Reflections On My Year as Chair of the American Board of Internal Medicine

Today is my last day as chair of the ABIM, and the end of my eight-year tenure on the Board. In this blog – a bookend to the one I wrote at the start of the year, which went near-viral – I’ll describe some of our accomplishments this year and a few of the challenges that I leave my talented successors to grapple with.

ABIM Board 2013 croppedI had two very tangible tasks to accomplish during my chairmanship. First, after a decade-long tenure as CEO and President of ABIM, Chris Cassel announced her intention to step down. (Chris is now CEO of the National Quality Forum, which is increasingly crucial in a world looking for robust measures of quality, safety, and value.) After an extensive search, we selected Richard Baron to become ABIM’s new CEO, and Rich began earlier this month. Rich is one of the most impressive people I’ve met in healthcare, and a perfect choice to lead ABIM into the future. As someone who practiced general internal medicine for nearly three decades in a mid-sized Philadelphia office, he is a “doctor’s doctor.” He is intimately familiar with the work of the Board, having served on the boards of both ABIM and the ABIM Foundation for over a decade (including a year as ABIM chair). He also has extensive policy experience, most recently as director for Seamless Care Models for the Center for Medicare & Medicaid Innovation (CMMI), where he was responsible for putting meat on the bones of concepts like the “Medical Home” and “Accountable Care Organization.” Rich is wickedly smart, a superb communicator, and a great listener with impeccable values and an unerring ethical compass. He’ll be splendid.

The second area may be a bit more Inside Baseball, but will ultimately be just as important. A couple of years ago, we began a process to redesign the ABIM’s governance. Our 28-person board was both too large and had too much on its plate for effective decision making. In work that was superbly led by then-chair Catherine Lucey, assisted by a crack committee, staff and governance expert Jamie Orlikoff, we decided to transform our governance structure. As of tomorrow, the ABIM board shrinks to 15 members – chosen for their experiences and competencies rather than because they represent a given medical subspecialty – and a new group, the ABIM Council, is formed. ABIM’s work is now divided: the new board is charged with developing and carrying out our overarching strategy and holds fiduciary responsibility; the Council is responsible for the core work of the organization: the certification and MOC processes. This separation (accompanied by appropriate cross-links) is designed to give both groups the time and support they need to focus on their very large agendas. My thanks to ABIM Governance Task ForceCatherine, Jamie, the staff, and the Governance Task Force (particularly Governance Committee chair Pat Conolly and inaugural Council chair Lee Berkowitz) for breathing life into this structure, and to the entire board for a thoughtful deliberation and a very bold decision.

There were several other initiatives we started under my watch but which I’ll hand off to our able new chair, David Johnson, the Board, Council, and staff. We created a committee called Assessment 2020, led by Harlan Krumholz, whose job is to rethink how we assess physicians in the future. Here are merely some of the issues we’re grappling with:

• In a world in which virtually every doctor is documenting his or her care in an electronic medical record system, how do we take advantage of these data, as seamlessly as possible, to assess the quality of care?

• As more of our assessments are drawn from data created during care delivery, how do we ensure that we’re also measuring things that are harder to assess than care processes or even outcomes, such as diagnostic acumen and empathy?

• Since we know that the quality of care delivered by individual doctors is profoundly influenced by their practice setting, how do we measure context and take it into account in our certification process?

• In a world of ubiquitous and instantaneous access to online information, does a purely closed-book test make sense?

• How do we integrate modern simulation techniques into our assessments?

• How can we assure that individual physicians have the skills they’ll need to contribute most effectively to a rapidly changing healthcare landscape?

While our methods must remain consistent with modern thinking and technology, we can’t abandon scientifically valid tools and assessments for the latest fads. The Assessment 2020 committee is an eclectic and accomplished group that includes experts from healthcare, education, simulation, and a variety of other domains. I look forward to seeing what we come up with (I’ll continue on as a committee member).

This year we also sharpened our focus on two other challenging and hugely important issues: harmonization and transparency. We know that many physicians complain of being crushed by the burden of being measured by a variety of payers, healthcare systems, quality coalitions, as well as the Boards. We have worked hard to integrate MOC with these efforts – our goal is to allow (if the diplomate wishes) the same activities to “count” for Medicare and other insurers’ quality incentive or public reporting programs, Joint Commission practice assessments, state Maintenance of Licensure programs, Meaningful Use incentives, and more. We’ve made some headway on this, but it remains a work in progress – these are some very big cats to herd. We’ve also worked hard to keep our costs down. They are among the lowest of boards that make up the American Board of Medical Specialties (the umbrella organization for the major certifying boards). I am confident that future boards will remain committed to this path.

Moreover, we recognize that many physicians are now participating in robust QI programs within their own healthcare institutions. We have created a pathway by which such organizations can oversee their physicians’ quality work – so a group of doctors in a given hospital working on a diabetes or heart failure improvement project can all receive MOC credit, offered by their own institution, for this work. In our harmonization efforts, we have been encouraged by the response of others (particularly Medicare, under CMO Patrick Conway’s superb leadership), who appreciate that physicians themselves (this is, after all, what the Boards are – groups of physicians creating standards for their own specialties) will do a better job than payers or regulators. This too is a work in progress, but we have made real advances.

In addition, a personal passion of mine was to push the Board to become more transparent. I mean this in both senses of the word. First, how we do our business and make our decisions should be accessible to everyone who wants to know. We’ve taken strong steps in this direction, with even more to come next year.

Even more importantly, I believe that the Board should, ultimately, make more information available to patients and other interested parties than simply whether physicians are, or are not, board certified. But what type of information? Should it be levels of performance (for example, expert vs. competent), areas of specialization within a specialty (for example, an endocrinologist who has a particular expertise in thyroidology), or something else? We’ve begun a process to think through these very hard questions, with a lot of input, over the next few years. Of course, this issue is highly intertwined with our Assessment 2020 work.

Our efforts to modernize our certification programs and consider issues of transparency will be facilitated by more frequent touch points with our diplomates. All of the boards under the ABMS have been asked to transition to a more continuous process in which physicians participate in MOC more frequently than every ten years. In focus groups that we conducted in planning our MOC transformation, many physicians begged us to “just tell me what I need to do.” Our soon-to-be launched web portal will fill this need. This is an extraordinarily complex undertaking: a senior physician might be “grandfathered” in internal medicine, but have certain requirements for, say, her subspecialty of cardiology, and others for her sub-sub specialty of electrophysiology. The new web portal will represent a real advance.

It would be wildly unusual for an accreditor or standard setter to be universally loved, and ABIM is no exception. We sit at a delicate interface. Patients and patient representatives often ask us to do more: provide them more information about physicians to help them make choices and weed out “bad apples.” Yet many physicians – including a particularly vocal group of readers of this blog – clearly want us to do less. After my tenure on the Board, I remain convinced of the value of professional self-regulation and assessment, and utterly unpersuaded by the argument that MOC should just go away, that every physician can be counted on to keep up with advances in their field on their own, and that patients don’t deserve to know whether their physicians have met a set of scientifically-valid standards set by experts in their own specialty.

But can the process be improved? Sure. I’ve done my best to help ABIM, which is filled with talented and highly committed staff and board members, to do just that. As we do, it will be important to look unblinkingly at where our programs fall short, but also to base such efforts on real data, not some of the misinformation I’ve seen flying around the web. For example, between 1997 and 2012, the pass rate on the MOC exam has been 87% for first time takers, with an ultimate pass rate of 96%, not the far-lower rate being suggested in some posts (though rates on individual exam administrations do vary). Between 1990 and 2001, more than 72,000 physicians received time-limited certificates from ABIM; 92% of them enrolled in MOC at the appropriate time, and 84% completed the process successfully. Finally, we ask physicians to assess their experience with the testing component of certification and MOC. Eighty-three percent of physicians who participated in certification were satisfied with the experience, as were 78% engaged in MOC (3% and 5% were unsatisfied, respectively; the rest were neutral). Seventy-nine percent of those who participated in MOC would recommend it to a colleague.

As important as physicians’ attitudes are those of patients. In a 2003 Gallup survey, 90% of patients felt it was important or very important that physicians be reevaluated every few years; 87% thought it was important or very important that doctors periodically pass a written test. More than half stated that they would find another doctor if their own physician’s board certification lapsed. Patients want and deserve a fair and robust certification and MOC process.

I look forward to seeing what the future holds, and wish my colleagues the best of luck in pursuing this crucial agenda. I’ll continue as a Trustee of the ABIM Foundation, whose main focus over the past few years has been the highly influential Choosing Wisely® campaign.

And, of course, I’ll continue to maintain my certification, proudly.

19 Responses to “Reflections On My Year as Chair of the American Board of Internal Medicine”

  1. Yul D. Ejnes, MD, MACP June 30, 2013 at 7:30 pm #

    Congratulations, Bob, on a job well done.

  2. Bob Wachter June 30, 2013 at 8:20 pm #

    Thanks, Yul. I appreciate your support and that of the ACP – it is a vital partnership.

    Let me note this point in time: the comments to this blog are running 100% positive. Judging by the nearly 200 comments to my prior blog on the ABIM, I wouldn’t bet on that percentage holding for very long ;-)

    • Yul Ejnes, MD, MACP June 30, 2013 at 9:57 pm #

      Bob,

      I was going to write “enjoy it while it lasts,” but it’s moot at this point.

  3. Marc S Frager MD June 30, 2013 at 9:39 pm #

    Dear Bob: Your comment shows exactly what is wrong with the American College of Physicians. THe ACP is a membership organization, to quote Dr. Weinberger, and should be representing the majority of its members, not partnering with any organization. The fact that prior ACP leaders like Dr. Cassel appear to have representation out of line with their individual membership is not in keeping with the purpose of the ACP, it seems to me. In my opinion the majority of ACP members oppose mandatory participation in MOC How do you reconcile the satisfaction of ABIM results of 83% of diplomates who were satisfied with MOC with the near universal evidence that the process is detested? That evidence includes the AAPS lawsuit against the ABMS alleging restraint of trade, the anti-MOC resolutions by the AMA and state medical societies of New Jersey, Michigan, Ohio, Oklahoma, New York, and North Carolina. And consider the potential side effects of those poor physicians, however many there are, who fail MOC. Has the ABIM given any thought to the devastating effect it may have on someone’s career to not pass the exam? Do you subscribe to the ABIM Foundation prescription for being skeptical of studies funded and performed by the pharmaceutical industry? Then please consider if it follows if an internist should be skeptical of studies attempting to show MOC efficacy funded by ABIM and performed by ABIM employees? Isn’t it amazing that the ABIM still continues to want to force its costly processes on its diplomates? MOC is truly voluntary in name only. If it were perceived to be beneficial, then diplomates would line up to participate. It is truly repulsive to many that diplomates are coerced into this MOC process for which there is little if any evidence for efficacy, Should we really mandate this process on the basis of one Gallup poll commissioned by the ABIM? If the ABIM wants to be transparent, then please tell us how it addresses these difficult issues, other than to ignore them. While regulatory agencies may be unloved, it is easy to understand their purpose when they have some sort of positive effect on society. We have very little high quality evidence that MOC has any beneficial effect on society or diplomates or patient safety or patient outcomes. We have seen repeatedly throughout history that bureaucratic organizations often lose track of their original purpose to protect the leaders of the organization. When all is said and done, an organization that compels participation is admitting its programs are not good enough to stand on their own.

  4. John Benson July 1, 2013 at 6:15 pm #

    Bob, a masterful reprise and expression of policy, goals, progress, and accommodation to external events and pressures. Your expression of philosophy about certification and MOC remind me of the thinking of your predecessors like Saul Farber, Bob Petersdorf, and Sam Thier, who were also responsive to their times.
    I hope that initial certification remains a benchmark credential for hospitals, faculties, clinics, and the public. At the same time I applaud the Board’s efforts within MOC to “harmonize” with the demands of other standard-setters, to simplify matters for busy clinicians, and to recognize that like politics, most evolving practices are local, especially as ACAs, subsubspecialization (eg, thyroidology), physicians as employees, etc. change the landscape. An adaptive, still strong MOC is an essential Board obligation to the public.
    Thank you for your strong leadership and service to ABIM.
    John Benson

  5. Bob Wachter July 1, 2013 at 6:47 pm #

    Thank you, John.

    For those who don’t know, John Benson was the first president of ABIM, and served in this role for 16 years — he is really the founding father of the organization and one of the towering figures in medical education over the past century. So his comments are particularly meaningful.

  6. Isaac Gorbaty MD July 3, 2013 at 5:31 am #

    I am proud to be a dissenter from the call to “crush the bastards”. Whereas error is subject to correction by verification, conviction is just what Webster’s dictionary says it is,i.e. “a strong belief”. The added value of any recertification vs completion of a supervised residency/fellowship at an approved program in a field of medical specialty has never been documented. The only published study comparing the care of physicians who completed a residency and were certified vs. those who never received Board certification, for failure to sit for or pass certification, appeared in the Annals of Internal Medicine and failed to find a statistical difference in the reviewed charts or in the perception of the interviewed patients. The discussion section of that study asserted that there was surely a difference but they had failed to find it. This study has never been repeated!.
    If the best Dr Bob can come up with to justify the assault on physicians is a 2003 Gallup poll of patients showing half to be of the sentiment that they would find another doctor if their doctor did not recertify, then the gruel is thin indeed. I am an older doctor and have passed Boards in four different fields. I am not a better doctor for it and I believe it to be misguided and unjust to suggest otherwise. I for one, welcome the opportunity to place the future of recertificaton and MOC to a vote of the Dplomates. If Doctor Bob and the fifteen members of the streamlined Board wish to serve the interests of their physician colleagues let them put their conviction to a vote and abide by the result.
    I am,
    Isaac Gorbaty, M.D.

  7. Mt Doc July 3, 2013 at 3:31 pm #

    Actually, Bob, if you access the change board recertification website you willl find the following statement:

    “While most polled physicians want MOC abolished, we feel that the system’s self-evaluation of medical knowledge modules can be worthwhile. We recommend that one open-book, open-colleague module be required within a 2-year period, and that it count for all MOC, CME and Maintenance of Licensure (MOL) requirements. We take issue with the rest of the MOC process: the Practice Improvement Modules and Patient and Peer Reviews amount to little more than busy work, and the costly, time-consuming Secure Examination – which requires time off from work and enormous amount of preparation – is clinically irrelevant and has no place in the life of a practicing physician.”

    This seems reasonable. For the ABIM to put in print the updates they think are relevant, require physicians to review it and stagger it over a reasonable time would I think meet with little resistance. Actually, MKSAP pretty much does this, and while I’ve heard complaints about the quality of the writing (“they can make an interesting subject as fascinating as reading a phone book” is one statement I’ve heard) I’ve heard no complaints about the MKSAP process itself. For one thing, your employability won’t hinge on your ability to pass one test which has little relevance to the way medicine is now practiced, with the ready availability of subspecialty and on-line support. A second point is, if the current ABIM procedure is so worthwhile, why do so few grandfathered physicians do it, and why do so many do the MKSAP?

  8. weakanddizzy July 4, 2013 at 12:56 am #

    Marc S Frager MD states” In my opinion the majority of ACP members oppose mandatory participation in MOC How do you reconcile the satisfaction of ABIM results of 83% of diplomates who were satisfied with MOC with the near universal evidence that the process is detested? ”

    Marc, after I took the MOC recertification test there were questions about how I felt about the test, the process, etc. Talk about BIAS! I wanted to blast the ABIM but a little voice inside said, ” Don’t do anything stupid, you don’t know if you passed yet”. I completely disregard the data from ABIM concerning what internists undergoing recertification really feel about the process. There is too much riding on you getting recertified, as several internists have stated in prior posts, to be truthful given the fear associated with not becoming recertified. The older I get, the more cynical I get. In my opinion this is just a money making scam by the ” boys at the top” who justify their highly paid salaries in the guise that they are ” protecting the public” by ” certifying” that the internists are ” highly qualified. I have no problem with an initial certification process and ongoing CME but being treated like an errant school boy my entire professional career is demeaning at best.

  9. menoalittle July 4, 2013 at 9:14 pm #

    Bob,

    You stated: “In a world in which virtually every doctor is documenting his or her care in an electronic medical record system, how do we take advantage of these data, as seamlessly as possible, to assess the quality of care? “

    But Bob, before you do that, why don’t you perform a study on how the electronic medical record and electronic ordering devices disrupt the quality physicians, causing errors, delays, and impediments to care serving as the genesis to adverse events that would never have occurred under prior care systems (eg, paper and pens), and grade the EMR on toxicity to care.

    Just this week, a critical test was ordered that was never done due to flaws in the communication wrought by the CPOE and EHR.

    And clinicians wanted to review orders contemporaneously as written, but the device made by a nationally ranked vendor would not permit that. Despicable, actually, but you are pushing to have doctors assessed by their work on these flawed devices?

    It is a well-known fact that the defects and design flaws in the EHR devices about which you speak cause errors and make seasoned competent clinicians look like fools, often. The EHR is always right, according to the vendors and hospital administrators. And the user is always in error.

    Oh yeah, before you assess doctors via EHR, please let us know how many admission orders and discharge TOC documents you have entered on the CPOE device at UCSF?

    Then, let us know of the opinions of MOC from the doctors who did not pass or who did not take it.

    Best regards,

    Menoalittle

  10. Marc S Frager MD July 5, 2013 at 10:55 am #

    I suspect our ultimate predecessor, Dr. William Osler, would be appalled at those who recognize some responsibility to the public, but do not recognize their responsibility to the diplomates to provide some proven method of assessment. Let us not forget that gastric freezing and bland diets for the treatment of peptic ulcer disease were felt to be scientifically valid standards by the experts of their day; Until indisputable, valid evidence of efficacy exists, forcing diplomates to participate in these costly assessment schemes is just not right.

  11. Willa Smith July 6, 2013 at 3:23 am #

    The evidence to support double and triple Board jeopardy is scant, if any. When you say that you want to assess doctors’ mangement of patients by using EHR systems, I begin to wonder what you are smoking. These care record systems keep me from determining who did what to a patient, and represent a potent impediment to sleuthing out how a patient’s illness got to its current state, and you want to use it to assess doctors? Cmon man!

  12. ARCpoint Labs of Salem July 15, 2013 at 4:29 pm #

    You have a great following on this blog. I really enjoyed reading your post, thanks.

  13. Dr. Pullen July 18, 2013 at 2:52 am #

    The challenges of medical education, residency training, and then assessment of young physicians for board certification has become increasingly complicated, and the higher fail rates recently likely reflect a complex mix of issues including less hours of work/training in residency, more reliance on easily accessible data online leading to less practical need form memorized data, and others we have yet to uncover. Thanks for your work and good luck to your successor and staff.

  14. ARCpoint Labs of Rock Hill July 24, 2013 at 3:38 pm #

    What’s your next goal?

  15. Shannon | Ready Medical Staff July 29, 2013 at 9:02 pm #

    We appreciate all your efforts toward the betterment of the profession. Kudos!

  16. Nina January 27, 2014 at 5:54 pm #

    Simple question: How does the ABIM reconcile that the MOC pass rates for Spring and Fall of 2013 approximated 70%. What other medical board has such a low pass rate? How can a test with this pass rate be deemed a “good test”?

  17. Scared of Reprisal February 10, 2014 at 10:59 am #

    The Boards have grown from private organizations into regulatory agencies without any growth of oversight mechanisms. Being board certified is as voluntary as having as Social Security Number or a driver’s license. When in a democracy when we rely upon appointment of positions for regulatory agencies, the appointee is designated by one elected body and approved by another elected body. The Boards have chosen not to recognize this tradition. The criticism of the Boards is largely mute if the executives were directly elected by those regulated. If India can undergo elections with a billion people speaking over 200 languages with variable literacy, we as physicians should be able to directly elect those who protect our patients and our professional reputation. The concept that appointed members of specialty societies can choose these guardians better than my colleagues is frankly insulting.

    As I have participated in the MOL/ MOC discussions at a number of national meetings, the bugaboo of “government oversight” is oft stated. I counter that we are regulated and taxed by Federal, State and Local governmental bodies currently, and if I must be honest I feel that government is far more representative and transparent than the Boards. Advancing that regulation by the Boards in there current structure as preferable to “the government” does not resonate.

    In conclusion, please do not misunderstand this missive. Physicians need to be held accountable for continuing education. I truly believe we all begin to slip if our feet are not held to the fire. Perhaps legislatively we need to decouple the Boards from measures of competence and continuing education and develop new representative, accountable mechanisms to do this. This would free the Boards to do what they do best; to be a private elite group maintained through judging by paternalistic cadre whose membership is energized by truly voluntary status.

  18. Paul Kempen, MD, PhD March 12, 2014 at 12:15 am #

    Anyone wishing to follow the important fight against the extortion of working physicians via the ABIM/ABMS’s MOC program is welcome to follow and comment at:
    http://paulmdphd.blogspot.com/

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