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Negative Secular Trends in Medicine: The ABIM Maintenance of Certification and Over-reaching Bureaucracy

      An important factor that I believe ties together many of the negative secular trends making it less likely our brightest young men and women will choose a career in Medicine can be summed up in 1 word—bureaucracy. More rules, more regulations, more wasted time, more red tape, more pain with less, or little, or no gain. And of course, more expense. Graduating medical students now submit scores or even 100 or more applications for a residency position. Some take a desultory approach and apply everywhere. The 2011 update for Resident work hours is longer by almost an order of magnitude than the original guidelines of 2003 and is so detailed it might even be characterized by someone trained in the bygone era of the late 1970s, like me, as silly. The trend in the length of training periods is unidirectional—longer. The expensive, time-consuming, and often frustrating Electronic Medical Record has yet to live up to its advance billing.
      But I think there is no better example of this trend of ever-expanding, over-reaching, and arbitrary bureaucracy than the recently proposed changes in the Maintenance of Certification (MOC) requirements by the American Board of Internal Medicine (ABIM). The revisions initially proposed in early 2014 required physicians to obtain 100 MOC points every 5 years and perform 1 MOC activity every 2 years. Physicians with time-limited certificates who did not participate would suffer their board certification to lapse, and those grandfathered with time-unlimited certification would be listed publically on the ABIM website as “not meeting MOC requirements.” The societal value of the proposed MOC to improve patient care was questioned,
      • Teirstein P.S.
      Boarder to death-why maintenance of certification is bad for doctors and patients.
      and it was estimated that the new requirements would cost the average internist $23,607 in time and money over 10 years, with a cumulative cost of 32.7 million physician-hours and $5.7 billion to all participants.
      • Sandhu A.T.
      • Dudley R.A.
      • Kazi D.S.
      A cost analysis of the American Board of Internal Medicine's Maintenance-of-Certification Program.
      The frustration was so great, the debate so intense, and the controversy so heated, that the rank and file members of the ABIM finally had what I call a “Popeye moment,” saying in essence “this is all we can stands, we can't stands no more.” A lawsuit was filed against the American Board of Medical Specialties (of which the ABIM is a member) alleging unfair trade practices,

      Association of American Physicians and Surgeons, Inc. v American Board of Medical Specialties, No. 1:14-CV-2705 (ND III 2014). Available at: http://aapsonline.org/AAPSvABMSresponse-6-3-2014. Accessed August 2, 2015.

      an online petition protesting the changes has received approximately 23,000 signatures,

      Physicians for Certification Change. ABIM should recall the recent changes to Maintenance of Certification (MOC). Available at: www.petitionbuzz.com/petitions/recallmoc. Accessed August 5, 2015.

      an alternative organization to replace the ABIM was founded,

      National Board of Physicians and Surgeons. Available at: https://nbpas.org. Accessed August 2, 2015.

      and the controversy was quickly picked up by the lay press.
      • Beck M.
      Doctors upset over skill reviews: new learning requirement to maintain certifications called costly, irrelevant.
      The ABIM issued a public apology, softened the language on its website, and rescinded, although it must be noted just temporarily, only some of the new requirements, leaving others, including the increased fee structure (vide infra), in place.
      • American Board of Internal Medicine
      Maintenance of certification guide.
      I will not make a point by point rebuttal of the changes in the MOC as proposed by the ABIM. Rather, I will discuss what I believe is the flawed philosophy and, more important, the questionable motives of the ABIM and what can be done to correct them.
      The initial establishment of regulations and certification-granting agencies often has a positive effect, providing basic ground rules and commonsense requirements where none previously existed. But no matter how initially well intentioned, all bureaucracies must eventually justify their continued existence. Unfortunately, the option most often taken is to impose more rules and regulations—the costlier the better.
      No one can predict the future: All we have to study is the past. Even on this question, history can provide useful context and perspective. The first attempt to codify physicians' behavior and performance was the Hippocratic Oath. Written in the late 5th century bce, its approximate 354 words proved adequate to govern medicine for 2300 years. Its simple wisdom still provides the basic outline and guidance for physicians in the 21st century.
      More recently, as of 1870, there were no operational state boards of medicine in the United States.
      • Howell J.D.
      The invention and development of American Internal Medicine.
      By the time of the Flexner report in 1910, recommending physicians be educated on the Johns Hopkins University model, all states had established boards. It was also generally appreciated that the public, fellow physicians, and hospitals needed a way to define a specialist. The American Board of Ophthalmology was established in 1917. Others quickly followed. The ABIM appeared in 1936, and by 1940 all major specialties had boards.
      It is worth noting that the founders of the ABIM saw themselves more as a national group to recognize a few outstanding internists than a regulatory or credentialing body. The initial examination was not designed to test “minimal standards of practice,” but whether the candidate had a “superb knowledge of the practice of Medicine.”
      Sometimes bureaucratic creep occurs slowly, sometimes more rapidly. Just 16 years later, in his 1951 Presidential address to the Central Society for Clinical Research, Dr William Bean, the Sir William Osler Professor and Chief of Medicine at the University of Iowa, pleaded that the control of specialty training be removed from the “stifling influence” and “overweening and crushing impact” of the ABIM.
      • Howell J.D.
      The invention and development of American Internal Medicine.
      How prescient. The current generation of disgruntled Internists may, or may not, take solace in knowing that others experienced similar frustrations with the ABIM 3 score and 4 years ago.
      I believe that 2 issues have contributed to the intensity of the current debate. First is that the new MOC requirements are backed with little or no scientific data to justify their imposition. This is really not surprising, because I can find little if any scientifically documented data to support many of the ABIM's previous decisions. Especially important to the current debate is their 1986 decision that required those certified in 1990 or later to recertify every 10 years, even though these physicians had already demonstrated their sound professional skills and expertise by completing mandatory training periods and passing all required examinations as determined by the ABIM.
      This alone was extremely controversial, but what makes the current debate especially acute are the accusations of financial impropriety at the ABIM.

      Eichenwald K. Medical mystery: Making Sense of the ABIM's Financial Report. Newsweek. Available at: www.newsweek.com/medical-mystery-making-sense-abim-financial-report-334772. Accessed August 2, 2015.

      There is no way I can determine whether illegality occurred or not, but the suggestion that the new MOC requirements were undertaken only to generate fees would be a breach of fiduciary duty and an indelible stain on the leadership of the ABIM.
      In 1990, a scandal involving bidding on US Treasury bills almost destroyed the venerable Wall Street firm of Salomon Brothers.

      Lowenstein R. Salomon's Court. In: Lowenstein R. Buffett: The Making of an American Capitalist. New York: Broadway Books; 1995:386-398.

      Board member Warren Buffett was made temporary Chief Executive Officer to clean up the mess. He said that Salomon must operate “way, way away from the (out-of-bounds) line,” at the “center of the court.”

      Lowenstein R. Salomon's Court. In: Lowenstein R. Buffett: The Making of an American Capitalist. New York: Broadway Books; 1995:386-398.

      Would you trust a physician who may or may not have stepped over the line? Should we trust a credentialing body that may or may not have stepped over the line? After all, isn't medicine all about playing in the center of the court, being above reproach?
      I believe the current leadership of the ABIM has lost all credibility with the membership and with the public at large. I see 2 options. In my opinion, an important reason physicians are in their current fix is that for the last 2 or 3 decades or longer, they have not been sufficiently forceful and aggressive in defending their interests against bureaucratic encroachment. I find it very encouraging that physicians are willing to stand up and establish an alternative organization, such as the National Board of Physicians and Surgeons. The other option, complementary, not exclusive, is for the current leadership of the ABIM to be replaced by physicians, preferably those familiar with the day-to-day realities of patient care, democratically elected by the membership.

      References

        • Teirstein P.S.
        Boarder to death-why maintenance of certification is bad for doctors and patients.
        N Engl J Med. 2015; 372: 106-108
        • Sandhu A.T.
        • Dudley R.A.
        • Kazi D.S.
        A cost analysis of the American Board of Internal Medicine's Maintenance-of-Certification Program.
        Ann Intern Med. 2015 Jul 28; ([Epub ahead of print])
      1. Association of American Physicians and Surgeons, Inc. v American Board of Medical Specialties, No. 1:14-CV-2705 (ND III 2014). Available at: http://aapsonline.org/AAPSvABMSresponse-6-3-2014. Accessed August 2, 2015.

      2. Physicians for Certification Change. ABIM should recall the recent changes to Maintenance of Certification (MOC). Available at: www.petitionbuzz.com/petitions/recallmoc. Accessed August 5, 2015.

      3. National Board of Physicians and Surgeons. Available at: https://nbpas.org. Accessed August 2, 2015.

        • Beck M.
        Doctors upset over skill reviews: new learning requirement to maintain certifications called costly, irrelevant.
        The Wall Street Journal. July 21, 2014; (Available at: http://www.wsj.com/articles/doctors-upset-over-skill-reviews-1405985224. Accessed September 12, 2015)
        • American Board of Internal Medicine
        Maintenance of certification guide.
        American Board of Internal Medicine, Philadelphia2015 (Available at:) (Accessed August 2, 2015)
        • Howell J.D.
        The invention and development of American Internal Medicine.
        J Gen Intern Med. 1989; 4: 127-133
      4. Eichenwald K. Medical mystery: Making Sense of the ABIM's Financial Report. Newsweek. Available at: www.newsweek.com/medical-mystery-making-sense-abim-financial-report-334772. Accessed August 2, 2015.

      5. Lowenstein R. Salomon's Court. In: Lowenstein R. Buffett: The Making of an American Capitalist. New York: Broadway Books; 1995:386-398.