An uproar over how to certify doctors
William R. Greer, a primary-care physician in Paoli, welcomes the scrutiny doctors endure to show they are keeping up with medical knowledge and improving patient care.
William R. Greer, a primary-care physician in Paoli, welcomes the scrutiny doctors endure to show they are keeping up with medical knowledge and improving patient care.
"It needs to be an ongoing process, and then, frankly, I think you need to sit down and put a doctor to the test," Greer said. "Boy, my friends aren't going to like that."
That's because Greer's view runs counter to a storm of protest over what some physicians view as burdensome rules for maintaining board certification, which is like a Good Housekeeping Seal for doctors, signaling expertise in a specialty.
Philadelphia's American Board of Internal Medicine has been the focal point for the uproar, partly because it is the largest of the boards that certify physicians, but also because last year it botched the introduction of an expanded certification process, decried by many as paper-pushing busy work not worth the time and money.
"We simply didn't have a smooth pathway for doctors" to show us their work, said Richard Baron, a longtime Mount Airy primary-care physician who became chief executive of the internal medicine board in June 2013.
For example, doctors had to manually input data from patient records into the board's system to get certification credit.
Physician dissent led to the start of a tiny competitor, the National Board of Physicians and Surgeons, in San Diego, which has certified about 2,600 doctors this year.
The issue is critical for patients because board certification is supposed to be one of the best ways to identify the most effective doctors. Yet passing the test has never been shown to denote a better-performing physician.
Where did the internal medicine board go wrong?
Lois Margaret Nora, CEO of the American Board of Medical Specialties, cited the breadth of the internal medicine board, which offers certificates in 20 subspecialties. It tried to create "a program that would fit the entire specialty of internal medicine," she said.
Much of the pushback has come from "cardiologists, pulmonologists, and gastroenterologists, who are saying, 'Wait a minute. That doesn't fit well enough with who I am and what I do,' " Nora said.
Gregory Kane, a pulmonologist at Jefferson who has three certifications from the internal medicine board and has helped write tests, said constant changes were a problem.
Until 1990, doctors had to pass one test and were certified for life. Then, doctors had to pass a high-stakes exam every 10 years, but recently the rules for staying certified have become ever more complicated, Kane said.
That was especially true with new requirements, including a patient survey, that took effect last year.
"Suddenly the anger reflected back at the ABIM," Kane said. "The ABIM didn't listen at first, and the anger intensified like a boil under the skin."
With doctors holding 215,871 of its certificates, the ABIM is far from crumbling. It is by far the largest of the 24 boards that operate under the American Board of Medical Specialities, which is based in Chicago and sets guidelines for member boards.
Physician certification is a business in the Philadelphia area, where five specialty boards, including the one for internal medicine, are located. The other local boards cover surgery, ophthalmology, and plastic surgery, as well as allergy and immunology.
None faced the same backlash as the ABIM, which this year suspended parts of its new certification regime while it makes them more palatable.
That led to fierce debates in the trade press about what doctors need to do to stay current. "It's hard to understand how this is all going to settle out. It's so emotionally laden," said Jeptha Curtis, an associate professor at Yale University School of Medicine, who cowrote a recent study showing that a doctor's board certification does not ensure better outcomes for certain cardiac procedures.
"We are being judged more rigorously and more often than ever," he said. "Then we're being asked to pay to be judged."
What is clear is that the broad push by hospitals, insurers, and government to measure the performance and the quality of doctors is unlikely to end.
"Measuring quality is the Holy Grail of medicine right now," but the profession's grasp of how to do it is "primitive," said Curtis, who has two internal medicine certifications in cardiology and generally supports the board.
Paul Teirstein, chief of cardiology for Scripps Clinic in Southern California, is among the leaders opposing the new regime.
"The doctors are upset because they are pushing us very hard to do all this what we think is busy work," said Teirstein, who also helped establish the National Board of Physicians and Surgeons.
Requirements for this board include initial certification from another specialty board, and 50 hours of education within two years of certification.
The internal medicine requirements must be met over a 10-year cycle.
Among 11 hospitals or systems accepting credentials from the upstart board is St. Mary Medical Center in Langhorne.
Richard Leshner, a St. Mary cardiologist and former medical staff president, led that effort. A so-called grandfather, he was certified for life until last year's changes.
Leshner says education is enough to keep doctors current: "I look at lawyers. Do they take the bar every 10 years?"
Others don't trust classwork, without a test. "That's a terrible idea because there needs to be some level of accountability that the CME was meaningful," said Mike Renzi, who has a family practice in Haddon Heights.
Renzi said a high-stakes test every 10 years is a good way to ensure "that there's a baseline level of knowledge, competency," but parts of the process feel "like a paper push."
Greer, the Paoli doctor, has another reason to support certification beyond improving his practice. "The people I interact with and send patients to, I want to know that their certification is up to date," he said.
215-854-4651 @InqBrubaker