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