What is ABEM thinking?

Here’s my column in this month’s Emergency Medicine News.

http://journals.lww.com/em-news/Fulltext/2011/12000/Second_Opinion__What_is_ABEM_Thinking_.5.aspx

In 1994 I was thrilled to become certified by the American Board of Emergency Medicine. I had worked very hard. I studied and read, I practiced oral board scenarios and even took an oral board preparatory course. It was, I believed, the pinnacle of my medical education. Indeed, if you counted the ACT, the MCAT, the three part board exams along the way and the in-service exams, it was my ultimate test. The one that I had been striving for throughout my higher education experience.

I am now disappointed to find that my certification was inadequate. In fact, all of us who worked so hard for our ABEM certification find ourselves facing ever more stringent rules to maintain that status. And it isn’t only emergency medicine. All medical specialties are facing the same crunch. Our certifying bodies expect more…and more…and more.

And the attitude is all predicated on the subtle but obvious assumption that those of us in practice are not competent to maintain our own knowledge base. Despite spending decades in education that we are not to be trusted. That we are not interested in learning. That we do not attempt to learn and that our practices are not, in fact, the endless learning experiences they actually are. They assume we need more supervision, despite demonstrating (by our continued practice) that we are willing to do hard work, in hard settings, and do the right thing.

Unfortunately, the rank and file is very unhappy. There is remarkable discontent, and considerable anger, among the lesser physicians. That is, the test takers, the physicians in practice subject to the new rules, the ones who have to add one more rule, one more activity, one more form, one more check to their already busy lives.

That discontent, that anger, that frustration on the part of practicing physicians is, in my opinion, very rational. It’s a tough time in medicine. Our regulatory burden grows by leaps and bounds every year. We are watched and harassed, by CMS, by JCAHO, by our state medical boards, by our insurers, by our hospital staff offices and now, most painfully, by our own specialties.

Of course, all of it comes in the context of falling reimbursements, a federal government licking its lips for any spurious allegation of fraud and a system in which EMTALA forces physicians of all specialties to see patients for free, even as government insurance programs pay less than the over-head to see their patients (and fulfill the regulatory guidelines required for the privilege of doing so).

In light of all of this, I have to ask ABEM and every other board certifying body, a simple question:

‘What are you people thinking?’

Here’s the reality. Our certifying bodies should be our greatest, most passionate advocates. When the Institute of Medicine issued a report some years ago that said physicians were killing people on a scale consistent with the holocaust, ABEM should have looked at the data and refuted it. ABEM, and ABIM and all the others should have taken our fees, run out and found the best PR firm they could afford. ‘We stand by our physicians and we have serious questions with these research results and the way they are being interpreted.’ That would have been a good use of my dues. That would have merited high salaries for everyone in every board that stepped up for its members.

Instead, at every step, ABEM seems to argue that ‘the public’ wants us to be watched more closely and tested more frequently. Except, I’m not confident that’s true. The public never cares where you went to medical school. The public thinks most emergency physicians are interns hoping for a ‘real practice’ someday. The public wants affordable, quality care. The public, in practical terms, doesn’t know the difference between a physician, a PA and a nurse practitioner, and often calls all of them ‘doctor.’ The public, furthermore, tends to believe that mid-level providers are more attentive to their needs. (Despite their lack of board certification; shocking indeed!)

More poignantly, more ironically, our policy-makers and academics often say that public needs a European-style health-care system with better outcomes and lower costs. Whether that is ultimately true or not, the funny thing is that Canadian and European physicians don’t have to do ongoing board-certification activities. Hmmm.

More irony: medical practice is supposed to be evidence-based. So where’s the data that board certification makes a difference in patient outcomes? Maybe it does, maybe it doesn’t. But even if it does, we’ll need to break it down to see if ongoing certification matters, if repeat testing matters, who sponsored the study. etc. Our certifying bodies should be eager to see independent evaluations of the question. Or would that be a problem?

It might be a problem from a financial standpoint. Is ABEM, or ABP or ABS or the ABMS simply ‘too big to fail?’ Do they employ too many people to cease to be relevant? Is there a financial imperative for them to continue doing what they do? With director salaries in the $200,000 to 800,000 range (depending on board), is there a potential hint of conflict of interest?

How is this different from the financial conflicts of big pharma? Their drugs help people, even if their techniques are shady. Is this an uncomfortable question for everyone to ask?

It’s a time of changing paradigms in the world at large. Print books are succumbing to electronic ones. The Internet is an unfettered land of free expression, uncontrollable by government entities or hospital administrators. People text more and talk less.

It may be time for us to look critically at the entire concept of board certification. It may be time for alternate boards to emerge. It’s certainly time for our boards to be our friends, our advocates, and thereby justify their cost. And it’s likely the future will not look like the present, when it comes to the way we certify physicians. In an era of impending physician shortages and fewer reasons to enter medicine as a whole, I hope that we can remove some obstacles and stand up for one another.

That’s a change I can get behind. And that’s a change that would make me much happier to write that check to ABEM when the time comes.

15 thoughts on “What is ABEM thinking?

  1. Excellent points. In my personal opinion, recertification should be based on your track record (outliers draw a volume of complaints), not based on assumptions (or better yet, arsesumptions)that we need “help” staying current.

    Staying in active practise and demonstrating adequate CME attendance, without generating a slew of complaints, is more than adequate.

    However, recertification has become an industry based on political correctness and lack of evidence – and we pay for it.

    You’re also quite right on the value of certification : there’s more than enough evidence to support “non certified” EMs being equally competent to “certified” EMs after period X of practice exposure in accredited facilities.

  2. Powerful stuff that needs to be said. Would I drop board certification if I could? Absolutely. Does being hounded every single year with CME, yearly $100 exams, every 10 year $1000 exams, and now other ridiculous requirements that no one even understands, make even a bit of difference in clinical practice? NO. Do patients care one bit? NO. Do I get even ONE benefit as I am forced to fork over thousands of dollars and spend hundreds of hours of my time? NO. Merely another permission slip we must have signed before we are allowed to work. It is a purely feel-good money-and-power-grubbing racket run by our obviously superior ivory tower physician administrators and their government bureaucrat pals. The serfs are trapped on the land of the feudal lord for life, so why not demand more tribute? Muahahaha.

  3. If you are interested in following the money, The ABMS boards collectively gross >$300 million in receipts yearly. This is a real cost to physicians and health care dollars!
    You can look at each indfividual board’s 990 IRS forms via these links:
    Here are the boards gross receipts by year most recent listed
    year Name gross receipts $ million URL
    2010 AMERICAN BOARD OF PATHOLOGY INC 6.4 http://www.guidestar.org/FinDocuments/2010/350/969/2010-350969609-0706e87c-9O.pdf
    2009 AMERICAN BOARD OF NUCLEAR MEDICINE 0.77 http://www.guidestar.org/FinDocuments/2009/132/690/2009-132690306-06c00499-9.pdf
    2009 AMERICAN BOARD OF MEDICAL GENETICS 1 http://www.guidestar.org/FinDocuments/2009/953/512/2009-953512145-064860ed-9O.pdf
    2010 ALLERGY & IMMUN 1.3 http://www.guidestar.org/FinDocuments/2010/237/171/2010-237171573-0751650d-9O.pdf
    2009 PREVENTIVE MEDICINE 1.7 http://www.guidestar.org/FinDocuments/2009/236/298/2009-236298444-0617c637-9O.pdf
    2009 NEUROLOGICAL SURGERY 2.6 http://www.guidestar.org/FinDocuments/2009/566/067/2009-566067043-06b1d70e-9O.pdf
    2008 DERMATOLOGY 2.9 http://www.guidestar.org/FinDocuments/2008/131/549/2008-131549125-05412c1b-9O.pdf
    2009 OTOLARYNGOLOGY 3 http://www.guidestar.org/FinDocuments/2009/420/112/2009-420112626-0604694c-9O.pdf
    2009 ACADEMY OF EMERGENCY MEDICINE 3.3 http://www.guidestar.org/FinDocuments/2009/263/697/2009-263697887-06728cc6-9O.pdf
    2010 Plastic surg 3.5 http://www.guidestar.org/FinDocuments/2010/436/000/2010-
    436000050-0721d321-9O.pdf
    2009 UROLOGY INC 3.6 http://www.guidestar.org/FinDocuments/2009/410/857/2009-410857968-06c450fb-9O.pdf
    PHYS MEDICINE & REHABILITATION 3.7 http://www.guidestar.org/FinDocuments/2010/416/029/2010-416029315-06b4cbd0-9O.pdf
    2010 THORACIC SURGERY 4 http://www.guidestar.org/FinDocuments/2010/364/111/2010-364111028-07387556-9O.pdf
    2010 ORTHOPAEDIC SURGERY 11.6 http://www.guidestar.org/FinDocuments/2010/366/000/2010-366000057-06cd8760-9O.pdf
    2009 AMERICAN BOARD OF SURGERY 15.6 http://www.guidestar.org/FinDocuments/2010/231/352/2010-231352007-0741c6ff-9O.pdf
    2009 AMERICAN BD OF EMERGENCY MEDICINE 16 http://www.guidestar.org/FinDocuments/2010/382/177/2010-382177886-06c34cb3-9O.pdf
    2009 OB GYN 16.7 http://www.guidestar.org/FinDocuments/2009/340/787/2009-340787715-063f2242-9O.pdf
    2010 AMERICAN BOARD OF PEDIATRICS 19.5 http://www.guidestar.org/FinDocuments//2010/231/417/2010-231417504-06d9e2d3-9O.pdf
    American Board of Psychiatry and Neurology (1935) 27.6 http://www.guidestar.org/FinDocuments/2009/410/654/2009-410654864-067692c9-9O.pdf

    2010 RADIOLOGY 29 http://www.guidestar.org/FinDocuments/2010/410/773/2010-410773787-06ac00b1-9O.pdf
    2009 FAMILY MEDICINE 34.5 http://www.guidestar.org/FinDocuments/2009/430/921/2009-430921226-067b60b6-9O.pdf
    2009 ANESTHESIOLOGY 40.1 http://www.guidestar.org/FinDocuments/2009/060/646/2009-060646523-06c0b82a-9.pdf
    2010 INTERNAL MEDICINE 42.3 http://www.guidestar.org/FinDocuments/2010/390/866/2010-390866228-06cfb006-9.pdf
    2008 AMERICAN BOARD OF OPHTHALMOLOGY 3.5 http://www.guidestar.org/FinDocuments/2008/231/693/2008-231693176-0533679e-9O.pdf
    sum of official boards gross receipts 294.17

    American Board of Colon and rectal surg NO Guidestar 990 listed

    2009 AMERICAN BOARD OF MEDICAL SPECIALTIES 10.2 http://www.guidestar.org/FinDocuments/2009/410/847/2009-410847713-065f6e4e-9O.pdf
    2010 FEDERATION OF STATE MEDICAL BOARDS 48.8 http://www.guidestar.org/FinDocuments/2010/751/092/2010-751092490-06dc1fbf-9O.pdf

  4. Sounds remarkably like some of the stuff happening tin education. More and more regulations and less and less support–no one trusts that most teachers really do know how to do their jobs and deal with an incredibly complex set of problems. It’s so sad that it’s happening to doctors as well.

  5. For a non-profit organization who’s duty is to protect its membership it would seem as though profit and gain have won over doing what is right. Aside from the astronomical assets listed in Dr. Kempen’s comment, the MOC alone has the potential of garnering ABMS a revenue of over $700 million. How will these monies be spent to raise the level of patient safety and care as well as protect the member physicians that make up the very organization who leadership does not protect them?

  6. This is a fantastic article.

    This is what I think the profession needs: You and other high profile spokesmen/ women like Greg Henry, Jerry Hoffman, Mel Herbert, etc to band together and start a groundswell of protest among the majority of us who are in agreement with you. At least make ABEM justify why they are doing this. Have a talk on EMRAP, get everyone to forward your post to ABEM. Have a profession wide boycott of the testing (the APP at least). This is a time to make a change and you are just the kind of intelligent, respected, articulate person to spearhead the effort!

    My partners and I have been angry about this for years. The LLSA is poorly designed and should at rock bottom least allow us to earn CME credits. In 2011 we can do so, but we have to pay an additional $50 for. The overhead in no way comes close to $50 per EP in the country. The LLSA, Continuing Certification, or Assessments of Practice Performance have no evidence that they work, are poorly implemented (the ABEM website could have been designed by a 12 year old).

    • Dan,

      I think the storm is brewing. MOC is the cover story of Medical Economics this month as well! Hopefully we can all band together for some serious civil disobedience and put a halt to this money machine! Thanks for the kind note and encouragement. Let’s all keep beating this drum together. I hope my column can keep encouraging dialogue and, quite frankly, anger at the monster this has become. Merry Christmas, Edwin

  7. I agree with your concerns, but I think you are failing to address the issues with the poor performers and/or bottom feeders out there. If there were no mandate forcing doctors to keep current, there are many physicians who would never pick up a book or journal again. These physicians aren’t going to conferences, and aren’t reading your articles. These are the physicians, we could argue, should have considered a different profession.
    Unfortunately, pretty much every regulatory body has to operate on the principle of keeping their lowest performers from killing anyone. I feel pretty confident that I will do my best to keep current with the changes in Emergency Medicine, regardless of my certification requirements . I can probably say the same about anyone who will happen this post. Unfortunately, our world is dominated by a system that caters to the low performers. I think the best /saddest example of this is the current version of AHA’s CPR guidelines!!

  8. THANK YOU for this column. And dont forget to do your yearly LLSA, your 50 hours of CME, your 10 year Boards, ACLS, PALS, aTLS, your six hours of CME from your malpractice carrier, the six hours of. Pain Management training from the state, the six hour Conscious Sedation training from your hospital, the ABEM PPI activity , the QA activity or two if you are recerted since 2004, and the Patient satisfaction Survey signed off by your department chair. By the way you cant pick your own PPI or QA now it has to be ased on ABEMS core measures or whatever they are called.

  9. It’s the usual bullshit conflict of self serving economic interest, ivory tower high altitude cerebral edema along with blimp like own image inflation. People who love telling others what to do while they themselves dance on the head of a pin to music only they can hear.

    Call me when reality re enters the picture. I don’t expect the phone to ring.

  10. With respect to Emergency Medicine, I believe if one has taken and passed the ABEM exams/requirements 3x over a 30 year lifetime career, that should automatically make the individual Boarded for the rest of his Emergency Medicine career. CME is important and needs to be continued and followed; however, to after 30 year implying that the boarded physician is now suddenly titled as “Previously Boarded” is a slap in the face…..

  11. Thanks for a very informative web site. Where else could I get that type of information written in such an ideal manner? I’ve a mission that I am just now operating on, and I have been on the look out for such info.

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