Elizabeth Loder examines the emergence of organized US physician opposition to revalidation requirements.

Something remarkable is happening right now in American medicine. A unified physician movement has emerged that cuts across the varied interests of different specialties to focus on a specific cause of dissatisfaction. It has already forced concessions from one powerful organization, and it shows no signs of fading. The targets? None other than the American Board of Internal Medicine (ABIM) and other specialty certifying boards, including their umbrella organization The American Board of Medical Specialties (ABMS).

The immediate sources of physician unhappiness are requirements for certification and maintenance of certification (MOC) that are perceived as time-consuming, irrelevant, expensive, and lacking evidence of effectiveness. The MOC requirements—similar to “revalidation” in the UK—have been a particular flashpoint. They come in addition to the examinations US doctors must take to acquire initial board certification in a medical specialty. Many specialty boards have instituted or expanded MOC requirements, but the ABIM is under the fiercest attack. It certifies internal medicine physicians, who account for roughly a quarter of all doctors in the US.

For many years, although there was a lot of grumbling, most US doctors seemed to accept that there was little they could do to address the problem. Doctors who criticized MOC were accused of being against high quality patient care. Still, some prominent physicians began to speak up. In 2010 the editor-in-chief of the New England Journal of Medicine wrote that he “recently became recertified in critical care medicine, but the recertification was not voluntary, since all certificates issued in this subspecialty are time-limited. Despite the ABIM’s claims of relevance, much of the secure examination was based on cases that this test taker had never encountered in more than 30 years of practice, and it emphasized factual recall rather than diagnostic reasoning.”

Other forms of opposition emerged. One group, the American Association of Physicians and Surgeons (AAPS), took the ABMS to court, charging it with restraint of trade by “entering into agreements” with its 24 specialty boards “to impose enormous ‘recertification’ burdens on physicians, which are not justified by any significant improvements in patient care.” Many physicians also expressed anger over what seemed a heavy-handed response by the ABIM to a cheating scandal on the 2010 examination. Slowly, the anti-MOC movement was gaining strength. Despite this, the prevailing fatalistic attitude among many doctors was that there was little point in challenging the powerful boards, which seemed to operate as monopolies.

And then something surprising happened. The ABIM announced its intention to change MOC requirements, since “every 10 years is not enough.” It would no longer be sufficient for internists to pass a test every 10 years and enroll in MOC a year or two before that test. Instead, all certified doctors were given a deadline of 31 March 2014 to sign up—and pay hefty fees—for ongoing and expanded MOC activities. If they did not, the ABIM website would no longer list them as board-certified. Rather, they would be listed as certified but “not meeting MOC requirements.” It seemed a small thing at the time, especially for doctors who had meekly accepted many other new mandates, but in hindsight leaders of the American College of Physicians (ACP), a specialty society representing roughly 140,000 US internists, acknowledge that these MOC changes were “the straw that broke the camel’s back.”

It is almost impossible to exaggerate the intensity of the pent-up rage that poured forth from US doctors. Now the ABIM faced a firestorm of opposition and condemnation, and this time the controversy did not die down. Physicians who were active in social media kept things alive, particularly in blogs. Numerous specialty and state medical societies went on record opposing MOC requirements. A scathing op-ed piece made the New York Times. 

The anti-MOC movement had progressively gained allies among important members of the medical establishment. One of them, Paul Teirstein, the chief of cardiology and director of interventional cardiology at the Scripps Clinic in San Diego, published an article in the New England Journal of Medicine titled “Boarded to Death?” In it he charged that the ABIM had “grown into a $55-million-per-year business, unfettered by competition, selling proprietary, copyrighted products.” He suggested, “we would all benefit if other organizations stepped up to compete with the ABIM, offering alternative certification options.” Shortly after the article was published, Teirstein and others announced the formation of just such an organization, the National Board of Physicians and Surgeons. It offers a low-cost, alternative pathway for recertification to physicians previously certified by an ABMS member board, and is working for acceptance by hospitals, employers and other groups that currently require or encourage certification by ABMS boards.

Another ABIM critic, Charles Cutler, is a former chair of both the Board of Governors and the Board of Regents of the ACP. According to Cutler, the ABIM “slowly began to go off track” in the late 1980s. In a December 2014 debate with Richard Baron, President and CEO of the ABIM, Cutler asserted that the ABIM and the ABIM Foundation had embraced an organizational “culture of luxury” while at the same time showing insensitivity to the financial and other burdens MOC imposed on physicians. He presented evidence of lavish salaries paid to ABIM executives, a retreat in a fancy hotel, the purchase of a luxury condominium by the ABIM Foundation, and expressed unease about the profitable non-ABIM activities and earnings of former ABIM and ABIM Foundation president and CEO Christine Cassell during her tenure. These charges of poor financial stewardship have been repeated and enlarged upon by others. One, a forensic healthcare accountant, has gone public with his misgivings about the financial affairs of the ABIM and ABIM Foundation (see also here and here.)

All of this backed ABIM into a corner. In February 2015 its new president and CEO Richard Baron sent a letter to the internal medicine community. In it he said “ABIM clearly got it wrong. We launched programs that weren’t ready and we didn’t deliver an MOC program that physicians found meaningful. We want to change that.” ABIM did not plan to back away from MOC, but it suspended some of the most controversial requirements, agreed to change some of the language it used on its website, pledged to make examinations more reflective of clinical practice, capped fees, and said it aimed to evaluate new methods of physician self-assessment. These were not radical reforms, but they included many of the things that MOC opponents had asked for, along with an apology.

Yet the ABIM’s promises and apology did not placate opponents. Instead, they seemed to rally even more physicians to the cause. “Way too little, way too late,” said a physician quoted in a Medscape article entitled “Physicians are outraged despite ABIM apology for MOC mess.” “Minor changes, proposed to placate the masses? Lifetime certificate holders are exempt? The good old boy network is alive and well.” Mack Harrell, president of the American College of Clinical Endocrinology, posted an amusing slow-jam music video in which he politely congratulated the ABIM for the changes, but then urged his members to visit the NBPAS website and “consider this new certification alternative.”

The fact that the ABIM had blinked was not lost on physicians in other medical specialties, who were newly optimistic that similar fights against other specialty boards would be successful. A large number of these movements, such as one aimed at the American Board of Psychiatry and Neurology (ABPN), were well underway. Apparently trying to stay ahead of the game, the American Board of Family Medicine (ABFM) issued a statement saying it was “aware of the current debate” but did not plan to make any changes to its processes. Observant doctors were quick to point out the similarity between the ABFM press release and that of the American Board of Pediatrics (ABP): “The same boards that treat doctors like criminals during our ‘secure board examinations’ blatantly copy each other’s press releases. They’re more than ‘fellow members of the community of medical boards,’ they’re in collusion against their own diplomates. Each board claims they are independently responding to their individual specialties, but they are clearly well-organized as a single entity against us. Faced with increasingly vocal opposition, a federal antitrust lawsuit, investigations into their finances, and a new competing board, they are up against the ropes and flailing wildly.”

Most ominously for ABIM, the ruckus has attracted attention outside the medical community. One nonmedical blogger recently described the ABIM as one of many “obscenely greedy non-profit people/institutions.” The mainstream media is taking notice, too. Newsweek has run a provocative story which includes the author’s opinion that “The ABIM is not what it was. Its original mission was to make sure doctors provide patients with the best care. When condominiums and lavish salaries and free trips and making money off of physicians failing tests became a priority, the evidence suggests the organization lost its way.”

How will this story end? Will the ABIM find its way and regain dominion over US internists? Until a few years ago, the ABIM was living large. Now, consensus about the value of certification has given way to dismay and skepticism. A credible alternative has emerged to the ABIM and other lucrative certifying organizations. All of these developments bode ill for the ABIM and bodies such as the ABMS, ABFM, ABP and ABPN.

These events also may portend a permanent change in the balance of power between US physicians and other parts of the medical system such as insurance companies or employers. The authority of the specialty boards has turned out to be more a matter of entrenched assumptions than actual fact. Physicians have learned they have real clout and that organized effort can overturn something many saw as inevitable. This is a potent lesson, and physicians are good at absorbing new knowledge. Look for this to be the first of many doctor-led revolts.

Conflicts of interest: Elizabeth Loder is certified in Internal Medicine by the American Board of Internal Medicine. Her certificate expires in 2020 and she is not participating in maintenance of certification activities. On behalf of the American Headache Society, she has been involved with the American Board of Internal Medicine Foundation Choosing Wisely project. She is also certified in the subspecialty of Headache Medicine. She sits on the Headache Medicine examination committee of the United Council of Neurologic Subspecialties and has written questions for its Headache Medicine certification examination. She is a colleague of Dr. Paul Mathew, who is among those seeking reform of the MOC requirements of the American Board of Psychiatry and Neurology.

Elizabeth Loder is the acting head of research, The BMJ.