Making a MOCkery of Medicine

NotABIMI thought I’d weigh in on the American Board of Internal Medicine (ABIM) recertification process after reading an excellent article on it today. After all, I’ve been through the process several times, most recently enduring it in 2012. I was lucky enough to be “grandfathered” with regard to my Internal Medicine and Cardiology board certifications. Unfortunately no such option exists for my Cardiac Electrophysiology board certification, it having been created in 1992 after the ABIM wised up the fact that life-time certifications were not profitable. Thus there was no option but to renew the certification in 2002 and 2012, which I duly did, much to my distress. I know a few physicians who claim to enjoy taking these tests, even retaking a certification exam that they are grandfathered into. More power to them. There are a few masochists in every crowd. But the ABIM is determined to take away even their fun, by ramping up the Maintenance of Certification (MOC) requirements to the point that even the most committed connoisseur of the painful is bound to cry uncle.

There are two aspects to recertification. First there is the test that one takes for an exorbitant fee every ten years. Note that physicians are already required to take many hours of Continuing Medical Education (CME) courses per year (which is another scam, but I will pass over that for now). All the physicians I know are very interested in keeping as current as possible in their specialty and don’t require external incentives like mandatory CME or board recertification to do so. Even if one is cynical and refuses to believe that physicians do things like this for the sake of delivering the best patient care, one should at least grant that medicine is a business and it is necessary to keep up to stay competitive with other physicians. Nevertheless in addition to mandatory CME the recertification exam pops up every ten years, and one risks being ostracized if it is not taken and passed. Unfortunately I can’t say much about the test itself. Before I took it I signed a form (in blood, I think) that forbad me from revealing anything about the test. I do know something about how the questions are selected. When I was in academics I, like many of my academic colleagues, was asked to submit 4 questions on electrophysiology to the board. These questions and the hundreds of others sent in were reviewed by the ABIM question selection committee (which I believe was also primarily made up of academicians) who then picked out the actual test questions. I remember when I made up my questions I made an effort to come up with something obscure or tricky. Having taken the test before, it seemed that those were the kinds of questions the board liked. Apparently the process hasn’t changed, judging by the types of questions on the most recent test I took in 2012.

I’ve been taking tests my whole life, and, as much as I dislike them, it wasn’t the test so much as the MOC requirements that rankled me. I was told that I should start the MOC a minimum of 1 year prior to the test. Really? (footnote: now the MOC requirements have changed and start within 2 years of the last test. Ugh!) I thought to myself, what could they possibly make me do that would take a whole year? So, when the countdown to recertification reached T – 1 year, I fired up the ABIM website to find out what I had to do.

My first reaction was that I must have pulled up the wrong web page. I was re-certifying in Cardiac Electrophysiology, the subspecialty of cardiology dealing with problems with the rhythm of the heart. The options presented looked like suggestions for a high school science project. Some were so vague as to be meaningless. For example, from the current ABIM website:

Approved Quality Improvement (AQI) Pathway

The Approved Quality Improvement (AQI) pathway offers diplomates the opportunity to earn practice assessment Maintenance of Certification (MOC) points for participating in externally developed quality improvement (QI) activities that have met ABIM’s standards for measuring and improving patient care.

Whatever that means. Some of the more understandable options had to do with collecting data from patients to send to the ABIM. What they wanted this data for or what they would do with it I had no idea. The striking thing though was that NONE of the options had anything to do with the subspecialty I was certifying in, i.e. Cardiac Electrophysiology. No MOC having to do with the heart rhythm. So this was all just a rather large hoop that I had to jump through. I ended up selecting the Hypertension Module because one of my colleagues had done that option before and had managed to complete it.

What the Hypertension Module involved was collecting a huge amount of data on 50 to 100 office patients. Supposedly the patients were to enter this data on their own on the Internet. In Kentucky this just wasn’t going to happen. So as an alternative I ordered 100 questionnaire booklets from the ABIM. I handed these out to the office patients and asked them to answer the questions. There was no IRB consent form or real explanation as to why I wanted this data from them. I told them that the ABIM required me to collect this data from my patients for some unknown reason but participation was voluntary. Most of my patients were nice enough to fill out the forms.

Not having my own staff of dedicated data entry personnel, I had my long-suffering medical assistant enter the data from the forms into the computer. I did pay her for this out of pocket, though not as much as she deserved (Thank you Karen!). Up until this point I really didn’t know what would happen once all the data was in. The ABIM site was very mysterious about where this module was heading. I was still in Step 1, and couldn’t go on to Step 2 until at least 50 sets of patient data were in the computer. So, after several months of data collection (I now saw why it was important to start the process a year ahead of time), the data was in, and the Step 2 button, which had been grayed out and disabled, stood before me in an activated state, ready to be pushed. It reminded me a little of a computer game, in which you try to open a door but it just gives a rattly sound and a text appears that says “you don’t have the key” until you actually find the key. So without further ado I clicked on the button and the computer churned away, analyzing my trove of what was admittedly somewhat sketchy data to begin with. Then after a dramatic pause the ABIM website announced its findings.

I wasn’t sure what it had to do with hypertension (this was the Hypertension Module, wasn’t it?) but the grand analysis revealed that a greater percentage of my patients than was deemed acceptable were failing to meet goals for lowering of serum cholesterol. (Flash forward 2 years: those goals have been thrown out the window anyway in the latest guidelines). Hmm. So my patients referred to me for the most part by other cardiologists for consideration of pacemaker or defibrillator implantation or catheter ablation of arrhythmias were not meeting standards for cholesterol lowering. I thought to myself: whose fault is that? I don’t usually have anything to do with managing lipid levels. I am a subspecialist, which one would think the ABIM would be aware of as they were requiring me to take their subspecialty certification test. As a matter of fact most of the cardiologists who referred patients to me had little to do with managing cholesterol levels either. In Louisville, Kentucky the management of lipid levels is the jealously guarded province of the family practice doctors. But there it was staring me in the face. After several months of effort that completely distracted me from my real job as an electrophysiologist, the answer to the question of Life, the Universe and Everything was a faulty cholesterol level.

So on to Step 3. The ordeal was not over. For the next step in the MOC Holy Quest was to develop a plan to address this dreadful oversight in my clinical practice and implement it. After that there was Step 4, which was to assess the wonderful success of my innovative plan and show how it had revolutionized my clinical practice so that I would be eternally grateful to the ABIM for my enlightenment that was only possibly through the MOC program. And they wanted me to do this assessment by repeating the data collection in another 50 patients after I had put my fool-proof-amazing-cholesterol-lowering plan into effect.

Excuse me, ABIM, but I do have a real job, and is there any way I can get on with it, instead of spending the rest of my life on your science project? Well, reading the proverbial fine print, there was a way. I could, if I so desired and were so lazy (though they would so much prefer the more complete option) only collect the specific data that was identified in the original number crunching and submit that to them. In other words, I could get 50 cholesterol levels (never mind that I virtually never order a cholesterol level in my field of work) and show that they were better than before. Ah, I know an out when I see one.

So I wrote my MASTER PLAN FOR THE LOWERING OF CHOLESTEROL AND THE SALVATION OF THE HUMAN RACE which I think had something to do with asking the patients to exercise more and eat fewer buckets of Kentucky Fried Chicken, and immediately put the plan into effect. Then, after waiting what I thought was a realistic number of months, I resubmitted my data. Wow, the cholesterol levels were much, much better. The plan had worked! I just hope the ABIM is not planning to publish my data. Because… I made it all up!  And I bet I’m not the first to have done so.

As a medical professional and former academic researcher, I never would dream of falsifying data under any normal circumstances, but I was driven to this by the completely unreasonable nature of the MOC requirement. To summarize this unreasonableness:

1) There were no MOC module options that were relevant to my subspecialty.

2) My patients, my staff and I were forced to waste time on a project of no clinical value.

3) There was ZERO educational value to this project.

4) There seemed to be some undisclosed (sinister?) ulterior motive for the ABIM to collect this data from my patients.

5) I was an unpaid data gatherer for the ABIM (No. Worse, I paid them for the privilege).

6) My patients were unwitting participants in a project that was not important to them or me. I’m sure many participated because they trusted me, but by asking them to participate I was violating or abusing that trust.

I’m not sure what else to say. It is unbelievable that physicians have to go through this process. As much as taking a clinically irrelevant test every 10 years irks me, it is still far preferable to the sham that is the MOC. It really has to go.

By mannd

I am a retired cardiac electrophysiologist who has worked both in private practice in Louisville, Kentucky and as a Professor of Medicine at the University of Colorado in Denver. I am interested not only in medicine, but also in computer programming, music, science fiction, fantasy, 30s pulp literature, and a whole lot more.

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