Board Recertification: There Has to Be a Better Way

Recertification: Less Is More

This is Seth Bilazarian from theheart.org on Medscape, speaking on the topic of recertification—why it is not a value proposition and "less is more."

In this era of trying to rein in costs and increase efficiency, it seems that the education of physicians and the maintenance of competencies and certifications have gone in the opposite direction. We are experiencing a lot of difficulty in this area in terms of what is the best way to move forward.

My recent board recertification was my 10th board exam in my 23 years in practice—internal medicine once, cardiology three times, interventional cardiology twice, endovascular medicine once, vascular medicine once, and I just took the nuclear medicine boards for the second time. The cost for this experience was similar to my other board certifications. Three days at a board review course was a cost in time. One day for the exam and countless hours of study away from my practice and my family. The cost in dollars was also significant:$1000 for a board review course, $1000 for the exam itself, $100 each for two books, and then the loss of revenue for being away from the practice for several days. These costs are substantial in both time and money. At the end of the day, the question is: Is there clinical value for it?

I took the exam with a colleague (my professional partner), and I asked him what he thought. Was there anything that he thought we gained out of it? Were there some specific pieces of information that moved our practice ahead or that filled in a deficiency? That is one of the problems with these experiences; when you take this exam (a 100-question test), at the end of it, you don't get feedback that says, "You have a deficiency in this particular area, and strengthening would be valuable." We just get a pass/fail answer. For me—fortunately, thus far—it's always been that I passed. But further definition of deficiencies isn't provided.

The other burden that has been new to my practice in 23 years is multiple areas of added learning. Some of it is state-required. Some of it is payer-required. Some of it is practice-required. We now have annual fluoroscopy training at each hospital that is required by our state. You can argue that this is a good thing so that people use fluoroscopy safely, but it's an added training. We have biannual advanced cardiac life support (ACLS) training—1 full day of basic life support (BLS) and ACLS training to maintain that certification. One hospital at which I attend has cultural sensitivity training. Two Mondays ago, our practice had training about electronic health records (EHRs) and meaningful use to satisfy federal government requirements for using EHRs with meaningful use to avoid a payer decrement.

No End to the Training Burdens

We also have annual healthcare system training. I'm an employee of two healthcare systems in the state. I have to do annual HIPAA training, ethics training, and billing and coding training. We expect to do ICD-10 training in the next year and infection control training. These are all separate modules. At each hospital, it takes about 4-6 hours to complete the training. From the Commonwealth of Massachusetts today I received an email from the Massachusetts Board of Registration in Medicine that stated that I will now be required, as a member of the board of medicine, to have proficiency in electronic healthcare. Now I'm going to have to prove proficiency in another area. There seems to be no end to these burdens.

Since I have been in practice, there has always been a requirement for continuing medical education (CME). In our state, 100 hours are required with 40 hours as Category 1 (classroom learning), 60 hours of other learning, and 10 risk management hours. It is a fair number of hours that we have grown accustomed to doing, and we accept this as part of learning. Who wouldn't want to spend 100 hours over 2 years (50 hours per year) on education? That's about an hour a week. Who wouldn't want to spend that much time? That's become part of the fabric of it, but now these other things have become layered on top of it. My question is: Why can't there be efficiencies in CME and all of these other learning requirements? And now we have Maintenance of Certification (MOC). The MOC issue is not what I'm covering today, but it's part of the foundation of what we are working with. To add on MOC is very problematic and a significant burden, and it has caused a groundswell of support that this is just not appropriate.

Commitment to Lifelong Learning

The American Board of Internal Medicine (ABIM) has had for years an excellent reputation, but they have slid into a scandal-ridden situation. They are out of touch with practicing clinicians. The ABIM obviously needs to get its own house in order and have greater transparency before it foists MOC further on our profession. Physicians largely are committed to lifelong learning. I don't know any physicians who don't want to do this because they see it as keeping up—as being an exciting part of our profession. So I don't think that physicians are unwilling or unable to do this because there is a desire to keep up with best medical therapies—best device therapy, best practices, and most efficient therapies. These are all things that physicians want to do. It's just that the way that we are being asked to do it is very fragmented and expensive both in terms of time and money. The mission should be to improve patient care—quality, cost, efficiency, value. The issues that I describe—for instance, not giving feedback to a physician certifying in a board exam—don't satisfy that. If I have a deficiency in the way I take care of the pregnant patient or the care of the HIV patient with cardiovascular disease, and that's discovered on a board exam, shouldn't I be told that? That's an area that requires added attention for me to proceed with.

Relevant and meaningful feedback is critical, and meaningful feedback means giving feedback specifically to the questions [asked during board recertification]. The ABIM said that it would be too expensive to disclose the question results, but it seems like that is an expense that they should bear because we are paying for the exams, and the real value is to get this feedback to physicians. They have to provide good value. They have to prove that they are adding value, both in time and money. Anything that is added going forward needs to replace something else—for example, the added value of maintenance of certification and the professional improvement modules that require physicians to evaluate other physicians. I have done this now for four different physicians, and it takes 20-30 minutes to evaluate a referring physician and how he practices. These are being foisted on us, and there seems to be no end of it. We are cannibalizing our professional time and our personal time, and there is a finite number of hours in a day. As the Beatles said, we are going to have to go to 8 days a week. At this point, physicians are bumping up against the edge of what is possible.

Until next time, I'm Seth Bilazarian.

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