This post was written by Dr. John Benson, Jr., President Emeritus, American Board of Internal Medicine and ABIM Foundation, and first appeared on The Medical Professionalism Blog.
The prospect of health care consuming 20% of the GDP by 2020 is unconscionable so corrective actions have enormous urgency. There are some initiatives underway that address this issue and still others that need to happen in order to bring stewardship to the forefront of individual physicians and organizations at-large.
Through its admirable Choosing Wisely® campaign, the ABIM Foundation has promulgated the concept of stewardship of limited resources—especially unnecessary, even harmful, costs—as a clinical competence to be stressed to trainees. None too soon, especially since only 36% of physicians polled in 2013 feel they are responsible for rising costs or their reduction. Obvious proof that there is so much more ground to cover in this area.
As a start:
- Some teaching hospital administrators, who see Graduate Medical Education’s acolytes as a risk to their current modus operandi, must stop acting as competitors in a local technology arms race: pricing services without relationship to costs, skimping on nurse/inpatient ratios, counting outpatient clinics as losers and regarding premature readmissions as revenue.
- ABIM could require candidates to achieve a perfect score on questions related to costs and redundant care as a requirement for admission to secure exams for initial certification or MOC.
- ACP could grade use of resources through MKSAP questions.
- CMS, which has the ultimate negotiating position in the form of reimbursement for Medicare services, could only accept negotiated bundled charges. It could also refuse payment for non-compliance with the Choosing Wisely recommendations.
- Educators, if forced to adhere to stricter ACGME’s accreditation standards, can reward suitable ordering behavior by trainees or require meaningful interventions.
The time is well past exhortation. The issue has been recognized for decades. Hard choices and penalties must go beyond training the next generation. 2020 is closing in.
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Posted in: Medical Education & Training, Patient-Centered Care, Physician Assessment, Uncategorized
HI I am recently ABIM certified 2013, I scored 736 out 800 with 10 th decile. I personally felt the exam needs more standard. I appreciate the new development of adding computer stimulation real life cases. ABIM should have more standard, means no one should pass this exam just reading a crash book course for 15 days. I also felt that after second year, residents give more important to fellowships than ABIM , they even skip exam because they have no time to prepare for exam. it should not be like that. ABIM should have some standard, those who respect those standard should get some reward in terms of getting fellowship.
Dr Benson,
I have included a link to a podcast that may be worth your time listening to, and I think has some merit regarding several issues raised in your post.
This approach, I think is an exciting and intriguing development, and personally am excited about being part of in this history making moment of the transformation of medicine in America today.
http://seen-heard.com/blog/technology-levels-playing-field-independent-physicians/
I am a practicing Board Certified Internist who recently finished taking the MOC exam. As a disclaimer, I would like to say that I have not received my score yet and that I did well on the initial certification exam that I took 10 years ago, so these comments are not driven by sour grapes.
My concern is that, as I saw it, the questions on the exam seemed to have very little to do with the practice of Internal Medicine, but rather were focused on tiny bits of obscure information which we Internists rarely use. Many also seemed to have a “trick” or one word which, when found, would point toward the answer and therefore were more of an IQ test than a test of useful medical knowledge.
My view of the practice of Internal Medicine, instead, requires Internists to direct the care of their patients. We must understand how the medical system works and in doing so, we need to know the broad concepts of each subspecialty, so that we can make appropriate referrals and communicate well with subspecialists. Our ability to treat our patients demands much more skill in communicating well with patients and their families than knowledge of the latest treatment for a specific leukemia, which truthfully, we would never order, but which could be looked up if necessary. And above all, we need to be comfortable managing a patient with multiple doctors, complex health problems, competing medications, and conflicting treatments.
There must be a better way to test those skills and evaluate a practicing physician than a 6-hour test on medical trivia. I think that even writing essays on different diseases or going to one of the week-long medical updates at a medical school would foster a better concept of medicine and disease than memorizing disjointed facts. I also find it distressing that a physician who has been “in the trenches” for 10 years could lose his certification because of a bad 6 hours.
Thank you for listening and for being willing to consider alternative means of assessing physicians.
Nancy Campbell, MD
As an Emeritus Professor of Medicine, and now part time practitioner of Endocrinology, I have a somewhat unique view to offer. I feel that the questions that are being developed for the MOC need to be directed to the practice of endocrinology, rather than the evaluation of minutia. I am all for learning the molecular origins of disease, but this is not relevant to the day to day practice of office endocrinology – which was ostensibly what triggered the MOC process. It has been said that patient demand closer examination and scrutiny of data base that practicing subspecialists possessed. Having assisted in the Beta Test of the newest MOC questions, and three years ago recredentialed for my Endocrine Boards, I fail to see what many of the question have to do with the practice of quality care. Focus on real office issues, on cost containment, and quality of clinical care should be the strength of this new requirement. Instead, I found far too many questions that were obtuse or evaluated trivial new bits of information. Now, many of these may ultimately prove essential to the practice of Endocrinology, but there are far more pressing bits of information on new diabetes medications, for instance, that were not even evaluated (either in the Board Exam or MOC pieces).
I encourage the board to focus on what needs to be be known to practice solid 2014 medicine, now what might be useful in 10 years. I for one won’t be practicing (having retired) in a decade. More questions that alienate older practitioners are only going to serve to drive them to earlier retirements, or to simply have them drop their MOC credentials.
Patrick J. Boyle, M.D.
What I question is the ABIM’s role in deciding what trainees ought to be taught. Is ABIM considered an arbiter of medical education? What/who gives ABIM that role, or is this self-proclaimed?
On a technical basis, Dr, Besnon, you ignore the fact that 64% of physicians in your example did not believe that they are responsible for rising health care costs. Even the New York Times recently published an article that clearly shows that physicians are not to main contributors to rising health care costs, but it is the rise n the cost of administrators or other middle men. http://www.nytimes.com/2014/05/18/sunday-review/doctors-salaries-are-not-the-big-cost.html?src=me&ref=general&_r=0
I find this statement very indicative of ABIM’s focus “ABIM could require candidates to achieve a perfect score on questions related to costs…” Don’t we not know by by now that results from tests have near-zero relevance to real life practice?
My only hope for ABIM is that it change this line of thinking very soon.
All 4 premised causal inferences lack logic and/or reason.
The costs of care, if one were to really analyze the data is DIRECTLY related to ADMINISTRATIVE expense(40-65%).
When the Administrators have increased by 3000% and the physician force by 2% where are the cost overruns?
This form of obfuscation to redirect causality serves no one, least of all the patients and directs more resources to the Administrators, Insurers, Policy wonks and self appointed arbiters of medical capital.
Pricing strategies are borne of the market needs. If they are arbitrarily dictated and governed by a meaningless format of MOC or certification exam (that has no proven value) as proposed, we will dig the hole further.
There is little will to change the paradigm for fear of losing the grip on the revenues that abound for the intermediaries. While Hospital managers command a large paycheck, some physicians struggle to survive.
It might be time to look at the whole Public Health System created mess rather than point fingers to redirect blame!
It is time for everyone to realize that The federal Government, patients, pharmacy and the ancillary industries including hospital administrations that follow the government mandates are wasting the largest amount of money-not doctors. The ABMS/ABIM is expanding the $400 million empire, forcing EVERY physician to consume their unnecessary products, duplicating the jobs of multiple oversight agencies that are actually mandated to have the objective to regulate medicine. As Board Certification itself has never been demonstrated to do anything to improve care, MOC is just another extention of that same failed program of “advertisement” of unproven competency. This competency does NOT matter in today’s world where Hospital administrators, government employees, patient’s “satisfaction scales” and other idiotic mechanisms including”certification extortion scams” are allowing non-physicians to practice medicine even outside the scope of state medical boards.
The Choosing Wisely program espouses discarding “wasteful testing” while the parent ABIM is forcing the most wasteful testing: MOC- which causes every one to be tested and we know that less than 0.005% of all physicians were ever challenged as incompetent-but this means “as competent as a NP or Midwife!
“ABIM could require…a perfect score…..as a requirement for admission..”
Are you hearing yourselves? Do you see yourselves as certifiers in medical competence or in public policy? Soon a board certification will tell little about the doctor, and a lot about ABIM.