This post has a very braggy shamelessly self-promotional part. So allow me to get that out of the way first. In October 2017 I took the American Board of Internal Medicine (ABIM) recertification exam. It’s a day-long multiple-choice test that covers the entire breadth of internal medicine and is done under the watchful eyes of proctors who make sure we only had access to the information between our ears. I had studied for dozens of hours over the preceding months. I did well. How well? I’m so glad you asked. Here are my scores.
Internal medicine board certification has been clouded with controversy in the last several years, perhaps deservedly so. Critics of the process of maintaining board certification make the following reasonable charges. Studying for the test takes a lot of time for doctors who are already over-scheduled. The test covers rare diseases that any individual doctor is unlikely to encounter in practice. A multiple-choice test in a secure location is a terrible approximation for actual medical practice, in which a doctor facing a difficult case can refer to reference materials or call a colleague for advice. Since we all use textbooks (and increasingly online resources) when we see patients, shouldn’t the test allow us to refer to them too? And finally, there is no persuasive evidence that studying for the board exam makes us better doctors, or that the patients of the doctors who pass have better outcomes than the patients of those who fail.
These are all legitimate criticisms, and the ABIM has faced a lot of pressure to evolve the certification process to one that is more clinically relevant and less burdensome. It has made some strides in that direction.
Without in any way dismissing the above charges, I’d like to raise a few defenses of board certification. First of all, it’s voluntary. Unlike state licensure, which is legally required to practice, board certification is not mandatory. Critics point out that many hospitals require board certification for hospital privileges, which is true, but not all do, and one can practice medicine without hospital privileges. The second benefit is that board certification is currently the only evaluation of internists that places them above the general standard of care, that is, it’s the only current way to try to assess excellence. Disciplinary action by state boards punish doctors when care falls below the standard, so patients can use that to make sure a doctor is at least adequate, but there is no other current standard that attempts to set a bar higher than adequacy. And third, it’s objective and impartial. Unlike the recommendations of friends, online reviews, and other ways doctors are judged, board certification is a uniform yardstick by which any internist can attempt to be measured.
So while acknowledging that the current board certification system has much to improve, I think that for patients attempting to find excellent doctors, it’s still an essential tool. I found the process of studying for the exam in 2017 extremely valuable. Yes, I am unlikely to see many of the diseases I studied. But the process of studying also solidified my understanding of advances in the treatment of very common diseases, like diabetes and heart disease.
It would be wonderful if we could accurately and objectively test the essence of great doctoring. It would be so valuable if I could study and be tested on the ability to motivate the complacent patient, to comfort the panicked patient, to intuit when a patient has undisclosed concerns, to be able to know when the time is right to break the tension with some levity, and when the time is to be quiet, make eye contact, and listen. Every good doctor I know struggles with these problems daily. We would all sign up for a class to teach us to excel at that test. ABIM certification is a poor substitute for that ideal, but it’s getting better, and for now it’s the best we’ve got.
Stop Wasting Doctors’ Time, Board-Certification Has Gone Too Far (New York Times op-ed by Dr. Danielle Ofri 2014)
To the Barricades! The Doctors’ Revolt Against ABIM is Succeeding! (Newsweek, 2015)
Physicians Passage of MOC Exam Linked to Fewer State Disciplinary Actions (MedicalResearch.com)
American Board of Internal Medicine – Check a physician’s certification