Editor’s Corner
Letter From a Cleveland Jail
to the ABIM Redux
American Board of Internal Medicine
Philadelphia, PA
February 2015
Mikkael A. Sekeres, MD, MS,
is director of the Leukemia
Program at the Cleveland Clinic
in Cleveland, OH.
DEAR AMERICAN BOARD of Internal Medicine,
How do you feel about
the ABIM MOC exam?
Let us know at
[email protected]
or tweet us at
@ASHClinicalNews
The ABIM has announced
immediate changes to the
MOC program. Read more
about these changes in ASH
Directions on page 6.
4
ASH Clinical News
Remember me? I’m the guy who sent those other letters to you
over the past couple of years, in which I channeled the spirits of
Henry David Thoreau and Martin Luther King Jr., both of whom
wrote passionate epistles while they were in jail — Thoreau for failing to pay his taxes and King for his role in a non-violent protest.
This time, I’m imprisoned behind the cinderblock walls of
incredulity as I hear yet more stories from colleagues who had to
recertify their boards, and from others who now have to fulfill the
new maintenance of certification (MOC) requirements.
Did you read Paul Teirstein’s recent Perspective in The New England Journal of Medicine, “Boarded to Death — Why Maintenance of
Certification is Bad for Doctors and Patients”? It mentions a petition
signed by almost 20,000 people against MOC, and another signed by
6,000 people taking a “pledge of noncompliance.”
Wow, I guess I’m not alone. I think that adds up to 26,000
people who won’t be sending you a holiday letter this year.
Dr. Teirstein went on to call the “research” supporting certification “inadequate” – citing a lack of studies showing an association
between recertification and performance on quality measures
– and accused you of being a bully. Quite a statement against a
Board that prides itself on basing certification on evidence-based
medicine. The author stopped just short of saying that your mother
wears combat boots. Not that there’s anything wrong with that,
mind you. I’m sure they’re quite becoming.
You’re probably reading this from the overstuffed leather chair
and ottoman in your office, which you purchased with some of
the $55 million in fees you received in one year from physicians
seeking certification. To be clear, you bought the chair, but were
resting your legs on a man named Otto, an internist who so feared
complaining to you and then being listed as “certified, not meeting
MOC requirements” that he offered his prostrate services to better
assist the venous return to your generous heart and brain so that
you could think up more board questions that don’t correlate to
better patient care.
My favorite part of the Perspective was when the author raised
the same point I’ve raised before to you: how relevant are closed
book/computer/colleague consulting/smartphone tests in an era
when Magnum PI isn’t must-see TV? I mean, I’m sure Flexner was
a huge fan of this method of assessing knowledge. I think he also
voted for Roosevelt for President. Teddy, that is, not Franklin D.
In addition, think about just how humiliating the entire process is. We spend weeks or months shunning family, friends, and
other social stimuli to memorize facts we could otherwise access
within seconds in our clinic workrooms. The day of the dreaded
exam, we huddle in a small waiting area in a building hidden
within a larger industrial complex, along with our residents and
fellows, to check in. Sometimes, the surly Pearson Vue employee
behind the desk can find our names and sometimes, for a few
stomach-plunging minutes, he can’t. Then, to verify our identities
over the course of the day, he scans our palms.
Scans our palms?
Since when did I volunteer to share the secrets my palm holds
with the Pearson Vue Stasi agents? How will they use this palm
information against me in the future? Is that why, soon after tak-
ing the recertification exam, I suddenly started receiving mailers
advertising Keri lotion for dry and flaky skin?
On the way into the testing room, the agent has us empty our
pockets to prove they are empty of anything we might have on us
every day when we see patients, like a smartphone. In my case, said
agent made a nearly career-ending discovery.
“What’s that?” The Pearson Vue Commandant asked me.
“Um, it’s a ball of lint,” I answered, holding it in my dry and
flaky palm.
“You know you can’t bring anything into the testing room,”
PVC said, glaring at me.
“I didn’t know my pocket had lint,” I answered, hoping this
sounded innocent enough. It wasn’t even big enough to write “Factor Xa” on, even if I had intended to use it for cheating purposes.
“Are you going to tell my Mom I had lint in my pocket?”
“Just put it in the trash can,” PVC responded, shaking his head
in disappointment.
Then, we sit down to finally take the test, absorbing question
after question like bullets on a firing range. Because we are doctors, we recognize the telltale signs of increased sympathetic tone
indicating extreme anxiety (sweating, increased heart rate, and
accelerated respiratory rate) as we try to convince ourselves that
the truly perplexing questions are actually just questions the ABIM
is piloting – that they don’t really count.
Wait a second.
You mean to tell me that we pay the ABIM millions of dollars a
year to go through this Cold War experience so that we can test the
psychometric properties of their own questions for them?
Are you kidding me?
Isn’t that a violation of the Declaration of Helsinki? I suffer
emotional and psychological trauma from trying to answer items
that ask more than one question, or for which there may be more
than one response, or that may have dangling participles or misplaced modifiers. Can’t the ABIM at least use some of the $55 million dollars per year they collect from us to hire people to do this?
So, ABIM, given all the outcry against your requirements, I
think it’s time you reconsider what you are having tens of thousands of doctors do to try to satisfy you.
Here’s a suggestion: Get rid of the sit-down exam. It’s anachronistic. It’s embarrassing. Its results only correlate with results on
other sit-down exams. As MOC doesn’t help patient care, why not
just replace it with documentation of CME? We all genuinely want
to learn throughout our careers to provide the best contemporary
care to our patients. MOC gets in the way of that.
And, for God’s sake, can you please let Otto go home to see his
family, or spend more time with his patients, or conduct research
that will cure terrible diseases – instead of wasting his valuable
time trying to fulfill your requirements?
Sincerely,
Mikkael Sekeres, MD, MS
Editor-in-Chief
Board-certified through 2022
February 2015