I was thrilled to become certified by the American Board of Emergency Medicine in 1994. I had worked very hard. I studied and read, I practiced oral board scenarios, and even took an oral board preparatory course. It was, I believed, the pinnacle of my medical education. Indeed, if you counted the ACT, the MCAT, the three-part board exams along the way, and the in-service exams, it was my ultimate test, the one that I had been striving for throughout my higher education experience.
I am now disappointed to find that my certification was inadequate. In fact, all of us who worked so hard for our ABEM certification find ourselves facing ever more stringent rules to maintain that status. And it isn't only emergency medicine. All medical specialties are facing the same crunch. Our certifying bodies expect more ... and more ... and more.
And the attitude is all predicated on the subtle but obvious assumption that those of us in practice are not competent to maintain our own knowledge base. Despite spending decades in education, we are not to be trusted. We are not interested in learning. Our practices are not, in fact, the endless learning experiences they actually are. They-assume we need more supervision, despite demonstrating (by our continued practice) that we are willing to do hard work in hard settings.
Unfortunately, the rank-and-file is unhappy. There is remarkable discontent and considerable anger among the “lesser” physicians, that is, the test takers, the physicians in practice subject to the new rules, the ones who have to add one more rule, one more activity, one more form, one more check to their already busy lives.
That discontent, that anger, that frustration on the part of practicing physicians is, in my opinion, very-rational. It's a tough time in medicine. Our regulatory burden grows by leaps and bounds every year. We are watched and harassed by CMS, by the Joint Commission, by our state medical boards, by our insurers, by our hospital staff offices, and now, most painfully, by our own specialties.
Of course, all of it comes in the context of falling reimbursements, a federal government licking its lips for any spurious allegation of fraud, and a system in which EMTALA forces physicians of all specialties to see patients for free, even as government insurance programs pay less than the overhead to see their patients (and fulfill the regulatory guidelines required for the privilege of doing so).
In light of all of this, I have to ask ABEM and every other board certifying body a simple question: What are you people thinking?
Here's the reality. Our certifying bodies should be our greatest, most passionate advocates. When the Institute of Medicine issued a report some years ago that said physicians were killing people on a scale consistent with the Holocaust, ABEM should have looked at the data and refuted it. ABEM and ABIM and all the others should have taken our fees, run out and found the best public relations firm they could afford. “We stand by our physicians, and we have serious questions with these research results and the way they are being interpreted,” they should have said. That would have been a good use of my dues. That would have merited high salaries for everyone on every board that stepped up for its members.
Instead, at every step, ABEM seems to argue that “the public” wants us to be watched more closely and tested more frequently. I'm not confident that's true. The public never cares where you went to medical school. The public thinks most emergency physicians are interns hoping for a “real practice” someday. The public wants affordable quality care. The public, in practical terms, doesn't know the difference between a physician, a PA, and a nurse practitioner, and often calls all of them “doctor.” The public, furthermore, tends to believe that midlevel providers are more attentive to their needs. (Despite their lack of board certification. Shocking, indeed!)
More poignantly, more ironically, our policymakers and academics often say that the public needs a European-style health care system with better outcomes and lower costs. Whether that is ultimately true, the funny thing is that Canadian and European physicians don't have to do ongoing board certification activities. Hmmm.
More irony: Medical practice is supposed to be evidence-based. So where are the data that board certification makes a difference in patient outcomes? Maybe it does; maybe it doesn't. But even if it does, we'll need to break it down to see if ongoing certification matters, if repeat testing matters, who sponsored the study, etc. Our certifying bodies should be eager to see-independent evaluations of the question. Or would that be a problem?
It might be a problem from a-financial standpoint. Is ABEM or the American Board of Pediatrics or the American Board of Surgery or the American Board of Medical Specialties simply too big to fail? Do they employ too many people to cease to be relevant? Is there a financial imperative for them to continue doing what they do? With director salaries in the $200,000 to $800,000 range (depending on board; ABEM's executive director makes $425,000 a year), is there a potential hint of conflict of interest?
How is this different from the-financial conflicts of big pharma? Their drugs help people, even if their techniques are shady. Is this an uncomfortable question for everyone to ask?
It's a time of changing paradigms in the world at large. Print books are succumbing to electronic ones. The Internet is an unfettered land of free expression, uncontrollable by government entities or hospital administrators. People text more and talk less.
It may be time for us to look critically at the entire concept of board certification. It may be time for alternate boards to emerge. It's certainly time for our boards to be our friends, our advocates, and thereby justify their cost. And it's likely the future will not look like the present when it comes to the way we certify physicians. In an era of impending physician shortages and fewer reasons to enter medicine as a whole, I hope we can remove some obstacles and stand up for one another.
That's a change I can get behind. And that's a change that would make me much happier to write that check to ABEM when the time comes.
Emergency medicine was born from the bold, cutting-edge foresight of physicians from many specialties. There was no board in the beginning, only dedication and compassion. From that pioneering start, we forged the specialty that is the fabric of our national health care safety net. All of that was accomplished without the LLSA, Continuing Certification, or Assessments of Practice Performance.
One wonders why we need anything more than the fact that every day physicians in our specialty go back to work, seeing the sickest and poorest, most dangerous, and most unstable patients possible, frequently with no expectation of payment for their care.
That should, in my opinion, be a-certification in itself.
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• Read Dr. Leap's blog at www.edwinleap.com/blog.
• Read his past columns in the EM-News.com archive.
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