Bored by the Board

Libertarian ideology rejects most of the modern regulatory systems that protect consumers, because everyone should be responsible for determining whether the hamburger contains E. coli on his own. But does that do-it-yourself dogma apply to the regulation of medicine, too? If you're Dr. Rand Paul, practicing ophthalmologist, the answer is emphatically yes.

According to an amusing story in today's Louisville Courier-Journal, the Kentucky Republican Senate candidate bills himself as a "board-certified" physician even though he is not actually certified by the American Board of Ophthalmology -- the only recognized body that certifies doctors in his specialty.

Paul's only certification was provided instead by something called the National Board of Ophthalmology, which is very convenient because he operates that organization himself.

Joe Conason, Salon.com, June 14, 2010

Most doctors in this country are board certified in something. In a nutshell, board certification means you have met certain training requirements and passed some kind of exam that qualifies you as a specialist in the field. In my case, becoming certified by the American Board of Emergency Medicine (ABEM) means I completed a three-year specialty training program and passed both a multiple-guess written exam and an oral exam consisting of a wide variety of patient scenarios. (Needless to say, the issue of being board certified and being certifiably boring are two separate discussions.)

ABEM was one of the first boards to require recertification. It was easy for them to do, as it was a relatively new specialty with no one who had been certified very long when the decision was made. As a result, nobody felt too inconvenienced. It was different for organizations like the American Board of Internal Medicine (ABIM), where there were already thousands of physicians out there who were certified once under a “one-and-done-for-life” agreement. If they suddenly required 20,000 physicians who had been functioning just fine for the last 40 years to spend their time and money on a new exam, they would have had a wholesale rebellion on their hands. So according to one of my ED colleagues who started life as an internist (he’s much better now), the ABIM sent everyone who was already certified a postcard that had two boxes on it. If you checked one box, you could take the exam again every decade or so, paying a hefty fee for the privilege. If you checked the other, you never had to see the inside of a test booklet for the rest of your natural life. Guess which one most people chose.

The next step is to add a component of continuous learning to the certification process. Most states already have Continuing Medical Education requirements, where you need to be able to document participation in so many hours of CME each year. But these requirements are written for physicians in general and do not relate to the individual specialty. Organizations such as ABEM are looking to fill this gap. For example, I am now required to read a selected panel of articles each year (for no CME credit, by the way), and then pay a fee ($95.00) to take an on-line test. If I do this successfully eight out of the ten years of my certification, I get to pay another fee to take a longer 205 question on-line comprehensive exam, which may or may not have anything to do with the articles I’ve read, for the low, low price of $1,715. If I miss one of the yearly exams, I can take an even longer written 305 question exam for the bargain price of $920. If I miss two or more, then I get to take the longer written exam and an oral recertification at a total cost of $2060. (But wait! There’s more! If you act now, we’ll throw in an amazing spiral slicer!) Interesting to note that it’s cheaper not to do the continuing process…there’s not exactly an incentive to participate.

The recertification process can be a pain, but I really don’t have a problem with it, at least in theory. (That being said, I’ll be perfectly happy to trash the system in the few months before I take the higher-priced exams with my money going to who-knows-where to do-who-knows-what except to make my life more miserable than it has to be, and Lord help me if I don’t use a number two pencil or blacken the oval completely.) But the next step in the evolution of board certification in emergency medicine is clear argument against intelligent design. It’s called Assessment of Practice Performance, or APP, and on the surface it’s not too bad. It’s supposed to assess competence in patient care, communications, professionalism, and practice-based learning through participation in quality improvement programs. Clearly, these are good things to know.

The part that bothers me is that these APP requirements apply only to “clinically active” diplomats of the board. What this means in practice is that if you’ve you’ve managed to get yourself out of the ED and into a comfy executive chair on the administrative floor, there’s no need to ever prove your clinical competence again. I have a real issue with this, as I have always been of the belief that no matter how high you rise in an organization, at some level you should still be able to do the job you were originally trained to do. So if you started out as a copier repairman and are now Chairman of IBM, you should still be able to fix a copier. I wouldn’t expect you to become a corporate accountant or a software engineer, even though your position in the food chain may be over those departments. But you ought to be able to fix the copier, and should go out of your way to do so every now and then. It “keeps it real,” as it were, and it’s incredibly difficult to lead with credibility when you are no longer able to work under the same conditions as those you‘re trying to direct. (That’s one of the main reasons I continued to do ED shifts while working full-time positions in public health.) If you’re unable to continually demonstrate competency in your original position, why should anyone assume you are competent in a higher post? And it certainly seems disrespectful, if not arrogant, on the part of non-practicing physicians to hold those doctors who actually see patients to a higher level of qualification despite the fact that they all present the same credential to the outside world.

And that’s the problem with the new scheme. Allowing those physicians who no longer see patients to hold themselves out as clinically competent ED docs (as the board certification would suggest they are) is contradictory at best and, in my mind, frankly disingenuous. But even if ABEM does the right thing and makes all diplomats meet the same standards, there’s always hope for those NPC (No Patient Care) docs. We can just ask Rand Paul to come up with another board or two…