Assessment 2020 blog
I am a member of the Assessment 2020 task force of the American Board of Internal Medicine (ABIM). The task force is looking at how to improve the assessment of physicians for purposes of board certification. We are seeking to engage physicians and the public in a conversation about physician assessment, quality of care, and what skills physicians need to provide effective, safe, efficient, and patient-centered care.
We’ve started a blog and so far there are posts up by Harlan Krumholz and Richard Baron (introducing the blog), Bob Wachter (on diagnostic error), and Ben Chesluk (on teamwork). Please go take a look and let us know what you think.
Posted on March 3, 2014, in health care and tagged American Board of Internal Medicine, Assessment 2020, Benjamin Chesluk, diagnostic error, Harlan Krumholz, Richard Baron, Robert Wachter, teamwork. Bookmark the permalink. 79 Comments.
Rather than looking at how to assess physicians, perhaps one should examine the value of the MOC process itself. As was stated by a group of medical educators editorializing in the New England Journal of Medicine 2010 poll about MOC “the true success of recertification will be defined not by whether physicians with time-limited certification maintain their certification but by whether ABIM can improve and reform the process of recertification sufficiently so that all physicians will choose to become recertified in a truly voluntary fashion.” By this parameter, MOC has been a total faliure. Pursing the current path of the ABIM is likely to guarantee it will remain so.
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Dr. Frager, thank you for commenting on my blog. I read the comments on that 2010 NEJM poll, and there were many doctors who stated that recertification was helpful and useful to their practice.
I do not really agree that recertification’s success should be gauged based on whether it is popular with physicians. I’m more interested in whether certification and recertification is useful to patients. There is evidence that it is.
Like any test, it is important to determine whether the test results are worth the time, cost, and energy expended to complete the test. Physicians are saying the results are not worth the cost and time. Many physicians feel they could accomplish more by studying on their own without the cost and bureaucratic overhead of the ABIM.
Of course some physicians feel the test is worthwhile. But by a 2;1 margin, they did not feel the test was worth recommending to a colleague.
Physicians would feel much better about MOC if they thought it would be truly useful to their patients, but they don’t.
The “evidence” that participating in MOC really accomplishes anything is very low quality, and much of it is funded by ABIM and performed by ABIM employees and therefore should be viewed with some skepticism. The ABIM foundation has warned physicians for this very reason the be skeptical of studies funded and performed by pharmaceutical companies.
The ABIM has a forty year history of trying to force more and more physicians to participate in MOC. Physicians are highly dubious for many good reasons. You might have a different understanding if you went through the medical training process
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Here is a response on Dr. Wachter’s blog (wachtersworld.com) when Dr. Wachter talked about how important MOC was. You should read the responses some time. Here is an excellent response (written by a lawyer) who clearly states why there will never be high quality evidence that board certification or recertification accomplishes anything,
Eric N. Grosch, MD, JD September 11, 2012 at 3:56 pm #
The ABIM’s claims on its website about “what the evidence shows” consists of retrospective data-dredging studies that demonstrate only marginal distinctions between board-certified and non-certified physicians’ clinical outcomes and those distinctions and others variably favor board-certified physicians and non-certified physicians. No study can ever adduce credible evidence that will definitively discern distinctions independently attributable to board-certification because education and training are confounders. That is, board-certified physicians and non-certified physicians have similar education and training, so to isolate and distinguish the independent effect of board-certification on clinical outcomes or any other index of quality of care, one would have to discern and compare the clinical distinctions attributable to four groups of physicians:
1. Residency-trained and board-certified
2. Residency-trained, not board-certified
3. Not residency-trained, board-certified
4. Not residency-trained, not board-certified
Since residency training is a prerequisite for eligibility to take the examination for board-certification, group 3 does not exist. Since most or all state boards of medical examiners require residency training for licensure, group 4 probably does not exist or is very small. The only extant studies of the distinctions between board-certified and non-certified physicians confine their comparisons to groups 1 and 2 and, since residency-training confounds the distinction in clinical outcomes and in other distinctions, the clinical differences in clinical outcomes and in other distinctions between board-certified and non-certified physicians chatter about zero.
Furthermore, the only extant studies of such distinctions treat distinctions in common, straightforward, bread-and-butter interventions that the practicing internist does every day or at least rather often, such as, for example, advising patients to stop smoking (see Ramsey PG et al. Predictive validity of certification by the American Board of Internal Medicine. Annals Int Med. 1989 May 1;110(9):719-26 PMID: 2930109) or prescribing beta-blockers and aspirin to patients with myocardial infarctions (see Chen Jersey MD, MPH, Rathore Saif S MPH, Wang Yongfei MS, Radford Martha J. MD, Krumholz Harlan M. MD, SM. Physician Board Certification and the Care and Outcomes of Elderly Patients with Acute Myocardial Infarction. Journal of General Internal Medicine. 2006 Mar;21(3):238-44), interventions for which large numbers of published instances exist in the medical literature and for which, therefore, some distinctions among practitioners might reach statistical significance. The trouble is that passing a board-certification examination does not depend on knowing about such obvious and straightforward interventions. Does telling a patient to stop smoking for the good of his or her health or prescribing aspirin to a patient suffering chest-pain really require board-certification? Not likely. Instead, passing a board-certification examination ostensibly requires quite esoteric knowledge about obscure conditions, such as idiopathic thrombocytopenic purpura or Wegener’s granulomatosis, conditions that the general internist might encounter once or never in a lifetime, both because nobody often encounters such conditions and because subspecialists, such as hematologists, pulmonologists or nephrologists, would most likely manage them, as a general internist would be foolish to try to manage them and wise to refer them to such subspecialists. Accordingly, the general internist is unlikely ever to apply the obscure, cutting-edge, esoteric knowledge, that he or she must acquire to pass the examination and which is likely to obsolesce between recertification-examinations, long before the general internist may happen to encounter such a rare patient. No study exists of how well general internists manage the many esoteric conditions, the characteristics, diagnosis and management of which they must book-learn to pass the board-certification examination in general internal medicine, compared to how well applicable subspecialists manage those esoteric conditions because the numbers needed to generate statistical significance do not arise and the number of general internists, whether board-certified or not, whose experiences in managing such patients appear in the published literature, is or approaches zero.
See my published, scientific peer-reviewed article, Does specialty board certification influence clinical outcomes? Journal of Evaluation in Clinical Practice, 2006 Jun;12(5):473–481, and its companion-article, Sharp Lisa K, Bashook Philip G, Lipsky Martin S, Horowitz Sheldon D, Miller Stephen H. Specialty board certification and clinical outcomes: the missing link. Acad Med. 2002 Jun;77(6):534-42..
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I agree with you that the studies showing an association between board certification and quality of care are observational studies and cannot prove that going through board certification causes doctors to provide better quality care. For that you would need a randomized controlled trial, and it is unlikely that any such trials will be done.
I still think that board certification is useful information for patients. A physician who never bothered to become board certified or who couldn’t pass the test is (on average) likely to be inferior to one who is board certified. Obviously that is not the only thing patients should look for.
I also think that medical evidence and practice is constantly changing and that it is reasonable to require physicians to take a test every 10 years to prove that they are up to date. Whether or not preparing for that test causes physicians to be better doctors, the fact that a doctor is able to pass the test gives patients some information that they are up to speed with current medical practice in their specialty.
I am also in favor of requiring law school graduates to pass a bar exam before they can practice law, even though there are no RCTs showing that preparing for and taking a bar exam makes someone a better lawyer. If someone doesn’t have what it takes to pass a bar exam I question if they have what it takes to be a good lawyer.
In any case, I think the recent changes in MOC are a done deal and are not going to be rescinded. It’s not just ABIM that is doing this, it is all the members of ABMS. I also think that if these changes, or something like them, were not made, that eventually similar requirements would be imposed by the licensing boards. I also understand that the licensing boards are going to accept meeting MOC requirements as satisfaction of their requirements.
I think requiring doctors to periodically do a quality improvement project in their practice is a good idea. Not all such projects will be useful, but many will.
I do understand that doctors are busy people and that MOC takes up a certain amount of time. So I think I do understand why some of them are not happy.
Testing every 10 years “to prove they are up to date” might be acceptable to physicians if that is what MOC did. But it doesn’t. I invite you to read Dr. Wachter’s blog “On becoming Chair of the ABIM…” where in over 200 responses physicians stated loudly and clearly that MOC is not relevant to their practice.
Please see “Taking the boards: a frisking, then a mugging” written by a prominent professor of gastrointestinal oncology which makes the same point. This was published 3/20/2014 on medscape. I will email you the text if you cannot access.
The problem is that MOC has gone through several iterations and has not gotten it right yet and is actually making it worse with each attempt. If you read the 2010 NEJM pro-ABIM editorial by King and Levinson, they write that they understand the MOC process needs improvement and they are working to make it better with input from diplomates. That is exactly what Dr. Baron and the current ABIM are saying at the present time. Isn’t it amazing that despite 40 years of ABIM effort, MOC still needs so much improvement?
Just as overtesting can occur in clinical medicine, overtesting can exist with testing of physicians. For example, please see The Step 2 Clinical Skills Exam- A Poor Value Proposition in the March 13, 2013 New England Journal. And please read the editorial in defense of this worthless exam by those who profit from it. Don’t they sound exactly like the ABIM defending MOC?
I know ABMS/ABIM say they are not going to change. The American Board of OB-GYN said that too about their recent definition of how an OB-GYN physician can practice and remained board certified. Two front page NY TImes articles about the absurdity of their definition and a lawsuit forced them to rescind their definition in January of this year. ABIM/ABMS says they won’t change, and they won’t until they are forced to either by overwhelming negative responses to their MOC process, or the outcome of the lawsuit alleging restraint of trade against the ABMS.
Right now the licensing boards of every state require self-directed CME to be licensed. It is the dream of Federation of State Medical Boards and ABMS to create a maintenance of licensure process which might be satisfied by MOC. They are not having any success implementing this program because of physician disapproval of MOC. They may keep trying, but they are not winning this battle. Physicians in each state are fighting tooth and nail to keep this from happening. Please read the details at changeboardrecert.com
By the way, I did my training at University of Michigan also!
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I’m sure there will be some change over time — there always is.
If you were the ABIM, wouldn’t you rather talk publicly about how to assess physicians in the future then to discuss how bad your assessment is at the present time?
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But that is what we are trying to do with the Assessment 2020 blog. We are also going to be soliciting comment from patient and physician groups. The task force I am on is focusing primarily on the cognitive exam, but comments can touch on other things. Please consider reading the Assessment 2020 blog and commenting on it. I wrote a post that is going to be posted at some point.
My only comment is “good luck.” I sincerely doubt the next generation of MOC will be any better than the debacle of the last 40 years.
This is a copy of what I posted on ABIM Assessment 2020 Blog,& e-mailed them. But they chose not to post it. Let’s see if you have more professionalism than ABIM.
I posted this on the Blog site but was not sure if it would survive the “moderation” process. Hence I have sent it via e-mail as well. I hope this will open honest dialogue within the Board and between the Board and its Diplomates.
Thanks for asking opinions from practicing physicians. Having recertified in 2005, and finding no real value, I decided to survey my fellow physicians if they felt they were getting value from MOC. Also, since in 17 years of clinical practice, not a single patient had ever asked if I was Board Certified (let alone MOC), I decided to ask my patients and those of other physicians, how they would select their physicians. The results are shown below.
How valuable is participation in MOC to your current medical practice?
1) N/A – I have not participated in MOC – 15.82%
2) Extremely valuable – 3.10%
3) Somewhat valuable – 10.28%
4) A little valuable – 17.46%
5) Not at all valuable – 53.34%
Which of the following is the single most important factor for you in choosing your doctor?
1) Local hospital membership – 1.01%
2) Friend or family recommendation – 12.41%
3) Personal experience (listens to me & helps solve my medical problems) – 58.59%
4) American Board of Medical Specialties Certification -5.63%
5) Another doctor’s recommendation – 13.42%
6) Doctor participating in your health plan – 6.49%
7) Doctor participating in Medicare/Medicaid – 1.88%
8) Website/phone book advertisements, Radio, TV, newspaper, magazine, billboard – 0.58%
As you can see, based on a large cohort, neither physicians nor patients, care much for MOC. The ABIM surely cannot ignore such findings from an objective, blinded study. It is clear that the current push for C-MOC is unsustainable, unnecessary, extremely unpopular, unproven, and will lead to loss of access to high quality physicians for millions of Americans. If the ABIM wants a meaningful discussion with practicing physicians, and intends to be a true partner, Dr. Baron and/or Dr. Krumholz should have an open discussion and I am willing to present the full results of my surveys.
For the good of the profession and the patient-physician relationship, I sincerely hope that ABIM will realize the fallacy of its current MOC program and quickly move to make it a truly voluntary process, one that practicing physicians will want to adopt, but without the threat of expiring Certificates.
If after reading this, you sill believe things you said earlier in this blog post, I’m afraid you are missing the forest for the trees.
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Hi Arvind. I’m not a physician — I’m an attorney. I’m on the task force as a patient/caregiver representative.
I guess a lawyer has more professionalism than a bunch of ivory tower doctors then. While I am a doctor, I am patient too. So I know patients don’t care for MOC, if they know about it, as is evidenced by my survey. If MOC is has no value for physicians or for patients, what is ABIM doing pushing it so hard on physicians working in the trenches? I hope you understand the gravity of the situation and convey that message to ABIM.
From the outset, let me state that I am against MOC, but, like nearly all doctors, I have a strong commitment to relelvant-to-my-practice self-directed lifelong learning; MOC simply does not serve that purpose. I am triple board certified in 3 disciplines: internal, pulmonary and critical care medicine. I have participated in MOC for 22 years and have passed every test and module on my first try. I can say unequivocally that no part of MOC has ever helped any part of my medical practice. MOC tests how good I am at passing tests and researching the answers to medical minutiae and esoterica and that is all it does and all it will ever do; in no way does it assess my skills as a doctor. The issue should not be how to improve MOC, since it is an inherently flawed concept that by it’s very nature cannot be improved. Rather, the issue is why a small group of privileged academics continue to work so hard to force it down the throats of front-line clinicians when there are no scientifically rigorous studies to validate its supposed benefits, and what few studies exist are dripping with conflict of interest issues due to at least some of the authors working for the very organizations that promote and benefit financially from the ongoing existence and, indeed, expansion of MOC, conflicts of interest that are NEVER acknowledged
In one of your responses to Dr. Frager above, you state: “I still think that board certification is useful information for patients. A physician who never bothered to become board certified or who couldn’t pass the test is (on average) likely to be inferior to one who is board certified.” What is your proof for making such outrageous claims? I suspect this is nothing more than your opinion, and if you or anyone is going to be part of a group whose agenda is to force a costly, onerous and time consuming process on another group, it better be based on far more than mere opinion. I can tell you for a fact that some of the greatest master physicians I have ever had the privilege to study under, and co-manage patients with, not only have never wasted their time on MOC, some were never even certified, yet I would trust them utterly above others to care for myself and my family. Conversely, I know some physicians who participate and succeed in MOC yet whose real world abilities are suspect.
If you want to know the measure of a doctor, it is something that cannot be ascertained by poorly written ambiguous outdated multiple choice questions. You need to assess physician rapport with patients, their ability to interview and examine a patient to obtain the maximum amount of useful data to then treat that patient. You need to take a measure of their compassion, moral and ethical standing, ability to work well with a team (as so much of medicine is now team based), how conscientious they are with follow up and follow through and many others intangibles. None of these critical elements are assessed by MOC.
MOC is artificial and flies in the face of real world medicine. Medical knowledge is far too vast and changes in that knowledge occur far too rapidly for rote memorization of vast amounts of medical knowledge to have any real world value and, in fact, is a gesture in futility. Medicine in this modern era is open-resource and open-colleague. Why should I try to remember all of the countless drug to drug interactions that exist for the thousands of drugs in common use when my EMR or my smart phone can give me that information more completely, quickly and accurately right at the point of care? My job is to take the time to check for such interactions, use my years of experience to decide which of them might be relevant to the patient sitting in front of me in my exam room, weigh the potential risks and benefits of a drug or combination of drugs for a specific patient, carefully explain all of this to the patient and then be sure to monitor the patient for any problems. I do all of this very well. Will your MOC ever be able to assess any of that? The answer, of course, is no, it won’t.
As an internist and lung specialist, I will never be the doctor who has to direct the primary cancer care of a patient with breast, colon or prostate cancer. For me to do so would be malpractice. Yet the MOC curriculum, if I wish to maximize my odds of passing, forces me to study such areas that are utterly irrelevant to what I do in my practice. Why? If I fail all of the cancer questions (other than lung cancer), what does that prove? That I am an incompetent doctor and no longer deserve to be certified? Really? And how important is it, really, for me to be up to date with the nuances of diseases caused by a parasitic worm that is endemic to the mountainous regions of China? The likelihood of my seeing such a case in my poor rural community in upstate New York is quite small and even if some global traveler recently in China ended up in my office with a medical problem related to that particular worm, my ability to help that patient will not be based on the fact that 2 years ago, I crammed knowledge about that worm into my brain for MOC (I’d estimate that I, and most doctors, retain less than 2% of knowledge that I “mastered” for MOC in areas irrelevant to what my practice is like within a few weeks of completing MOC). In the real world, I will take a thorough history, including a thorough travel history, conduct a thorough exam, consult, in real time, one of my favorite online infectious disease databases, which will help me order the appropriate tests and treatment for this patient with an unusual problem (for my geographic location) and deliver excellent overall care. So Marilyn, how did my studying about that worm two years ago help make me a better doctor? The answer, again, is it did not. But the time, cost, pointlessness, aggravation and frustration of having to study about that worm, or about cancers that I will never treat, or any of dozens of other examples I could share with you regarding irrelevant medical minutiae that the ABIM feels I and all internists ought to know not only makes me an unhappy human being, taking me away from my patients, my family and friends, but it inevitably cuts into the limited free time I have to study medical topics that are of interest to me, and that clearly does not help me be a better doctor. And let’s not even get started with the pointless busy-work PIM or the patient or colleague surveys.
Please don’t sprout the party line that MOC is voluntary, and if MOC does not work for this or that doctor, then such a doctor can simply skip it. We all know about the ceaseless overt or covert efforts being made by the boards, and other entities to make MOC, de facto, mandatory, or nearly so, by linking it to licensure, hospital privileges and reimbursement. At the very least, via various online reporting websites, attempts will be made to besmirch a good doctor’s name by revealing whether that doctor is or is not “participating” in MOC, bringing yet more pressure to bear for that doctor to cave in to the MOC mandate.
in a brief aside, here are 4 random MOC related questions to ponder: Why is it that 25-30% of doctors fail the secure exam at least once? Are we to believe that a quarter or more of doctors in this country are incompetent? Or maybe it is a ridiculous test designed with a high failure rate in mind, because retesting brings more money into the boards? Why do members of the ABIM steadfastly refuse to meet MOC opponents in an open forum debate? Why do some board members, especially chairmans, make obscene salaries? Why have some board members shown zero interest in doing MOC themselves, in some cases for decades, until they got jobs working for the boards, at which point they scrambled to update their personal MOC status (and even that is not uniformly true; some board members still are not “participating in MOC”, or are doing so selectively).
In my 20 years of being in private practice, I kid you not when I say not a single patient has ever expressed any interest in my board certification status, and the same is true for my partners. My schedule is full every day because I am a good physician despite MOC, not because of MOC. Patients stay with me because I meet their needs and new patients come to me on the recommendation of already established patients of mine, not because of an updated MOC piece of paper hanging on my office wall. You can talk all you want about how MOC is good for patients and good for doctors, in the absence of any compelling proof, but all MOC is good for is to add to doctor frustration and contribute to physician burn out and premature retirement, when our country is facing a doctor shortage. Oh yes, it also handsomely fills the coffers of the ABIM, and other boards, with lots of money on the backs of hard working, over-regulated doctors. Well done.
Since you have revealed that you are a lawyer, let me ask you this. MOC, especially the secure exam, is very analogous to taking the Bar. How willing would you be to have to retake your Bar exam periodically to prove to your clients that you are “up to date”? If you would be willing, I would venture to say that that would put you in the minority of your fellow lawyers, as my lawyer friends have all told me that they would never consider such a thing and would fight tooth and nail to prevent any external entity from trying to force it on them. If you would be really willing to “re-BAR”, would you be willing to do it every 10 years? Every 2 years? Do you really feel that relearning the broad-based spectrum of legal knowledge that was necessary to pass the Bar when you were fresh out of school would be relevant to you and worth the time and cost, now that your law practice has undoubtedly evolved into the specific legal areas that interest you, areas that I’m sure as a professional, you stay up to date with?
Gee, MarilynI I too am a U of Mich alumnusand have written about and studied MOC and MOL for these past 4 years extensively. As an anesthesiologist with extensive training in Europe including PhD, I have repeatedly offered my services to the ABIM and ABMS regarding their desire to develop a meaningful and useful process to improve patient care. Still waiting! ABIM extortion MOC is certainly NOT the way to go. How soon do you think I might get invited to work with the the ABIM in actually making this a useful and meainingful concept? If this is to be meaningful at all, it would be a first step to provide educational access to journal publications as well as information regarding scientific vs statistical weight of studies. I say this because the weight of all the publications of the ABMS and affiliates is almost exclusively that of Paid, ghostwritten and “demonstrations of associations via retrospective data analysis” heavily biased by the corporate bias of the ABIM and ABMS sponsors. I suggest that night and day are highly associated but by no means causative of each other-right. So is the “ABIM proof” of ABMS “higher standards better care”. Did you know that the worst physicians of 2013 were also Certified and taht incompetence as actions for state boards runs at less than 0.005%. Do you recognize wIth recertification failure rates of 28% that you will find so many competent physicians unworthy of certification, that they will be driven from practice in such numbers as to hurt patient care? The Boomers are just going to retire.
I understand you as a lawyer may not understand the importance of RCT vs the “garbage in garbage out” associations produced by the ABIM authors or the deep conflicts of interests which are NOT disclosed when these authors publish.
Recognize that Drs Nora, Wachter and Cassel have gone for decades without recertification while spewing this support for recertification and otherwise actively imposing it on their subjects for monetary gain. This has recently become very evident in the National Quality Forum affair.
IF MOC is so great,make it really elective by returning to lifelong certifications and then Capitalism will cause it to succeed as the very best means for physicians to remain updated. But wait-the ABMS does not really produce any education-just tests!
I think you are perfect for the ABIM-a hired mouthpiece without experience in frontline medicine. I would again openly invite the ABIM to an open discussion before a large crowd of working physicians. This might actually benefit your “cause” at finding what these physicians really think of ABIM’s plans. You might personally find it enlightening. I know I would look forward to debating any of your best on equal footing-any time any place. The Benjamin Rush society sponsored and invited ABMS and ABIM to do this in Philadelphia just last year-and the ABIM/ABMS cowards simply did not show-in their home town. What do you say to that?
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Hi Dr. Kempen. Actually, I am not accepting any compensation for serving on the task force, just travel expenses. And I don’t represent the ABIM, I only represent myself. And the task force is primarily looking at what the cognitive exam should look like in the future, so the scope of what we are discussing doesn’t have that much to do with the issues you are concerned about.
I thought my response to Dr. Frager was pretty clear on the point of there being no randomized controlled trials on board certification. And, as it happens, I do understand the purpose of randomization. I read a textbook in clinical epidemiology in order to be able to research family health issues, such as whether my then teenage daughter should start taking a statin to control her cholesterol. She has heterozygous familial hypercholesterolemia. Unfortunately, it turns out that FH patients were excluded from all the statin trials that had clinical endpoints for ethical reasons, so there is no high level evidence on what age children with FH should start treatment, and there never will be any. There are two observational studies of statins in adults with FH based on the UK and Netherlands FH registries, and there was a trial in kids with FH using carotid intima media thickness as an endpoint. Of course, there have been many trials of statins in non-FH patients with high LDL, so there is not really a serious question as to whether statins benefit patients with FH. The question is when do you start treatment and how intensive does it need to be, and definitive answers on those points are lacking.
Like many of the participants here, I take lifelong learning very, very seriously. I am in a highly competitive field (EP) in a highly competitive, referral driven environment-if I am not up to date, my practice fails. In addition, I submit QI reports to every hospital I work at as well as to CMS. I do not need the imprimatur of MOC to demonstrate my capability nor my commitment to excellence.
I am triple ABIM boarded and have never had a problem with these tests, apart from the inordinate cost (my last one was 3000.00!) and time away from doing what I do best-take care of a lot of patients, publish papers, run a practice, and try to see my family once in a while. I spend on average 60+ hours a week in direct patient care and another 10-20 doing paperwork. I spend maybe 12 hours a week with quality family time for my wife and two daughters; the rest is work and sleep. You can imagine how excited I am to enroll in MOC this month. I look forward to catching up with my kids after I retire. I can assure you that my participation in MOC earns no points with them.
And because my practice is driven by evidence, I am skeptical of MOC. There is really no solid evidence that it separates good from bad doctors, especially ones who works with their hands. I have read the editorials that pass for scholarship regarding MOC and they simply do not pass muster.
In order for MOC to add value, it must be a value for patients and physicians. It must be affordable in an environment where overhead continues to rise while reimbursement declines. It must be truly and completely voluntary. It must replace all other relevant CME requirements. And it must value and respect the time (or lack thereof) that physicians have in an environment where virtually any organization can (and does) establish a new high water mark for mandatory participation. At present, MOC falls short in each of these metrics.
I am trying to imagine attorneys allowing this burden in their ever changing, highly specialized fields. Would your profession submit to MOC? Would any profession?
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I certainly support eliminating duplicative requirements and having MOC replace all or most other CME requirements. And I support efforts to make QI projects at your institutions count toward MOC, and my understanding is that there has been some progress on that front.
Many attorneys have CLE requirements. It depends on what bars you belong to. Some have CLE requirements and some don’t. And lawyers who have no CLE requirements often participate in seminars and conferences where CLE is available to those who need it. A lot of CLE is quite expensive, too.
I work at a federal agency, and we have training programs all the time that we need to attend in order to do our jobs.
There are only about 15 states that have certification for lawyers, and it is voluntary and limited to certain types of practice, so certification is not something most lawyers participate in.
The bar exam does not really serve the same purpose as board certification. The bar exam’s purpose, in my opinion, is to provide some baseline standard that law school graduates have to meet before they can be unleashed on an unsuspecting public. There are many, many law schools that admit almost anybody with a bachelor’s degree. Many of these people simply do not have the intellectual wherewithal to practice law. Many of them succeed in graduating from law school but do not succeed in passing the bar exam and never are able to practice. Thank God for that. The bar exam is a way of keeping at least some incompetent people from being able to practice law. The bar exam is not something that could be repeated periodically. Even for elite law school graduates, law school does not prepare you to pass the bar. One must take a bar review course, which requires full time classes and studying for at least a couple of months. The reason is that the bar exam tests a wide array of legal doctrine but at a very shallow level. Law schools, especially elite law schools, do not teach to the bar exam. Everyone takes a bar review course after graduation and before taking the bar if they hope to pass. Usually people do not work while studying for the bar because they would be at risk of failing. If you did take another bar exam (some people have to do this because they practice in more than one state, or they move) the studying you would do for the exam would be of very little use to you in practicing law. The reason is that the knowledge on the exam is far too general to be helpful in solving any client’s problem. In addition, the bar exam only covers certain subjects, and many people practice in areas that are not covered by a bar exam whatsoever.
Moreover, practicing law requires that one do research for almost anything you do. Whether you are looking at statutes, regulations, administrative law, case law, etc., there is very little you can do without doing research. However, the research you do for one client may never be useful for another client. I guess what I’m trying to say is that practicing law usually does not require you to come up with an immediate answer. It requires you to find out the answer, and may require you to learn things for one client that will never come up again in the course of your career. This does vary somewhat depending on what kind of law you practice and so forth. I guess what I’m saying is that practicing law is more about learning how to find the answer than it is about knowing the answer.
By contrast, if you are a pediatrician you will see kids with ear infections or what have you over and over again, for example. And in most cases, doctors have limited time to look things up while the patient is in the room. They have to make a decision on what to do and then go on to the next patient. So I think comparing lawyers and physicians doesn’t get you all that far.
Are you all reading my blog just because of those few tweets I sent out?
Wonderful comments, especially this one “I guess what I’m saying is that practicing law is more about learning how to find the answer than it is about knowing the answer” – This sounds exactly like practicing medicine. I couldn’t have said it better – if I didn’t know you were talking about law, I would presume you were talking about medicine. Therefore, you just made the perfect argument to get rid of MOC and recertifying exams. I believe you are a good lawyer, but have a difficult time understanding physicians and medical practice.
Just like we docs don’t go about saying – if you prosecute or defend a murderer, you pretty much do the same over and over again – because we know better. So I think your ear infection example is a show of ignorance, and I’ll leave it at that.
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Again, with instant access to the interment and similar tools (e.g., Epocrates, Up-To-Date and many other high quality e-tools), it is entirely possible, even with the “limited time to look things up” that you mentioned above, to look something up in seconds at the point of care; I do it dozens of times every day in the presence of patients, and when done correctly, it is unobtrusive and very helpful, and spares me the pointless task of rote memorization of hundreds of thousands of medical facts and allows me to instantly find and use those facts relevant to the patient in front of me and synthesize them into a cohesive plan for that patient. As for your comment that the bar exam does not serve the same purpose as MOC, I could not agree with you more; you make our point for us. Original Board Certification should be analogous to the Bar, and it should end there. None of us are against Certification. But just as lawyers don’t get re-Barred with a process that encompasses all of law, doctors should not have to be re-Certifed with a process that expects knowledge of all of medicine. I gave several examples in my earlier post and could give dozens more. Why should an ob/gyne who has abandoned the ob part of their practice to focus exclusively on gyne be held accountable for up to date knowledge on deliveries? Yet the MOC process, at least in regard to the secure exam and the take home open book test modules, in terms of content, targets exactly the same material conceptually as our original Certification (the ENTIRE spectrum of IM, pediatrics, surgery, ob/gyne, or whatever specialty). And again, it is all an illusion of accomplishment. We memorize material for the secure exam, research the answers for the home modules, forget nearly all of it within weeks of finishing that cycle of MOC, and then continue to research, on a case by case basis, what we actually need to know for the case sitting in front of us. You state that lawyers need to research nearly every case they handle. Using your pediatric cookie cutter ear infection example, surely you see legal cases that have many similarities to prior cases you’ve handled. If you saw and researched a case 18 months ago and now are about to start work on a very similar case, do you completely and utterly rely on the research you did 18 months ago, or do you revisit your research, perhaps because there might be new relevant information since then, or perhaps because your recognize that the human mind and memory is imperfect and you may well have forgotten a key fact or two from your efforts 18 months ago, or perhaps a little of both reasons? Being diligent, you review NOW what you need to do the best job for the client in front of you NOW. The MOC preparation I did 18 months ago, or 12 months ago, or 24 months ago, is all highly suspect for something I need to do today, and so I review what I need to review TODAY to do the best job for my patient I’m seeing TODAY, and the MOC hoops I was made to jump through in the distant or recent past, so I can be declared “re-Certified”, did nothing to help me with today’s patient, but did cost me inordinate amounts of time and money, and subjected me to stress, aggravation and frustration for no discernible benefit to me or my patients, but, again, of great financial benefit to the ABIM.
I’m not a physician. Why can ABIM aka ABMS just state the truth about the reality of these organizations. They are glorified testing companies that just happen to utilize their nonprofit status to get a tax-exemption. The public good they do primarily services their pockets based on the revenue. The 990s are available to check out. As an attorney, you should understand the terms duty of loyalty and duty of care. The fiduciary responsibilities these organizations are supposed to uphold as nonprofits are being violated continually. And let’s not forget the blatant conflict of interest that exists with the board members of these organizations. Board members who promote their “product” to medical schools, residency programs, hospitals and insurance companies. Ms. Mann, please research the organization you claim to be supporting. While “quality measures” sounds nice and you are really just being used to promote another source of revenue for nonpracticing physicians making upwards of $800-900K a year.
One of the issues ABIM has been considering is whether to have a point of care resource available during the exam. This is referenced here: http://assessment2020.abim.org/projects/
Look under the heading “In Research and Development” and “Providing physicians with access to web resources during an exam.”
Marilyn, The “currently being implemented” point of care resources described in the web link are a joke. “Embedding high quality audio exhibits into exam questions” and giving the test taker the ability to zoom in on an image are a far cry from real world resources. They are not even referred to as point of care resources on the web page, but rather as “cognitive exam innovations” (there’s some metric techno-speak jargon for you). Other cognitive exam innovations include Implementation of multi-stage computer adaptive testing Providing physicians with access to Web resources during an exam Including computer-based clinical simulations in exams Inclusion of Clinical Calculators
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Marilyn, The point of care resources referenced in your link are essentially a joke. They consist of two groups, the “Currently Being Implemented” group, itself consisting of 1) the “embedding of high quality audio exhibits into exam questions” (how is that a “resource”?), 2) the ability to “zoom in on images” and 3) “enhanced exam performance feedback”. You’ll forgive me if I am utterly underwhelmed by these “resources”, given how far away any of them are, even when taken together, from the full spectrum of real world resources available to me and all physicians today. Both the zoom and audio items, in fact, seem more likely to allow for even more esoteric test questions rather then recreate real world care and unless a majority of the test questions will involve the need to hear various heart or lung sounds, or will contain EKGs or X-rays, it is very hard to see how the arrival of audio embedding or zooming abilities is going to significantly alter the overall nature of the test, and I can’t for the life of me figure out how “enhanced test feedback” will be much of a real world resource. The second group, “In Research and Development”, consists of the following: 1) “implementation of multistage computer adaptive testing”, 2) “including computer based clinical simulations in exams”, 3) “providing physicians with access to web resources” and 4) “inclusion of clinical calculators”. Only the last two really come close to being real world resources and each has immediate and obvious limitations. With regard to someday being able to “access to web resources”, as with the test content itself, the ABIM will have no choice but to be the ones to pick a uniform set of “resources”, perhaps only one, to be made available to all MOC participants, otherwise it will not be possible for the test to be “standardized” and statistically reliable. But in the real world, just as my practice (like every doctor’s practice) has uniquely evolved into its current state and niche, the combination of resources/devices that I have grown comfortable with, and which I find useful, has evolved over time and are unique to me, and are undoubtedly different than what suits the doctor up the street or in the next town. I know my resources like the back of my hand, and can use them effectively and efficiently, at light speed, at the point of care. Ask me to use the resources and/or devices (keyboard/mouse driven computers vs. touch screen/app driven smart phones or tablets) that another doctor favors, or worse, what the ABIM ultimately decides, in their infinite wisdom, magnanimity and benevolence, to mandate all MOC participants use for MOC purposes, and I may stumble about like a clueless idiot. Hardly my real world. As far as calculators, as I’m sure you know, they allow us to quickly take measured test results, like numbers from a cholesterol panel, and calculate other clinically useful parameters from the raw data. In many cases, our labs already do this automatically, for example calculating the LDL from the measured total cholesterol, HDL and triglycerides and also calculating the non-HDL cholesterol, and including those calculated results in the test report. In a testing situation, what does it possibly prove about my medical skills to make me plug numbers into such a calculator to come up with other numbers? What’s really important is for me to know what to do with the final numbers, so don’t waste my time checking my calculation skills and my ability to plug numbers into calculators, rather just tell me what the LDL and non-HDL cholesterol results are, and then, perhaps, ask me what the results mean and what I would do about them (and this would be true for any of the dozens of other medical calculators that exist to crunch medical numbers of all sorts). My point is that offering me, the MOC participant, access to one or more medical calculators is no great leap forward in making MOC more real world, but it is great propaganda for the ABIM to tout it as such, to lay members of their advisory panel, such as you, to doctors being coerced into doing MOC, and to the public, as needed. If it is to be a real world assessment, let each doc use for MOC whatever devices and resources they use in their office or hospital. Of course that will never happen, not only because it will make the standardization and statistical reliability of MOC all but impossible, but also because it will raise grave concerns, at least on the part of the ABIM, about the security of the secure test. Considering how I was essentially strip searched when I took the IM secure exam less than two years ago, and was forced to undergo both digital palm print analysis and show photo ID to the same test proctor 4 times in the same day, as I left the testing center between modules to have a power bar and return 10 minutes later, and could not even bring my own watch or handkerchief into the testing room (not sure if they were too worried that I had somehow managed to copy all of internal medicine on my hanky in invisible ink, or that I might somehow copy test questions onto my hanky for sale to the highest bidder later, despite being under constant video surveillance), there is no way they are going to let me bring my smart phone, with all of its audio and video recording abilities, into the testing room. But my smart phone is part of my real medical world, and a critical part of it at that. Both groups of the so-called resources your link took me too are collectively, and somewhat ominously entitled with the following metric techno-speak rubric: “Cognitive Exam Innovations”. You’ll forgive me if I continue to struggle with seeing how any of this metric mumbo jumbo mirrors my real world, although I should note that the ABIM has been talking up these “innovations” a great deal of late, in an apparent effort to show how “responsive” they are to the concerns of the rank and file docs who take their tests perhaps? Hah! Plus, over half of these “innovations” are only in the “R & D” stage; who knows how long it will take the ABIM to get any of them ready for prime time? And what happens in the meantime? Years pass while committees and committee members come and go, looking at the “problem” and ways to make “improvements”, while all the while, the cost, time involved and requirements of doing MOC go up and up, along with the symbiotic cost of preparing for MOC. Select board members continue to rake in huge salaries for as long as feasible, then, when things get too hot, or when they’ve milked the cow as long as feasible, they move on and others come in and start milking the cow, with no one every really fixing the unfixable problem that is MOC, and all with the assumption that docs will grumble, but will continue to be cowered into doing MOC. Newsflash! Those days are coming to an end Marilyn. We are mad as hell and are not going to take it anymore. Again, broad based testing for certification when I finished my training, and before my practice evolved into its current unique niche, served a reasonable purpose, just as your Bar did. Recertification years later, via a similar broad based testing process, serves no legitimate purpose, just as making you re-Bar with a broad based legal assessment would serve no legitimate purpose either. If you want to evaluate how competent I am, come watch me work with my patients and analyze my charts to see if I have successfully controlled blood pressure, cholesterol levels, glucose levels in diabetics, etc, etc. That is the only way to really assess me, but of course, studying every doctor in the country as they work with their patients and reviewing tens of thousands of charts to see if recommended goal parameters are being met would be unacceptably costly and onerous to accomplish, which is unfortunate, but not our fault. But don’t expect us to stand by quietly while the ABIM continues their tireless efforts to subject us to the costly, onerous, unproven bogus process that is MOC.
Sincerely, Dr. Jonathan Weiss
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You know nothing about me. You do not know what I think and believe and you are making a lot of unwarranted assumptions.
Your belief that they are unwarranted goes to show that you really do not understand these organizations. Many of the physicians commenting are pointing out fact, not assumption and nothing I stated in my previous comment was based on assumption.
“You must accept the truth from whatever source it comes” – Maimonides
Wow, Marilyn. Whoever Suja is, has pointed to non-clinical issues, which we docs may not have knowledge of. Somehow, general statements like such seem to have touched a nerve in you. Can you imagine how irate we docs with 15-25 years practice experience must feel when non-practicing, ivory tower folks impose unproven mandates on us! After all this discussion, we hope you will be convinced of the futility of this whole exercise called MOC.
If one is going to promote some kind of continuous board re-certification system, take a look at the prime movers for such an effort, and ask what they have to gain, and how they use the power of government to obtain those gains. You must certainly be aware that Dr. Cassel, as CEO of the ABIM, was taking home a compensation package of $800 or $900 K. Not bad, but it paled in comparison to the Pediatric board package of $1.2 million.
Where did Dr. Cassel go? To the National Quality Forum, as CEO of that group, which is largely funded by the Center for Medicare and Medicaid! And that is where you see a confluence of “quality” and “patient safety” people, all vying to get their products and services listed on the approved list of NQF. Yes, Dr. Chuck Denham was paid $11.6 million for his efforts in getting CareFusion’s product on that “approved” list. Where was the science behind this? Evanescent, to say the least. Well, CareFusion settled those charges by the U.S. Justice Dept. for north of $40 million, a drop in the bucket. Meanwhile, Cassel accused Denham of being a liar for not divulging is side “job”. However, as it turned out, Cassel recently resigned from two boards she received lucrative contracts with. Apparently she had not divulged those either!
Hey, these people might be properly termed a ring of criminals in some circles. Yet, they are entrusted with passing judgment on their fellow physicians? Why can’t somebody find them a real job?
As it happens, I am not a big fan of outsize executive compensation packages, especially for nonprofits.
I’m not a fan of any of these “quality” and “patient safety” people. Let’s find these people real jobs in the real world so they can earn an honest living.
Harlan Krumholz is a good friend of mine. Terrific person.
Sorry to see you have failed to post my latest comment earlier today (I know because these later posts have taken precedent-perhaps the truth is for you too hard to hear, like your ABIM friends earning off the backs of working physicians and the public at large.SO when will they agree to debate this matter in open forum of THEIR choosing!
I’m quite certain all the “quality” and “patient safety” people in this ring are terrific. Let’s help them get terrific jobs so they can deliver the “quality” care that all patients deserve.
I have posted all the comments and there is nothing in my spam filter. I’m sorry, but if you do not see your comment I do not know what happened to it.
Dear Marilyn: Thanks, lets just try again one more time. This is from : http://www.abms.org/maintenance_of_certification/pdfs/ABMS_MOCMythsFacts_3-20-13.pdf
“FACT: For 80 years, ABMS has been a reliable and trusted resource for consumers and health care professionals seeking information about physician qualifications”
And if you look at the articles there you will see a overwhelming preponderance of ABMS authored, paid and published articles just ripe with Bias. So WHY has the ABMS with over $350 million in gross revenues yearly been unable to deliver proof that Board Certification makes for the “Higher standards, better care” of the ABMS copyrighted logo? You yourself indicated there are no studies to document the value of certification, Also find there:
“FACT: ABMS recognizes that regardless of the profession – whether it is health care, law enforcement, education or accounting – there is no certification that guarantees performance or positive outcomes.”
So just why have you personally committed yourself to supporting this group of extortionists, people who went to congress to utilize the regulatory capture of medicine-using legislation to force compliance to corporate profitable mandates under the PQRS-MOC?
Board Certification has been corrupted from a document of “attainment of consultant status” to a mere entry requirement to MOC-which the ABMS lobbied congress to impose 2% financial penalties if doctors fail to buy that product! My board clearly indicated that this was a losing proposition-yet were forced by the ABMS to comply or “lose their franchise”!!!! These facts are documented in ABMS literature at: http://www.theaba.org/pdf/MOC_PQRS.pdf Please read the document there!
Extortion is extortion and YOU as a lawyer should know this and be repulsed by it.
Also from above:
MYTH: MOC is not voluntary and will be a mandatory part of Maintenance of Licensure (MOL).
FACT: Participation in the MOC program is voluntary and there is no intent to make it part of MOL.
What nonsense! The ABMS lobbied congress to impose financial penalties. Insurance programs deny physician inclusion without certification. Lifelong certification WAS how the ABMS built this house of cards. They have changed the rules repeatedly and exponentially in these past years to FORCE DOCTORS to subscribe or lose hospital privileges and insurance payments. This is the basis of the AAPS lawsuit which can be reviewed at: http://www.aapsonline.org/AAPSvABMScomplaint.pdf
What do you think of that lawsuit? Do you th ink FTC regulations, Sherman act or RICO laws may eventually be pressed to point?
I have so much to share with you and IF you are truly independent and legally interested in the multiple affronts to heath care this ABMS propaganda/lie of quality and better care constitutes, I encourage you to contact me directly and we can talk at alumni:email@example.com.
feel free to google KEMPEN-MOC MOL and you will find I have not been idle these past years in documenting the atrocities of MOC and MOL. If you are truly independent-then you will really WANT to delve into the truth.
On the side, what do you think of the AAPS lawsuit-do you think practicing FP docs should be removed from any hospital because they failed to re-certify??? Remember just how voluntary all that is! Should 30 years of sound practice without malpractice justify discharge from treating in a hospital? Remember, this is primary care physician! What do YOU make of the failure rates of 28% and 33% found in recertification testing in recent years for IM and FP ?? Do you think this entices people to enter THESE primary care specialties-areas of SHORTAGES when pass rates near 100% exist in very circumscript specialties? Sure we hear that medicine advances so fast-but anatomy and physiology remain extremely CONSTANT! The advances in medicine are overwhelmingly based in pharma and other device based products CORPORATE goals.
On the side- I am a very capable anesthesiologist who has a long history of academic work and teaching. I will NOT recertify,but retire in preference to submitting to EXTORTION! Where do you as an American, and U of M alumnus and lawyer stand to the issue of ABMS extortion-using a totally unproven, ever changing corporate product as method of extortion?? Simply because they believe they can extort working physicians to support their ability to earn high pay without ever seeing a patient-these are politicians not doctors! But then, these professionals are very similar to you and your lawyer friends! NO?
Oh yes, and when the public hears that NPs, PAs and CRNAs are “certified” does this make them better than physicians who have worked for 30 years, and then let that nonsense “lapse”? Not to mention they might have only been out of a school and are licensed outside of a state medical board, yet may even present themselves as “doctors” (i.e,. of nursing or psychology or pharmacy …………………………..
The ABIM and ABMS is killing this profession! The government want “cheaper care” and these money sucking corporations are pricing doctors out of competition. What do YOU think all the MOC really costs? Remember, doing that on a weekend trip to Chicago or NY costs you travel, hotel, time and locums coverage. What do YOU think a three day weekend costs to complete MOC and I am not even asking the damn course fees!DO you make $300/hour and how do you charge YOUR weekend time away from your LIFE and FAMILY!
I have read the defendant’s brief in support of the motion to dismiss in AAPS vs. ABMS. I am not an antitrust lawyer, but I found their arguments persuasive. I do not currently see the basis for a successful lawsuit based on antitrust violations. However, not being an antitrust lawyer, I am not the best source of information on that issue.
I am merely playing an advisory role in a committee that has been set up to come up with some new ideas on how to improve the cognitive test. I feel my role is very limited here.
Do you agree that antitrust laws were passed in order to prevent monopolistic companies to control certain markets and thus charge exorbitant rates? Do you think the ABMS has lobbied hard so that it can be the only licensing agent that physicians are required to pay in order to be able to practice medicine? Do you really think this is proper when there is no reliable evidence that these products yield a higher quality of care? Do you think this is proper when those sellling these products are associated with other “patient safety” people who are peddling products by getting them onto that “approved” NQF list?
If you want to improve the cognitive test it must be worth something. It would need to be very low cost, have a failure rate/threshold that indicates serious lack of medical judgement, be universally applicable to all physicians irrespective of specialty and be voluntary. This would mean getting rid of time limits and concentrating on “Updating” physicians to those new and perhaps controversial developments actively discussed from the past 24 months. This would mean that the ABMS would need to actively publish online a catalog of recent issues/article/guidelines and also recognize that all of these are NOT written in stone and the answers to the questions must be RIGHT and not “most likely correct” without being wrote memorization but Judgement.. Have you read:
BMJ 2013;346:f3830 doi: 10.1136/bmj.f3830 (Published 14 June 2013)
Why we can’t trust clinical guidelines
Despite repeated calls to prohibit or limit conflicts of interests among authors and sponsors of clinical guidelines, the problem persists.
This applies to the ABIM and ABMS severely!
Also important for you as ABIM consultant are:
Mayo Clin Proc. n August 2013;88(8):790-798 n http://dx.doi.org/10.1016/j.mayocp.2013.05.012
A Decade of Reversal: An Analysis of 146
Contradicted Medical Practices
Objective: To identify medical practices that offer no net benefits.
Methods: We reviewed all original articles published in 10 years (2001-2010) in one high-impact journal.
Articles were classified on the basis of whether they addressed a medical practice, whether they tested a
new or existing therapy, and whether results were positive or negative. Articles were then classified as 1 of
4 types: replacement, when a new practice surpasses standard of care; back to the drawing board, when a
new practice is no better than current practice; reaffirmation, when an existing practice is found to be
better than a lesser standard; and reversal, when an existing practice is found to be no better than a lesser
therapy. This study was conducted from August 1, 2011, through October 31, 2012.
Results: We reviewed 2044 original articles, 1344 of which concerned a medical practice. Of these, 981
articles (73.0%) examined a new medical practice, whereas 363 (27.0%) tested an established practice. A
total of 947 studies (70.5%) had positive findings, whereas 397 (29.5%) reached a negative conclusion. A
total of 756 articles addressing a medical practice constituted replacement, 165 were back to the drawing
board, 146 were medical reversals, 138 were reaffirmations, and 139 were inconclusive. Of the 363 articles
testing standard of care, 146 (40.2%) reversed that practice, whereas 138 (38.0%) reaffirmed it.
Conclusion: The reversal of established medical practice is common and occurs across all classes of
medical practice. This investigation sheds light on low-value practices and patterns of medical research.
And if the ABMS fails to deal with the realities of modern medicine-I will continue to look to Europe for hope and point out to you that Very excellent care at low cost can be obtained there (in the complete absence of any ABIM or ABMS mind you) and my 10 year experience from living and working there is the reason I am so committed to exposing the falsehoods propagated by the ABIM and ABMS which are damaging to this profession and patient care:
BMJ 2011;343:d4519 doi: 10.1136/bmj.d4519
Disinvestment from low value clinical interventions:
Over the past 10 years NICE has identified over 800 clinical interventions for potential disinvestment.
So when experienced physicians do less well on these arbitrary and capricious ABMS tests than recent grads, that does NOT indicate they are “out of date”, but rather are experienced enough to know that the scientific weight of many guidelines are overwhelmingly mere opinion, often propagated behind corporate interests like the ABIM/ABMS-out to sell new medical products”looking for a niche” to make profits!
You might also note that the national medical societies are all led by the same cadre of academic leaders circulating in the various boards and BOTH are making mucho denira off of this testing.
If the ABMS remains committed to extortion I believe physicians will continue to work against them and they may soon find themselves completely irrelevant when NPs and PAs are permitted widespread latitude to compete with overly expensive doctors, who fade into the background because they have been driven out by costs.
Take a long look at this and see how it fits your friends at the ABMS/ABIM regarding the future of ever increasing demands and costs to stay in business as a physician. Make clear to them that 17 US states already allow CRNAs to practice without ANY physician supervision and under the boards of nursing, completely out of reach of any State Medical Boards!
Look below at the AGENDA of the College of Nurse Practitioners. They have a vision and a concerted plan of attack on mind for
1) equitable pay – meaning they want same pay rate as docs
2) no restrictions/control by other professions, ie by docs.
3) non-hierarchical team care
What is our counterattack plan, P4P and AAPS?
ACNP STRATEGIC PLAN
Adopted February 2005
TO ENSURE A SOLID POLICY AND REGULATORY FOUNDATION THAT ENABLES NURSE PRACTITIONERS TO CONTINUE PROVIDING ACCESSIBLE, HIGH QUALITY HEALTHCARE.
WE BELIEVE THAT:
NURSE PRACTITIONERS HAVE THE ABILITY AND RESPONSIBILITY TO POSITIVELY INFLUENCE HEALTH POLICY.
THE CARE OF INDIVIDUALS, FAMILIES, AND COMMUNITIES IS THE FOUNDATION OF OUR NURSING PROFESSION.
NURSE PRACTITIONERS PROVIDE HIGH QUALITY, COST-EFFECTIVE CARE.
INTERDISCIPLINARY NON-HIERARCHICAL TEAM CARE IS THE HIGHEST QUALITY OF CARE.
ORGANIZATIONAL COLLABORATION AND INCLUSIVENESS IS ESSENTIAL.
NURSE PRACTITIONERS WILL BE ABLE TO PRACTICE TO THEIR FULL CAPACITY AND WILL BE VITAL AND INDISPENSABLE TO QUALITY HEALTHCARE.
NURSE PRACTITIONERS WILL BE RECOGNIZED AS VITAL AND INDISPENSABLE TO QUALITY HEALTHCARE.
NURSE PRACTITIONERS WILL HAVE A NATIONALLY RECOGNIZED SCOPE OF PRACTICE AND WILL BE EQUITABLY PAID FOR THEIR SERVICES. THEY WILL BE PRACTICING WITHOUT RESTRICTION IN EVERY SECTOR OF HEALTHCARE DELIVERY.
THE PUBLIC WILL BE FULLY AWARE OF THE VALUE OF NURSE PRACTITIONERS. CONSUMERS WILL DEMAND AND OBTAIN DIRECT ACCESS TO CARE FROM NURSE PRACTITIONERS IN ALL AREAS OF THE COUNTRY.
EVIDENCE WILL UNQUESTIONABLY DEMONSTRATE THAT PATIENT OUTCOMES IMPROVE WHEN CARE IS PROVIDED BY NURSE PRACTITIONERS.
NURSE PRACTITIONERS WILL BE KEY POLICY DECISION-MAKERS IN TRANSFORMING HEALTHCARE.
ACNP WILL BE THE NATIONALLY RECOGNIZED LEADER IN PUBLIC POLICY ISSUES FOR NURSE PRACTITIONERS, WITH EMINENT INFLUENCE ON POLICY FORMULATION.
NURSE PRACTITIONERS WILL BE ABLE TO PRACTICE ANYWHERE IN THE UNITED STATES, SO THERE WILL BE NO BARRIERS ACROSS STATES.
ADVANCED PRACTICE NURSES WILL EXPAND THEIR INFLUENCE IN THE HEALTH POLICY ARENA THROUGH GREATER COLLABORATION; SPEAKING AS A COLLECTIVE VOICE.
ALL STATES WILL USE SAME CREDENTIALS/TITLE.
OUTCOME ORIENTED GOALS
PUBLIC POLICY- ACNP WILL HAVE THE CAPACITY TO IMPACT POLICY AND REGULATION AFFECTING NURSE PRACTITIONER PRACTICE.
HEALTHCARE INDUSTRY INFLUENCE- ACNP WILL BE RECOGNIZED AS AN ESSENTIAL PARTICIPANT IN DIALOGUE ON HEALTHCARE ISSUES.
LEADERSHIP AND EMPOWERMENT- NURSE PRACTITIONERS WILL HAVE THE CAPACITY AND EXPERTISE TO INFLUENCE POLICY AT ALL LEVELS.
KNOWLEDGE SOURCE- ACNP WILL BE A LEADER AND PREFERRED PARTNER IN EXPANDING, DISSEMINATING AND TRANSLATING KNOWLEDGE ABOUT NURSE PRACTITIONER ISSUES.
ORGANIZATION – ACNP WILL HAVE EFFECTIVE STRUCTURES, PROCESSES, RESOURCES, AND CULTURE TO ACCOMPLISH ITS VISION.
A number of comments in this thread contain personal attacks, insults, rudeness and are just plain uncivil. While I welcome comments on my blog, I will not be approving any more comments that do not meet reasonable standards for civility.
Although there is nothing wrong with some emotion working its way into a discourse about something people feel passionate about, you are correct that the dialogue should never become personal, rude or uncivil toward any of the discussants. Hopefully, the dialogue can continue without those elements.
I find these comments on this thread quite interesting—-Marilyn as a regulator and as a lawyer, are you advising that all lawyers retake the Bar exam every year or two? If not are you advising that the federal government mandate that lawyers take a national certification or recertification exam? How about architects, engineers, nurses and other professionals? Every time testing goes on there is a pro and a con, a cost and a benefit——where does the money come from to pay for this? If there were proven benefit, we all could have a different discussion, but there is no scientifically proven benefit—-only cost. Lawyers are trained to argue based on law and interpretation of the law; doctors argue based on scientific fact. Doctors opine based on scientific fact, pros and cons, risks and benefits. MOC has never been proven to be beneficial but it does have real costs. Some of those costs are non economic and are harmful to the medical profession. There are decreased attendance to educational meetings that are more relevant to those individuals practice, there is decreased comradery and decreased time for physicians to read/study articles that apply to their specific patient populations. America has a very diverse population—-one size does not fit all. Do you think that all women should only buy a size “4″ pair of jeans? All men drive the same kind of car? Nobody should be uncivil. The tone that we all pick up from the thread is obviously one of anger and frustration. As a lawyer and defender of peoples rights, I can not figure out why you would defend MOC. It is a one size fits all program that has never been proven to improve the quality of care. It takes away individual freedom of physicians who have sought varied approved ways to keep current and it is weakening the profession of medicine by destroying other long proven quality CME programs and meetings.
Actually, I’ve got some issues that have cropped up since yesterday afternoon and I just am not going to be able to respond. My mother was taken to the ER this morning and has been diagnosed with Ogilvie’s Syndrome. I’m going to have to make arrangements to fly out to California.
Plus at my oncologist’s yesterday afternoon they found a lump in my breast and today I had to go for an ultrasound and then a biopsy.
I should have time to approve comments if the rest of you want to talk to each other but I’m tied up right now. Thanks for understanding.
Very sorry to hear about your personal and family health issues; by all means, please tend to these matters and return to the blog when possible. Dr. Weiss
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Sorry to hear you are having personal troubles. I do hope you did not mean me when you indicated there were personal attacks-I hope to discuss the shortfalls of the MOC system;
this from a local listserv…the story is from a very experienced managed care/healthcare industry attorney (his local claim to fame was that he was fired by a local managed care org/insurer administrator when he found out $100s of millions of defrauded excessive admin fees by said company, a very politically inconvenient discovery and as yet still unexplained all the way to the DOJ). NOt a mention of MOC or Certification and this reflects the patient reality as it really is-no concern for certifications and busywork-contact time is important.
” Let me tell you a true story. I’m recovering from a little surgery. My first encounter, as a patient ,with the medical establishment in a long time. You want to know how I selected my surgeon? I remembered many years ago when I was a grad student, I had a summer job doing building maintenance. One of the other guys working there said he was going to go to medical school and become a surgeon. I remembered his name, looked him up on the Internet, called his office and asked his assistant to ask him if he was the guy who worked at this company. I left my number and said I would call her back the next day to find out. I didn’t get the chance. The next day Mike called me. He said he remembered me, we caught up after all these years and he said:” you come see me and I’ll take care of you.”
That’s what I wanted to hear. That this Physician thought of me as a person and that he was willing to employ his skill to “care for me”. I didn’t want a procedure, I didn’t want an evaluation, I wanted someone to care for me. He took time from his very busy schedule to call me and tell me it was going to be alright because he would care for me. That is how a person with 4 graduate degrees selects a physician. No community measurement bullshit, no peer grouping, no council of health plans horseshit, no mymedica, no Healthpartners crap. Just a bunch of foolishness we used to call Doctor/patient relationship. Here’s the funny part, it worked just fine. When I had a problem, he always had time. If I was concerned, he wanted to see me to make sure everything was OK. And it was. BTW, quality measurement of insurance companies? What value or quality do insurance companies add? Complexity? Obfuscation? Useless requirements? On most days, I can get a better price from a provider by telling them I’m uninsured. Seems strange, doesn’t it? “
I received this Email today from a fellow concerned physician:
Most doctors are opposed to MOL, MOC, and OCC. Why are our organizations promoting them?
Most physicians feel it is a costly, time consuming, onerous, bogus process. These physicians much prefer to following self-directed lifelong learning by pursuing CMEs of their own choosing.
Where are the numbers so we can evaluate all of them not just the cherry picked ones.
Good news! The radiologist called me this morning and said my biopsy only showed benign findings. They recommend another mammogram in 6 months. My mom was discharged from the hospital today, although she is not fully recovered. She is being treated on an outpatient basis.
I happened to see the following study in JAMA Internal Medicine, which seems relevant to some of the discussion about whether doctors regularly look things up while they are seeing patients.
Del Fiol, et al. Clinical Questions Raised by Clinicians at the Point of Care: A Systematic Review. JAMA Internal Med, published online March 24, 2014.
Some people have brought up the issue of attorneys and whether they should be subject to periodic examinations and continuing education requirements. Most state bars do have CLE requirements. I certainly agree that the issue of competence is very important in choosing a lawyer. I also think many lawyers are not very competent. However, I don’t really have an answer to improving the situation. The bar exam is not suitable to be given as a periodic exam.
For many years, lawyers were forbidden by bar rules to advertise as being expert in a particular area of law. Then because of certain Supreme Court and other court decisions, the advertising rules were loosened. Now it is common for lawyers to advertise as being expert in certain areas of law. Certain states have passed legislation allowing for specialty certification of lawyers. The number of lawyers who hold specialty certifications has been growing. Typically the requirements include an exam and continuing legal education requirements, with recertification required every 3-5 years. Certification is voluntary and is available only for certain specialties. Currently, only a small percentage of lawyers are board certified.
Lawyers can, of course, be sued for malpractice, and there are also bar discipline programs.
So glad yours and your mom’s medical issues are moving in a good direction and thanks for continuing the discussion. I’m not totally sure how the issues raised in this article directly relate to MOC. The article basically says that medical folks are pretty good at tracking down answers to stuff they don’t know at the point of care, but only do so about 50% of the time and that the ongoing adoption of EHRs and other electronic point of care tools (like my irreplaceable smartphone) will likely improve this, which seems good. Returning to MOC, you state clearly that the “bar is not suitable as a periodic exam” and since the majority of MOC is highly analogous to the bar, then perhaps you can now see why us docs are having such majors issues with MOC and why, on a conceptual basis, it cannot be improved or fixed, because it is not, by it’s very nature suitable for it’s intended purpose.
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I think the fact that they only do so about 50% of the time could relate to lack of time to do so. Whether EHRs and other electronic point of care tools will make a big diference remains to be seen.
I have not taken a physician board exam and I assume you have not taken a bar exam so we are both somewhat hampered in making a comparison between the two, but I’m not sure the two are all that similar. The bar exam covers a broad array of topics at a very shallow level. The knowledge needed to pass the bar exam does not get you very far in actually practicing law.
By contrast, physician board exams are much more specific about describing clinical scenarios and how they should be handled. I’m sure the exams are not perfect in that regard, but that’s the general idea.
I do understand why many physicians are not happy with MOC. They are busy people, the requirements take time, the exams are anxiety producing, there is a certain financial cost in fees and time away from practice.
Well, Marilyn, I believe you were the one who brought up the idea that recertification exams were not possible for the bar. You are quite right, in that the lawyers would never ever stand for such nonsense. They would immediately pass laws which would prevent such useless intrusions into their lives.
Of course, the subject matter between the bar and medical specialty exams is very different, but the idea of re-certification once having successfully passed either of these rigorous exams is essentially the same for each. In other words, just make people go over the process AGAIN and AGAIN and AGAIN.
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Well, it seems a number of colleagues have already chimed in, but I will expound a little further. Yes it is true, I have never look at at a Bar exam; my knowledge of it is based on what my lawyer friends say about it, and now also what you have said about it. The consensus seems to be that it is broad based (perhaps “shallow”, as you stated), may serve a purpose of sorts at the conclusion of law school and would serve no value thereafter. You suggest that MOC is different in that it is far more specific and covers clinical scenarios, and you may well be right in that assessment, but does that make it of value to docs pressured into taking it? I will again revisit my example of presenting me with specific scenarios about treating various cancers and testing me on them. What is the value of that to me, when, by the nature of my practice, primary cancer treatment is something I have never had to due in 20 years of practice and will never have to do until the day I retire? I posed this concern in a letter to Dr. Cassel, former President and CEO of the ABIM (and currently experiencing not a small amount of disgrace embroiled in a scandal as President and CEO of the National Quality Forum – how deliciously ironic) and she palmed it off on her guard dog, Dr. Holmboe, co-author of the majority of the “research articles” (of dubious scientific validity) cited by the ABIM as “proving” that MOC improves care (while never ever acknowledging any conflict of interest-really?) and he was kind enough to reply, in his usual remarkably patronizing fashion, that while the ABIM in essence “feels my pain”, I may as well get used to more pain because the omniscient board “knows” what areas of medicine docs should study and be tested on (again, their “one size fits all” premise that is inherently flawed). Surely you, as an intelligent educated person, need not be a doctor to question why any doc who does not provide the primary care for cancer should be held accountable for such knowledge about cancer. Yes, such test question scenarios may be quite specific and detailed, but can they possibly be relevant to all docs? And how about docs who exclusively provide outpatient care, and never do inpatient care, being asked questions on how best to adjust ventilator settings for an intubated patient scenario in the ICU? If such docs get those questions wrong, are they really subpar and incompetent, and deserve to have their livelihoods threatened by being designated as “not being up to date with MOC”, or perhaps it is MOC that is subpar and incompetent? And I can give example after example. MOC, like initial certification, like the Bar, is a broad based evaluation, regardless of how shallow or how specific, yet the target audience of MOC are a group of professionals who are well past the “broad based” phase of their professional lives and are instead deep into practices that have all evolved into unique, distinct and different niches. For this reason, broad based testing is inherently inappropriate and self-directed learning via CME (analogous to the CLEs you espouse for ongoing legal learning) is clearing the only logical way for physicians to stay up to date in a way that is meaningful to each of us. As a point of interest, perhaps mentioned earlier, the percentage of state board actions taken agains errant physicians that involve physician incompetence are less than 1%; rather the vast majority of such actions are for issues unrelated to competency (substance abuse, alas, being among the more prevalent reasons, although perhaps the ABIM would like to try and make a case that MOC will solve that problem as well). This is a yet another example of a select group of privileged people trying to fix something that is not broken, and with signifiant dollars hanging in the balance. As Ken said above, layers would NEVER put up with this, but doctors are expected to; why, I wonder, is that?
By the way, if lack of time might explain why docs only pursue answers to medical issues they don’t know at the point of care 50% of the time, then subjecting docs to the exponentially increasing time required by MOC, which nearly all docs not on a board find useless, does not seem like the right strategy to give docs the additional time they need to look up the stuff they need to look up at the point of care, does it? Or we can simply give up eating, sleeping and seeing our family and friends to get both MOC done and nudge up that 50%.
Welcome back, Marilyn. You do mention some of the less important reasons why physicians are not happy with MOC. One of the more important reasons is that physicians feel MOC IS NOT RELEVANT to their practice. And furthermore, physicians are very unhappy that they are forced by some self-proclaimed experts to participate in an expensive, onerous process of no clear benefit to them or to their patients.
It has been said that the worst tyranny is forcing someone to buy something they don’t want. Physicians are well aware that when MOC was truly voluntary, no one participated because the process was, and remains, so time-consuming, expensive, and irrelevant.One can understand how the very well paid bureaucrats forcing this on others can be considered to be parasitic, no matter how good the intentions of the bureaucrats are.
Again, as in my earlier post, when physicians want to participate in MOC, instead of being forced into participation, then we will know that MOC is relevant. One thing about self-directed CME is that each physician can determine how they want to use their hours to study instead of having some bureaucracy tell them what they have to study. Independent study…..WHAT A CONCEPT!!!!
And finally MOC has a forty year track record of, at the very least, being perceived as a failure by those forced to participate. When is it time to say enough?
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Marilyn, it is good hear better news on the personal front. This experience also goes to prove how personal health care relationship is. No exam can evaluate this process. Therefore, I believe you should be even more convinced now that MOC is not a good deal for patients either. I can only hope you will convey such sentiments to the board.
Thanks. I will say communication in health care is extremely important. I am a big believer in shared decision making.
Besides the reasons you listed (see below) the fact remains that MOC is a waste of time and money, remains unvalidated, teaches nothing is mainly a busywork task system to “validate” the ABIM/ABMS’s need to charge for and provide reassurance to “whomever” that THEIR certified people are somehow “Better”, while openly stating recently and openly:
‘FACT: ABMS recognizes that regardless of the profession – whether it is
health care, law enforcement, education or accounting – there is no certification that guarantees performance or positive outcomes’.
Reference: ABMS (2012). ABMS Maintenance of Certiﬁcation† (ABMS
MOC†) Myths & Facts. http://www.abms.org/Maintenance_of_Certiﬁcation/
The real question remains why would anyone purchase such nonsense from a corporation which provides NO educational materials (and openly admits that)-where is the improvement in healthcare-after 50 years of trying the ABMS has Failed to provide outcome based studies to validate these false claims. Have you reviewed the ABIM’s most recent IRS 990 which indicate they are over $45 MIllion IN DEBT??? I would not by anything from a corporation that insolvent!
“I do understand why many physicians are not happy with MOC. They are busy people, the requirements take time, the exams are anxiety producing, there is a certain financial cost in fees and time away from practice.
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Great!! Now that you understand why many physicians are not happy with MOC, because they are “busy people, the requirements take time, the exams are anxiety producing, there is a certain financial cost in fees, and time away from practice”.
So, you are now ready to help dismantle this beast, as you understand its evils. Let’s get this done as soon as possible, so that physicians can get on with their lives. Thanks for your understanding.
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great comments couldn’t agree more–if board members need something to do suggest continuing efforts to scrub Pharma influ from the Board and academic institutions
Susan Molchan MD (psychiatrist)
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What a coincidence that you should comment on my blog, Dr. Molchan. I was just reading your interesting perspective in JAMA Internal Medicine on the Right Care conference and amyloid PET scans.
Great–I pressed send earlier and wasn’t sure if it went through–am new to blog-commenting, twitter, etc. But re the ongoing layering of MOC demands on docs–it’s a bit disingenuous too as I believe many who make the rules don’t deal w/ all the real demands of practice as they do a lot of shilling (make a dispropor amt of $) for drugs companies
If you look on the ABIM website, there is a link at the bottom of each bio of board members, Council members, and officers, listing their COIs.
Hi Marilyn–They can list away, but this doesn’t preclude the influence of their other interests –attached one of my favorite articles on this. And now there’s the recent case of Dr Cassel. A real shame given her contributions to the field/multiple fields.
Click to access PitfallsdisclosingCOI.pdf
I agree that disclosure, in and of itself, is not a cure for COI.
You should read this: http://hcrenewal.blogspot.com/2014/03/american-board-of-internal-medicine.html
Dear Marilyn, please ask your pal Dr. Krumholz how he can advocate against the use of ezetimibe, an expensive drug of uncertain utility with no high quality outcome studies showing efficacy, and advocate for MOC, an expensive process of uncertain utility with no high quality outcome studies showing efficacy.
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I would agree with Dr Frager this is an important question for the Board companies to address, as they HAVE been trying to demonstrate this for over 50 years for board certification and without success by their own admission.
I would also suggest that in the response, Dr Krumholz et al also address the fallacy of the recertificaiton as a test/quality criteria using Bayes principles-given the extremely high false positive (fail rate) of competent physicians and the fact that they assert it is “voluntary” and I.e. without any consequences! You might ask Dr Cassel and the “Choosing wisely” crowd to add their comments on why an ABIM $$$$ making boards testing/MOC is so valuable, and things directed to patient care are being discarded which are actually more valuable than MOC or Certification! Remember Value= Quality/cost and MOC/Certification is Infinitely small or Zero “value” when no Quality is demonstrated and the cost in 2011 was $400 million-simple math!
And if you are interested in the questions raised recently because of the conflicts of interest by the board and ex members, please take a look at:
I can not fathom how the boards get away with publishing articles on MOC (all positive discussions without any validating proof as a typical test) in their own and general medical journals while being paid to work and write-and all in violation of the ICMJE and COPE international guidelines on this topic.
I will quote this passage found there:
“How are Conflicts of Interest Publicly Disclosed?
The short answer is they are not. The relevant wording is:
Information that is disclosed will be kept confidential except to the
President and Chair of the Board;
The chairs of the relevant Subspecialty Boards, Test-Writing Committees, and other Committees of the Board, members who serve on the relevant Boards and Committees, and staff working with the respective committees;
The Conflict of Interest Committee members and Conflict of Interest Committee staff,
except as required for the purposes of continuing medical education.
Let me reiterate, conflicts of interest are NOT PUBLICLY DISCLOSED. They are kept confidential, secret, hidden, opaque. Only the insiders listed above may know about them.”
Dear Drs. Frager and Kempen
I am not inclined to ask Dr. Krumholz any of those questions and I don’t know Dr. Cassel. Feel free to contact Dr. Krumholz yourself. His email is firstname.lastname@example.org.
Thank you so much, Marilyn. I actually did ask through the assessment 20/20 website, but you never know what’s going to happen when dealing with ABIM bureaucrats. I will be pleased to email directly since I did not have his address.
Dear Ms. Mann: You seem to focus on some sort of cognitive exam, and how to make it better. I guess that means that you realize it is presently worthless. The rest of the commentators seem unanimous in scrapping MOC and the “cognitive exams” altogether. You must be either a slow learner or else committed to continuing the MOC gravy train. While I discount the former, as I believe you are highly intelligent, I can only assume that you are committed to perpetuating the “scandal”, as Dr. Bob Wachter called it.
I personally believe that it is deplorable that some physicians have tasked themselves with the responsibility of policing their colleagues in order to live extravagant lifestyles. Oh, yes, it is all done in the name of “quality” and “patient safety”. I understand that. But, isn’t there any shame in perpetuating a product that is known to be costly and worthless?
I would strongly urge you to collaborate with your fellow physicians and help shut down MOC. Help your fellow comrades find real jobs in the real world taking care of real patients.
Apologies for the delay in posting a couple of your comments. Two comments were stuck in my spam filter and I just now realized it.
Thanks. Since that post by Roy Poses you linked to the ABIM has posted links to disclosures with the bios of the directors, council and officers. If you look on the ABIM website you will see them.
I do not think the cognitive exam is currently worthless, but I am interested in hearing your suggestions on how to improve it.
(When you urge me to collaborate with my fellow physicians you must be forgetting that I am not a physician. I’m a lawyer.)
Ms. Mann: That is just the point I was trying to make. The cognitive exam should NOT be fiddled with. It should be either relegated to the junk heap or should be exported to the bar, where a “perpetual cognitive exam” might prove to be useful. Try selling this to your fellow lawyers. There is a gold mine there, and some entrepreneur could start mining it.
He’s relentless, but this one was pretty good.
I think the general gist of nearly all of the feedback above, in which no one has offered any meaningful suggestions for improving the cognitive exam, is that that the cognitive exam, by its very nature, is flawed beyond repair or utility. An infectious disease colleague who recently blogged about his experience taking the infectious disease cognitive exam had this to say (excerpts): “I faced more than 100 convoluted psychometrically tweeked questions (120 seconds each) whose answers I needed to GUESS correctly, based on their (the test writers) opinion, relying on data from TWO YEARS previously (the typical time lag between when new medical knowledge can make it from journals to practicing doctors to test questions) and my passing such a process was supposed to demonstrate my infectious disease competency for the next five or ten years! Really? And is acute a matter of minutes, hours, or days? And don’t forget ABIM typographical errors and other ambiguities, whereby, for infectious diseases, SVR means sustained viral remission/response but may be printed accidentally as “systemic vascular resistance”, a term more familiar to critical care docs. And on and on…”
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