Last week, Newsweek published an article entitled “The Ugly Civil War in American Medicine,” in which the author derided the American Board of Internal Medicine’s (ABIM) certification process for doctors. The author accused the ABIM of requiring unnecessary testing requirements “to fatten the board’s bloated coffers.” The ABIM quickly fired back that the Newsweek article contained "numerous and serious misstatements, selective omissions, inaccurate information and erroneous reporting.”
Newsweek writer Kurt Eichenwald framed the problem like this:
For decades, doctors took one exam, usually just after finishing training, to prove they had absorbed enough medical knowledge to treat patients. Internists—best known as primary care physicians—would take one test while those who chose subspecialties of internal medicine—cardiovascular disease, critical care, infectious disease, rheumatology—sat for additional exams. Doctors maintained their certification status by participating in programs known as “continuing medical education,” which, when done right, keep physicians up on developments in their field.
The value to a doctor of being certified can scarcely be overstated. Many organizations will not hire uncertified doctors. And, without that stamp of approval, even doctors who open their own practices rarely receive permission from hospital boards to treat their patients in hospitals. It was a sensible way to make sure doctors stayed on top of their game and weed out incompetent clinicians.
Eichenwald argues, however, that the certification process began to go downhill:
But then ABIM decided that rather than just having doctors take one certification test, maybe they should take two. Or three. Or more. Under this new rule adopted in the early 1990s, internists and subspecialists recertify every 10 years with new tests. In other words, a doctor certified at the age of 30 could look forward to taking an ABIM exam at least three more times before retirement. This was not cheap—doctors spend thousands of dollars not only for the tests, but for review sessions, for time away from their practices. And with each new test, the ABIM made more money.
More troubling than additional testing was the fact that "tests started including questions about problems that had nothing to do with how doctors did their jobs," Eichenwald writes.
For example, endocrinologists who worked exclusively with adults said they were forced to answer questions about endocrinology for children, even though the pediatric information was irrelevant to their practices. Heart specialists who do not perform transplants – and even those at hospitals with no heart transplant programs – said they had to study techniques for reading transplant tissue slides and how best to evaluate these patients so they could answer questions on the tests. But that knowledge was unrelated to the care they provide to their real patients, they said, and took time that they could have spent learning the latest medical findings about the cardiology work they actually perform.
He argues that the result of these out-dated questions was lower passage rates across the board. Last year we wrote an article on how pass rates for internal medicine had dropped from 90 percent in 2009, to below 80 percent in 2013. “Either doctors are getting dumber each year, or the test that helps determine who gets to practice medicine has less and less to do with the actual practice of medicine,” notes Eichenwald.
After outlining the potential problems with the MOC process, Eichenwald then lays out how much money ABIM has made as a certifying body.
[A]ccording to the Form 990s filed with the Internal Revenue Service, in 2001—just as the earliest round of new-test standard was kicking in—the ABIM brought in $16 million in revenue. Its total compensation for all of its top officers and directors was $1.3 million. The highest paid officer received about $230,000 a year. Two others made about $200,000, and the starting salary below that was less than $150,000. Printing was its largest contractor expense. That was followed by legal fees of $106,000.
Twelve years later? ABIM is showering cash on its top executives—including some officers earning more than $400,000 a year. In the tax period ending June 2013—the latest data available—ABIM brought in $55 million in revenue. Its highest paid officer made more than $800,000 a year from ABIM and related ventures. The total pay for ABIM’s top officers quadrupled. Its largest contractor expense went to the same law firm it was using a decade earlier, but the amounts charged were 20 times more.
Eihenwald writes that the watershed moment against MOC came in January 2014, when the ABIM “issued a series of new requirements for maintaining certification—that would have generated all new fees.” In response, Paul Teirstein, a noted “Maintenance of Certification dissenter,” along with a prestigious group of colleagues formed a new recertification organization called the “National Board of Physicians and Surgeons.” According to the article:
This new board is not just about breaking the ABIM monopoly, Teirstein says, but is also part of an effort to put the right people in charge of the profession’s future. Medicine has been “controlled by individuals who are not involved with the day to day care of patients,” he says. “It is time for practicing physicians to take back the leadership.”
We wrote earlier this year that the ABIM had responded to the criticism coming from the internal medicine community. Indeed, they announced many changes regarding their MOC process in February 2015.
After the Newsweek article was published, the ABIM released a strongly worded response:
A recent article posted to the Newsweek website regarding the American Board of Internal Medicine (ABIM) contains numerous and serious misstatements, selective omissions, inaccurate information and erroneous reporting.
The author asserts that ABIM has made the exams that physicians periodically take to maintain their certification harder in hopes of failing more physicians, who then must re-take the test and pay more fees to ABIM. This is untrue and not supported by data. The author says pass rates are steadily declining, but in fact they rise and fall over the years and vary across disciplines. In total, 96% of physicians who ABIM certifies passed an exam to maintain their certification.
The author asserts that ABIM has a monopoly on certifying internists, but in reality, internists have a choice among certifying boards that certify physicians in internal medicine and its subspecialties.
The author also presents an untrue and misleading interpretation of information from ABIM and ABIM Foundation's tax returns. His reporting reflects a poor understanding of that information and a highly selective presentation of information designed to prove his faulty premises.
Finally, the author failed to disclose that his wife is an internist.
"ABIM recognizes serious challenges in developing a relevant, meaningful Maintenance of Certification program that identifies physicians whose knowledge has been reassessed and who have shown that they have kept up to date with evolving medical information," they wrote. "That is why, last month, we announced immediate changes to the requirements for maintaining certification and the way ABIM works. We are sincere in our desire to work openly with the internal medicine community to rethink the ways in which ABIM serves physicians and the public."