism.
“The Salaries are Outrageous, and Then There’s The Condo”
Here, the allegations are flying fast and furious. The latest concerns CEO Richard Baron’s salary. Rich is one of the smartest and most committed people I’ve met in medicine. He is a person of unending integrity. The fact that the critics have now seen fit to take him on with caricatures and half-truths is cynical and sickening.
Part of the reason that Rich emerged as our preferred candidate was his real-world experience, which we felt was crucial as the Board worked to connect better to physicians engaged in the day-to-day practice of medicine. Rich’s current base pay of $579,000, with a bonus opportunity of another 20 percent, is significantly lower than that of his predecessor (Dr. Cassel’s salary was higher because she was recruited from a prior job as the dean of a major medical school and she served as ABIM CEO for a decade). The salary I offered Rich (as chair, I led the negotiations) was in the range recommended by consultants after a detailed analysis of salaries of other CEOs of healthcare nonprofits. It is a lot of money (and more than twice what Rich earned as a primary care physician), but he is paid to run a large, complex organization in a swirling political environment. In the grand scheme of things, taking into account what other healthcare executives earn, it seems fair to me.
If there is one money issue that has become a piñata, it has got to be “The Condo.” Like many large, complex organizations, the ABIM often has consultants coming into Philadelphia to help it with its work. When Chris Cassel was CEO, after analyzing the costs of putting these folks up in hotels, she decided to purchase a condo to serve the same function. This was designed to be revenue neutral, and it has been. But, of course, it creates a hanging curveball for those looking for profligacy. Do I wish we had never bought it? Of course; politically it was a dumb thing to do. Is it a scandal? No.
The Test
Critics have also taken on the test itself – everything from the testing procedure (which involves going to secure test centers and being fingerprinted) to the actual substance of the test. They have also looked at the pass rate and pointed to what appears to be an increasing rate of failures.
The secure testing center is necessary given that it is such a high-stakes exam: failure is meaningful, and, sadly, cheating has occurred on a number of occasions. The test itself is written by experts in the specialty, and reviewed in detail by psychometricians to determine that questions are valid and up to date. This is a rigorous, expensive, and time-consuming process.
Another point made by the critics is that the failure rate on some ABIM MOC exams has increased, further evidence (to them) that the Board is actually trying to fail hardworking doctors in order to make money. The cut score for passing is an absolute standard determined through a sophisticated process that follows best practices in the testing industry. Once a cut score is set, pass rates for first-time takers may vary from time to time, but approximately 95% percent of physicians ultimately pass ABIM’s MOC exams, though it sometimes takes a couple of tries. There is no predetermined passing rate, and if 100 percent of people did well enough, all of them would pass. Unfortunately, they do not. To my mind, requiring that physicians demonstrate that they are keeping up every ten years is a reasonable requirement, and the fact that some people fail the test is evidence that some people lack the knowledge in their specialty to be declared competent.
The Bottom Line
We physicians are granted enormous privileges by society, and with these privileges comes the expectation of self-governance. That expectation flows from the knowledge that only members of the profession can determine what it means to be a competent internist, or cardiologist, or rheumatologist.
The boards are the human and organizational expression of that expectation. The work we ask of them is difficult: to create standards that truly are meaningful for patients, defensible to other stakeholders, and acceptable to the profession. The boards are not government-funded or -managed entities, and thus they require the resources of the professionals who are being assessed to do their work.
Over the last decade or so, many have looked at medical care in the U.S. and deemed it wanting – with frequent mistakes, spotty quality, relatively low patient satisfaction, and high costs. While many of the reasons for this have little to do with physician competence, some of them do. Our society is asking us to raise our standards, so that patients and others can be confident that their doctor is competent at the completion of training, and remains so throughout his or her career. This is a reasonable expectation of us, and of our certifying bodies.
ABIM has tried to do this work with integrity and thoughtfulness. Without question, the organization did not get everything right. In retrospect, non-academic physicians should have had a greater voice on the Board, to help connect us better to the community. Our tools to measure the newer competencies such as patient experience, quality improvement, and safety should have been better vetted. Our website should have been more user-friendly. We should have spent more energy working with medical societies to ensure that they were on board – if not with the precise methods, at least with the goals and values that we were jointly trying to achieve.
Earlier this year, Rich Baron, speaking on behalf of the Board, issued a powerful letter, unambiguously apologizing for these missteps. It was a brave and bold thing to do. In his letter, he suspended some of the MOC requirements – particularly the ones that involved practice-based measurements – to allow time for a deep reassessment. He also committed the organization to a period of listening and to a new effort designed to co-create the MOC process with our community of physicians and other stakeholders.
Where are we now? While Baron’s apology was widely praised, the critics still seem to be controlling the terms of the debate. This is not too surprising – they are tapping into a deep well of physician anger and angst. Clearly some of this anger goes well beyond certification – to electronic health records, to quality measurement, to value-based purchasing, to the push toward large systems of care and away from small practices. All of these transitions are challenging, all have unanticipated consequences, and – for the doctor who prized his or her autonomy and was comfortable under the old model – all of them feel wrong.
Yet it would be too easy to say that the anger toward and controversy regarding the ABIM is limited to a group of grumpy, change-resistant doctors. The concerns that the boards have been too disconnected from the practicing physician community are real, and it will require strong action to remedy this. And the actual substance of MOC needs to be modernized and made less burdensome, while remaining appropriately rigorous. I am proud of Rich Baron and my successors on the ABIM Board for rethinking the work and being open to change… perhaps even radical change. The process has been painful, but the actions to date are steps in the right direction, and there is more to come.
But what if the changes aren’t enough to satisfy the critics? What if these alternative boards win the day, and hospitals and insurers choose to accept a watered-down board process – basically, CME – as “good enough”? This outcome – and with it, the demise of the board enterprise, or at least of MOC – is not impossible.
To an unhappy doctor, bringing down the ABIM may feel good, but what will fill the resulting vacuum? Can we really say that passing a test at age 29 is sufficient to demonstrate that a physician is competent for an entire lifetime of practice? Or that evidence that a doctor spent a few dozen hours at CME courses is enough to reassure patients and other stakeholders that a doctor is currently competent? Or that a process in which no physician is ever judged to be below standards is legitimate and defensible?
I believe that there will always be a need for a rigorous, scientifically valid process to judge that physicians are competent in their specialty, and that they remain so through their career. I further believe that this process must be crafted by members of the profession itself – and if we abrogate that responsibility, others will fill the void. The values of ABIM are strong, and the half-truths that are being used by critics and at least one journalist with an apparent conflict of interest to smear the organization must not win the day. The ABIM needs to evolve, and it is doing just that.
“Throw the bums out!” can feel like progress. But, as the Arab Spring protesters have learned, sometimes it’s relatively easy to tear down institutions. Rebuilding them is much harder.
Bob Wachter is a professor of medicine at the University of California San Francisco. He is the author of “The Digital Doctor: Hope, Hype and Harm at the Dawn of Medicine’s Digital Age.”