Elizabeth Loder examines charges of lax oversight and governance at organizations that assess doctors. 

The medical specialty boards that test and certify US doctors are facing a tough test of their own, with plenty of reasons to worry about the outcome. 24 specialty boards administer the tests doctors must pass in order to say they are “board-certified” in a particular field. The boards are represented by an umbrella organization known as the American Board of Medical Specialties (ABMS). The ABMS and its member boards profess a noble mission to serve the public, improve the quality of healthcare, and ensure that they certify doctors who “demonstrate the knowledge, skills and attitudes essential for excellent patient care.” And yet these organizations are now under siege from disgruntled doctors, who paint a far less favorable picture of their motives.

The idea that doctors should be tested to make sure they are up to date has widespread appeal. Until recently this has been an easy proposition for the boards to defend. Unfortunately, however, the evidence linking certification with improved patient outcomes or better care is extremely modest. Despite this, the certifying boards have aggressively increased the number and costs of tests and other activities required to achieve and maintain board certification. These tests and activities are expensive. Physicians spend a great deal of time preparing for them and are unconvinced of their relevance to clinical practice.

The dispute about the value of testing is a sideshow, however, to allegations of a different sort. High stakes testing of US doctors has become a very big business. According to an analysis of yearly revenue, expenses, and other financial indicators, most boards have experienced very large increases in net yearly income in association with the expansion of testing and certification requirements. Executive and employee salaries are also high, particularly when considered in relation to the average salaries of the doctors they certify and the large debt load of new graduates. The financial affairs of the American Board of Internal Medicine (ABIM) and its foundation (ABIMF) have come under particularly intense scrutiny. The boards, many suggest, have overreached themselves and it is no longer tenable to believe that they are entirely motivated by the public interest.

At the same time, countless physicians who are unhappy with the behavior of the boards say they have no choice but to comply with certification requirements. Many hospitals and other physician employers require current certification by one of the ABMS boards as a condition of employment. An alternative certifying board has emerged—the National Board of Physicians and Surgeons—but its credentials are not yet widely accepted. The ABMS boards thus are in a position to dispense something doctors need to practice their profession. In the absence of credible competitors, they can impose additional requirements and fees with impunity. An antitrust lawsuit filed against the ABMS by the American Academy of Physicians and Surgeons accuses ABMS of conspiring with its member boards and other organizations to restrain trade and engage in other forms of anticompetitive behavior.

These charges against the boards raise questions about accountability. Who or what oversees the certifying boards? Are there any governance standards in place? I wanted to learn whether the ABMS exercises any supervision of member boards, so I was pleased when Lois Margaret Nora, the CEO of ABMS, agreed to speak with me. I’ve included highlights from that interview at the end of this blog.
The interview with Nora persuaded me that the ABMS should consider taking a more active supervisory role in relation to its member organizations. At present, the ABMS does not appear to exercise oversight of governance procedures at its member boards or enforce any other standards of behavior. Even if the ABMS encourages member boards to make changes, though, they might resist a transformation of their longstanding culture and prove reluctant to enact real reforms. Such changes often must be imposed or motivated by outside authorities through adversarial processes.

The most effective form of external scrutiny could come from the government. For example, the Internal Revenue Service might examine the salaries of individual board employees. For tax-exempt organizations, no part of net income can “inure to the benefit” of private individuals, and excess compensation is a violation of that standard. Similarly, state Attorneys General could bring suit against officers or directors of the individual boards if they believe there have been breaches of fiduciary duty or that charitable assets have been wasted through lax oversight. Finally, the US Department of Justice could investigate the boards and the ABMS for restraint of trade or monopolistic behavior.

Or perhaps we are nearing a time when the ABMS and member boards will decide they have no choice but to change their behavior. This seems unlikely to occur as long as the boards and the ABMS fail to acknowledge the seriousness of the situation, but that may change. The process of certification has become so burdensome that purchasers of the service are threatening to abandon it in large numbers, and are vigorously seeking alternatives and judicial relief. A report from the US National Institutes of Health identifies “increasingly time consuming and demanding” maintenance of certification processes developed by the boards as a key factor “discouraging physician-scientists from maintaining their clinical privileges.” Finally, the behavior of the boards has attracted an increasing amount of unfavorable publicity and criticism from the mainstream media as well as criticism from respected senior physicians whose motives are not in question. Rather oddly, however, a recent issue of JAMA that was devoted to matters of professionalism, licensure, and certification contained almost no discussion of the large profits and salaries at member boards, instead suggesting that “the actions of the ABMS, and in particular the ABIM, in response to the concerns that have been raised about maintenance of certification epitomize professionalism.”

Internal reform could occur if the outside trustees of the individual boards decided to take a more active role in corporate governance by monitoring and guiding the boards’ behavior. They could act to rein in financial excesses and work to restore credibility to the certification process. In the absence of such effective self-regulation, outside entities seem likely to step in to fill the void. In the end, physician board certification is only worth as much as the trust that physicians and members of the public have in it. That trust has been eroded, and the reputation of the boards has suffered. Does the US physician board certification and testing process provide real value or is it mainly a sophisticated shakedown scheme? The future conduct of the boards will provide an answer to that question.

Interview with Lois Margaret Nora, the CEO of ABMS. April 2015
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What is your mission? To whom are you accountable?
LMN: “The mission of the ABMS is to improve the health of the public through working with the 24 member boards on standard setting and assessment designed to result in improved health care. The board’s movement is also a century old. The American Board of Ophthalmology was the first board that evolved and set standards. A number of years later that board and three others began the ABMS.” She went on to say that the ABMS has 80 years of history and is the umbrella board for 24 member boards. The member certifying boards are independent organizations but “together ABMS board certification from any one of the member boards has been a longstanding marker of trust and quality for the physicians who are certified.”

Is ABMS a trade organization or does it exercise oversight of any kind? What is its responsibility to oversee these boards? Has it ever disciplined any board or exercised authority in any way?
Nora responded that ABMS was created by the member boards to set standards related to assessment, and those standards “at this point” relate more to the certification process. ABMS leaves “standards regarding governance to the individual boards.” Dr. Nora said “I would just point out that this type of governance model is not unusual in the medical community.”

There has been a sense that salaries have gotten out of line. They are perceived to be very high, particularly in relation to the salaries of the doctors the boards oversee. Have you spent any time thinking about that question? Do you have a view about that?
Speaking generally, but not in relation to any specific salaries at member boards, Nora said that “…the work of the boards is extremely complex and demands a high level of expertise…senior level salaries are set by the boards. They obtain comparables from outside organizations to determine appropriate salary levels for highly trained individuals who have substantial responsibility.”

What are the safeguards in place to prevent certifying boards from abusing their authority to extract fees from people who need to be certified, or behaving in ways that further their own interests?
LMN: “I can’t say that we have established such standards. This has never been an issue and there is no evidence that boards have behaved inappropriately in this manner. And in fact, the work of the boards and board certification is and has been under a magnifying glass for many years. The board certification process has been evaluated and is recognized as an important standard…”

Nora concluded our interview by saying that “If I were going to leave you with one thought, it would be that board certification as an important part of professional self-regulation is well recognized in the US for the difference it is making to the care of patients. We remain committed to the concept of board certification and that certification being more than just a single point in time.”

Conflicts of interest: Elizabeth Loder was certified in Internal Medicine by the American Board of Internal Medicine in 1990, and recertified in 2000 and 2010. 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.