What to Do About the Maintenance of Certification Mess

Want to start a food fight? During a banquet at a medical convention, innocently ask the question: “Is board recertification a valid measure of your professional knowledge and ability?”

Within minutes, asparagus spears, mashed potato grenades, and mystery-meat landmines will explode all around, as proponents and adversaries of the ritual called “board certification” express themselves in a scene reminiscent of the film classic “Animal House.”

The proponents offer valid and logical reasons to continue a process that once served to distinguish true healers from hucksters, for the benefit of both patients and physicians.

The adversaries have marshaled over 19,000 petitioners calling for an end to meaningless metrics that lack validity and hang over them like a sword of Damocles,  threatening to sever them from participation or to reduce their reimbursement, using “quality” as a weapon.

Perhaps no other professional issue today creates such divisive and emotional battle lines, and has received such broad press coverage, from the Annals of Internal Medicine to the Wall Street Journal.

As a rheumatologist in solo private practice in the under-served backwaters of a Southern state, I will venture into the no-man’s-land that separates the two warring camps and offer a dispatch from the home front of a busy clinical practice.

The issue arose recently at lunch in the doctor’s lounge. (This being only lunchtime, no food was lobbed.) Everyone agreed that the current system is flawed, but solutions were as varied as the doctors who offered them.

•    A surgeon told me he liked the annual maintenance of certification (MOC) process, but he felt that an examination given every decade was meaningless.

•   An internist said almost the opposite: that ongoing MOC tasks cluttered an already difficult clinic day, but that the periodic examination stimulated continued learning.

•   One innovative hospitalist suggested that we test certification the way we really practice 21^st century medicine, by evaluating a clinical presentation using all the open-book tools of web searches and online textbooks that we really employ daily when facing a challenging patient.

I heard many potential solutions, but also one unified opinion: The current method must be changed.

How, then, do we declare a cease-fire and begin to clean the turnip greens from the wall and the ham hocks from under the chair?

When exploring a contentious issue, it is essential to identify agendas, so I will divulge mine.

1.   I want to provide my patients with the very best, scientifically validated, cost-effective care possible. Y’all (remember, I am Southern) may be right there with me on that agenda.

2.  I also want to do this with the least possible interference from third parties who lack my experience and education. (Some of y’all are getting nervous about my agenda now, knowing that we shall never rid ourselves of government and insurance regulators.)

3.  I want to demonstrate my ability in a meaningful way. (Uh, where’d y’all go?)

This is where we lose ourselves in the smokescreen of what defines “quality” and what is meaningful. Again, there are two camps in conflict: Regulators--and I include my esteemed colleagues at the American Board of Internal Medicine (ABIM) in that category--who revel in metrics that rigidly define “good” by the numbers, and my physician colleagues, who understand quality as a symphony of characteristics that blend into a harmonious outcome.

The metrics offer a simplistic binary outcome: Maintain certification, or not. Convenient, yes, but (as recent studies suggest) that metric lacks scientific validity to measure real differences in physician performance. Unfortunately, a qualitative measurement tool applied to all physicians might also become arbitrary, and would lack the rigor we expect from a validated instrument.

The smoke thickens. Let’s step out of it for a minute to ask a practical question: Does there have to be only one way to demonstrate quality? You would call me a fool if I advocated only one proper way to treat rheumatoid arthritis. So why should I embrace only one proper way to measure quality?

We can all agree that we want to provide optimum care, and we may agree that we want definitions of quality to be set by the people who care for patients, rather than by those who “administer health delivery.” Can we then agree on a best means to do this? Is it an electronic chart audit of how many patients I asked about smoking? Is it a two-day eye-straining marathon in front of a computer monitor, answering multiple-choice questions about renal biopsies and the molecular biology of presumed medication actions?

Old ways served us well when we learned from books and did not have access to a library at our fingertips. We do need new tools now for the new way we practice. But I would plead that we consider practicality in the resolution of this conflict:

1. As a busy clinician in an underserved area with a months-long waiting list, please don’t demand long absences from my practice. I can’t afford the overhead, and my patients depend on me. Do I really need to spend two days in a cubicle pretending I know how to interpret immunofluorescent-labeled skin biopsies? (If I did that in the real world, any lawyer worth his salt would sue me.)

2. In this age of iPhone apps and Wi-Fi connectivity, I would ask the ABIM to invest some of the money I pay for the privilege of recertification in software that allows me to show that I can recognize problems when they arise and ask questions real-time in the clinic. Go ahead, I dare you: Track my use of UpToDate and PubMed!

3.  As a scientist and a pragmatist, I would also insist that any means selected to measure my “quality” be subject to the same standards of significant outcomes as a clinical drug trial or a new diagnostic test. I want validated measures, because I don’t have time to waste doing busy-work just to satisfy someone’s educational theory or to advance a social agenda.

4.  As a consumer of goods and services, I would ask that there be more than one process for certification, because competition is good. I like competition, and our marketplace of goods and services depends on competition to best meet consumers’ needs. Far from creating confusion, having several options for demonstrating quality would benefit doctors and patients alike.*

So instead of trying to find a monopolistic “best” way to assure certification ,we should develop several, possibly competing, ways to demonstrate our value to our patients, to third party payers, and to government regulators so that we’re not just evaluated like soybean or pork belly commodities. We are capable professionals practicing the healing arts.

(As one esteemed member of this network’s Board asked in an internal email thread on the subject: “Is anybody of the ABIM listening?”)

(This article is the author's own opinion and does not reflect the opinion of the Rheumatology Network staff or that of its Editorial or Advisory Board members.)

*For the importance of social policy having just enough choices, but not too many, see Thaler RH, Sunstein CR.Nudge: Improving Decisions About Health, Wealth, and Happiness.  New Haven CT: Yale University Press; 2008.

For further reading:

Hertz BT. MOC changes aim to lessen burden on physicians, but debate continues. Medical Economics, March 24, 2014.

Beck M. Doctors Upset Over Skill Reviews. Wall Street Journal, July 21, 2014.

Changes to ABIM MOC Requirements Stir Debate. tctmd.com Sept. 13, 2014

Fisher WG. The ABIM Foundation, Choosing Wisely®, and the $2.3 Million Condominium. Dr. Wes (blog) Dec. 16, 2014

Ofri D. Stop Wasting Doctors' Time: Board Certification Has Gone Too Far. New York Times, Dec. 15, 2014