Questioning the Validity, Cost, and Effectiveness of Recredentialling: It's About Time

Letter sent to Connecticut Medicine.


December 5, 2011
Connecticut Medicine
Letter to the Editor

Questioning the Validity, Methodology, Cost, and Effectiveness of ReCredentialling: It’s About Time

One of the several actions taken by the Connecticut State Medical Society’s (CSMS) delegates at the annual meeting of the AMA held in Chicago in June 2011, was requesting the AMA to further study the “validity, methodology, cost, and effectiveness” of the American Board of Medical Specialties’ (ABMS) recredentialing system. 1

The CSMS and its AMA delegates deserve commendation for their courage and persistence in keeping this very contentious issue alive. Some members may not know it but this issue had its origin on the floor of the CSMS House of Delegates in 2008.
It was then brought to the New England Delegation to the AMA where it was further discussed and following it approval there, the decision was made to present it at the Organized Medical Staff Section of the AMA’s annual meeting in 2008

Discussion on the resolution was overwhelmingly favorable and it was referred for further study. The Young Physicians’ Section at that time also presented a resolution that questioned the methods of the ABMS. Their concerns added both political and moral strength to the resolution that emerged from the floor of the CSMS House of Delegates.

Criticizing the methods of the ABMS may seem naïve or overly-ambitious or even quixotic to some. Some may even be insulted, but, increasingly physicians are making known their unhappiness over the boards’ methods; and the inordinate power they possess over physicians’ reputations and their professional lives.
In a recent New York Times article 2 the author an internist complained about the time spent on preparation and the impracticality of the recertification test itself.

The internist mentioned how in the real world, cases were discussed with colleagues and that extensive data bases exist where information can be readily retrieved; and that caring for patients “rarely comes down to a single right answer that can be checked off in a blissful isolation”. Most of the blog responses to the article were critical of the boards’ philosophy.

It is interesting that the move to making recertification mandatory occurred in 2000, the same year that Institute of Medicine (IOM) published its To Err is Human report. That report announced that hospital errors were causing as many as 100,000 deaths yearly. Although a follow-up study published in the Journal of the American Medical Association challenged the conclusions of the report, attempts at damage control were futile. For patient advocacy groups quickly used the “100,000 deaths by medical errors” as their mantra in pushing for physician accountability and it was used by many groups whose interests were opposed to those of organized medicine. This included above all, the malpractice lawyers.

Whether the launching of mandatory recredentialing and the appearance of the IOM report was coincidence or related in some way, only the leadership of the two organizations can answer. But it is tempting to speculate that the ABMS saw the IOM report as a once-in- a lifetime opportunity to extend its monopolistic control over the credentialing business and control over the way physicians practice; not to mention a public-spirited way of increasing the revenues of the ABMS..
Correcting the defects in the boards is important because they plan to make physicians’ certification status public. 3

The boards’ claim that certification goes above and beyond basic medical licensure is a subtle way of casting suspicion on physicians who are not certified or who have not recertified and coercing them to recertify . This is wrong because the boards started as voluntary exams.

I think that the intentions of the ABMS to provide a voluntary testing service to physicians by which they can assess the knowledge they need in their individual practices are commendable.
But there are several defects that cannot be overlooked. Here are some of the most troublesome:
(1) The pass/fail method is punitive and unnecessary for physicians who have already been certified. Ideally the boards should uncover areas of weakness and recommend remedial study. “De-certifying” a physician is demeaning and unprofessional. It should be rare for physicians to be de-certified. It should occur only if a physician has repeatedly demonstrated an inability to provide good care and if so, has failed to improve with remedial study.
(2) The boards were intended to be voluntary and never meant to infringe on physicians’ abilities to make a living.
(3) There are many qualities that good physicians have and which can never be identified on a computer-based exam. Compassion, empathy, connecting with patients and colleagues, working as a team member, and participating in medical affairs are just a few of the traits that contribute to a physician’s complete professionalism.
(4) Physicians should only be tested in knowledge that they actually use.
The ABMS’s influence extends into every specialty and into every physician’s life in one way or another, for better or worse. Such wide-ranging power gives it a privilege unsurpassed among our medical organizations. Unchecked, such power can lead to exploitation of the very profession that it should be serving.
It is difficult to convince large organizations to change. We need look no further than the many organizations on Wall Street that in recent years lost their way and succumbed to the lust for power and prestige and ultimately caused much grief to those who had placed their trust in them.
For this reason it is good that the CSMS has continued to ask the AMA to study the “validity, methodology, cost, and effectiveness”, of its recredentialing system. It’s about time.
Edward J. Volpintesta MD
Bethel


1. Summary of Proceedings: CSMS House of Delegates—Annual Meeting, Mystic Marriott Hotel &Spa, Groton, September 16-17, 2011. Conn Med 2011; 75(10):647-651.
2. Ofri D. Being a med student. New York Times [well.blogs.nytimes.com.] accessed 11/5/2011.
3. Krupa C. ABMS to make physician maintenance-of-certification status public [amednews.com] accessed 11/14/2011.