Down the rabbit hole of recertification.
Subject: Medicine (Practice)
Medicine (Analysis)
Author: Hieb, Lee D.
Pub Date: 06/22/2011
Publication: Name: Journal of American Physicians and Surgeons Publisher: Association of American Physicians and Surgeons, Inc. Audience: Academic Format: Magazine/Journal Subject: Health care industry Copyright: COPYRIGHT 2011 Association of American Physicians and Surgeons, Inc. ISSN: 1543-4826
Issue: Date: Summer, 2011 Source Volume: 16 Source Issue: 2
Topic: Event Code: 360 Services information
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 267810794
Full Text: The Cat: We're all mad here. I'm mad. You're mad.

Alice: How do you know I'm mad?

The Cat: You must be. Or you wouldn't have come here.

Lewis Carroll, Alice's Adventures in Wonderland

This year I was almost stripped of my title as a board-certified orthopaedic surgeon--an action with significant consequences to my ability to practice in my hospital, and to be contracted with various insurance companies. It didn't matter that I had graduated from an accredited medical school; passed parts I, II, and III of the National Board of Medical Examiners; completed a five-year orthopaedic residency and a year of fellowship; passed my written and oral board examinations in orthopaedics; practiced my specialty for more than 20 years; attended countless "continuing medical education" (CME) meetings; and passed the American Board of Orthopaedics Recertification in 1999.

Did this threatened loss of credentials occur because of malfeasance, malpractice, misbehavior, or general incompetence? Was it for failing to meet some new CME requirement or to keep up to date with procedures? No. It was for failing to supply a signature sheet to the office that oversees the applications for recertification testing.

In the last few years, various specialty societies--apparently responding to alleged demands from the average citizen crying for "more testing of our doctors!"--have begun implementing new "pathways" for maintenance of certification, or MOC. Of course, the oldest members of our professions are all exempt, but those of us unlucky enough to have graduated in the "transition" years are faced with instructions in algorithmic form, the complexity of the application rivaling the blueprints for the particle accelerator at Cern. And trust me--the bugs are not all worked out.

When I first received notice about the change, I looked at the website, which contained a matrix of information based on the year my certification expired. My first mistake was to think I had ample time to decipher this Rosetta Stone of recertification. But, alas, it was necessary to start the process nearly three years prior to the date my certification would expire. (In fact, the deadline for submission of data to the Board was well before the test application was even available!) And, try as I might, in spite of a reasonable degree of intelligence and education, I could not understand the matrix options. I thought this would be no problem, since I would be attending a state specialty meeting and could talk face to face with a director of the Board. After I presented my questions to him, he looked long and hard at the printed matrix, and he--a director of the Board--also could not determine exactly what steps I needed to take to recertify. He said, "Better call the Board." I did that--only to receive incorrect information, but information upon which I acted.

Now, it is no mean feat to assemble all the paperwork for recertification. For those of us outside the university, not on a salary, who see 60 patients per day, and who do not have a department secretarial pool to help us, this was taxing in both time and money. I hired a part-time person to input the data from my cases into the computer, and took time away from seeing the walking wounded to personally complete the information on each case. I made several clarifying calls to the Board, and finally submitted the forms well before the deadline. Because of the crucial nature of this certification, I called later, a week prior to the deadline to ensure that everything had been received, and was told, "We're too busy going through the applications, and we can't look for that right now."

So I waited politely until a month or so after the deadline, and called again because I had heard nothing from them. At that time I was told, "We didn't get your signature sheet."

Me: "So wait," I said tentatively, "are you telling me I can't sit for the board?"

Board bureaucrat: "Yes, that's right."

Me: "Because of a signature sheet."

Bureaucrat: "Yes, that's right."

Me (dumbfounded and feeling like Alice): "And I can't resubmit it now?"

Bureaucrat: "No"

Me: "Can you check again? You got my CME, how could you not have my signature sheet?"

Bureaucrat: "It's not here."

Me: "Are you telling me that as of January 2010 I will no longer be board certified?"

Bureaucrat: "Yes, that's what I'm telling you."

At this point I admitted defeat and knew that more drastic action was needed. Much as I despised doing so, I called a lawyer.

After a year of legal letter-writing and appealing Board decisions, which granted a stay of execution by the Board during the appeals process, I was finally able to take the test. And I passed, even though most of the questions on the test pertained to areas of my specialty I do not currently practice.

There are many issues with recertification. Does it improve medical care? Does it improve doctor competence? In this age of "evidence-based medicine," where is the evidence that recertification matters?

I have not met one practicing non-university physician in my specialty who believes that recertification improves surgeon performance. Let's look at the reality of test-taking and preparation. What would a smart person study for such a test? He would study the areas of medicine he doesn't do on a daily basis. For my first exam I studied total joint theory even though, as a spine surgeon, I did no total joints and hadn't done one since leaving residency. In point of fact, such preparation takes time that could be more productively used to study and improve performance in those areas that target one's specific practice.

Secondly, how does this contribute to patient care? It doesn't. At a time when emergency rooms all over the country cannot find orthopaedic surgeons to take trauma call, we waste the time of those in practice (at least a week per surgeon) preparing and taking this recertification test. At a time of physician shortages, especially in certain subspecialties and in under-served areas, we are putting more barriers and burdens upon physicians' practices. Growing numbers of physicians are planning to choose retirement a year or two early rather than recertify, and this will further aggravate the physician shortage.

Testing is certainly an economic loss. It cost me at least $1,000 in staff time, two days of lost productivity to travel to a test center, other lost time from patient care in preparation, an $800 fee, and the cost of a special and mandatory CME offered only by the American Academy of Orthopaedic Surgeons, which claims no association with the American Board of Orthopaedic Surgery.

Who does benefit from all this? Well, it keeps more people at the Board employed. It gave a financial boost (I won't use the term "kickback," however much I want to) to the Academy, whose CME is mandatory. And then there is the nationwide chain of "learning centers," which have morphed into big computer testing facilities in recent years. It will keep a few more lawyers employed, because who, after more than 20 years in successful practice, would give up certification without a fight because of failing the exam? (As noted, I needed legal help just to get past the gatekeepers at the Board.)

Recertification has become a cottage industry of bureaucrats and testing agencies, dragging with them a few university physicians, who, even if they see the issues, couldn't stop this financial juggernaut if they wanted to.

I was told by a Board member that the issue of recertification is a "done deal" and not open for further debate. But, the process benefits neither patients nor physicians, and certainly adds nothing to the time-honored practice of medicine. I will never participate again. It is time to just say no.

Lee D. Hieb, M.D., practices orthopedic spine surgery in Lake City, Iowa, and serves as president of AAPS. Contact: loganpod@gmail.com.
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