Bob Wachter has written a lengthy defense of the American Board of Internal Medicine (ABIM) and its Maintenance of Certification (MOC®) program, addressing contentions that the ABIM may have engaged in questionable financial practices, and that MOC® is irrelevant, time consuming, and onerous.
These allegations, however, are not the only questions board organizations may need to confront. Along with several recent articles devoted to the topic of professionalism, Wachter’s piece provides us with an opportunity to examine three foundational arguments that board leaders invariably bring forth to justify the commerce of certification.
1. Public demands and “medicine’s social contract”
Referring to a recent JAMA editorial by Richard Baron, CEO of the ABIM, Wachter writes that:
…the board movement launched around the time of the Civil War, when the AMA began grappling with the question of how to determine whether a doctor was competent to call him or herself a specialist in a given field.
Baron and Wachter would have us think that the movement arose in order to fulfill a public demand. Says Baron:
How does the public know who is qualified to practice medicine? Given the critically important responsibility that practicing physicians assume every day, and given the inability of patients to judge independently the quality of their physician’s training, knowledge, and skill, the profession has always been involved in efforts to better serve the public by defining medical competence in a consequential way.
I have previously pointed out that late nineteenth century patients in backwater Rochester, Minnesota, seemed perfectly able to “independently judge the quality of their physician training” without the help of the AMA, licensing, or certification, thus allowing the Mayo Clinic to emerge as the nation’s premier clinical institution. But in defense of the new board initiatives, Wachter adds:
After all, even though it might be attractive to some physicians to water down board certification, it seemed inconceivable to me that our profession – or the public – would accept the argument that participation in [continuing medical education] should be enough to demonstrate lifelong competence (emphasis mine).
Strengthening Wachter’s impression that board organizations are invested by societal demands, Lois Nora, President and CEO of the American Board of Medical Specialties (ABMS) recently opined:
Specialty board certification arose at the beginning of the 20th century, when the profession began to set standards for medical training, hospital management, and specialty practice. The public needed ways to distinguish qualified specialists from others (emphasis mine).
Unfortunately for board leaders, the claim that board certification arose to fulfill a public demand is not remotely substantiated by any empirical evidence. But undeterred by the lacuna, MOC® apologists invoke “medicine’s social contract,” a sociopolitical theory constructed in the 1980’s by health care sociologist Paul Starr, and seized upon by the AMA and its progeny to justify various board and licensing activities.
Thus, in the same issue of JAMA, Jordan Cohen, President Emeritus of the Association of American Medical Colleges, explains the touted social contract as one whereby society bestows upon doctors the privilege to practice medicine “on the expectation that physicians would remain competent, altruistic, and moral.”
Did society specifically charge the AMA or ABMS to enforce the social contract and guarantee physician competence, altruism, and morality? That, of course, is hard to tell since, as Cohen explains,
There is no legal document, no signed contract, no specific quid pro quo that enshrines these mutual obligations. It is as if the agreement were sealed with just a handshake as a sign of the trust society had that physicians would deliver on their promise.
For self-proclaimed champions of science and enemies of magical thinking, this appeal to an invisible contract that “enshrines mutual obligations” may seem like a paradox. As it turns out, the exact circumstances that gave rise to board certification are not so mysterious. Baron himself relates that
The modern “board movement” can trace its roots to a meeting in Boston, Massachusetts, of the American Medical Association (AMA) in 1865, during which the New York delegation raised concerns about the problem of specialism. The concerns related to the anxieties of general practitioners arising from the fact that some physicians in New York had been advertising that they had special expertise in a “palpable effort to attract business…”
So a more accurate explanation for board certification is that it arose not in response to public demands, but out of a trade dispute between generalists and specialists. The AMA sided with the specialists, a position in line with their effort to promote a “scientific medicine” grounded in empirical methods of inquiry.¹
Baron calls these early lobbyists “heroes of the 1860 AMA Chicago meeting.” Perhaps that assessment is not too surprising. But the late historian Ronald Hamowy gave a more empirically-grounded account of the motivations of our medical founding fathers. In reading Hamowy’s report, it becomes apparent that a true concern for meeting public demands was not prominent on the AMA’s agenda.
2. “Medicine is advancing too fast”
Another favorite justification for requiring certification and MOC® points to rapid changes in medical science and medical practice. Thus, in a separate issue of JAMA, Thomas H. Lee, chief medical officer of Press Ganey, a “healthcare improvement” corporation, asserts that
Early in the 2000s, it became clear that medicine was moving so rapidly that testing physicians every 10 years was not enough to ensure that they would stay up to date, so the ABIM and other boards moved to more continuous processes for assessing competence.
And in reply to a readers’ comment, he confirms,
…medicine is advancing too fast to assume that anyone is practicing state-of-the-science medicine on the basis of successfully completing training decades ago.
The same argument was recently made by Nora as follows:
…with scientific knowledge growing exponentially and research revealing the extent to which skills declined with age, the medical profession would need a more consistent way to ensure each physician’s continued expertise, judgment, and skills
It is a bit disconcerting that specialty boards should only now come to realize that medical changes are happening fast, given that these organizations are precisely invested with the task of surveying the cutting edge of medical science.
More importantly, we may reasonably wonder about the method with which Drs. Lee, Nora and their associates could quantify the pace of medical advancement so as to relate it to the amount of testing a doctor must be subjected to.
An empirical analysis, for example, might look at the following time frames parsed according to intensification of certification rules:
1) 1935-1990: Lifetime certification
2) 1990-2005: Recertification every 10 years
3) 2005-2012: Introduction of MOC® modules
4) 2012-present: “Continuous” MOC® process
Looking at these time periods, one would be hard-pressed to justify certification requirements on the basis of advancement in medical science. After all, incremental improvements in drug therapy, intensive care, operative technique, and management of chronic conditions have been much less pronounced in the last 20 years compared to the first decades after certification was established.
In all fairness, board supporters may have in mind the kind of innovation specifically identified as fruitful by the academic community. If such is the case, though, keeping up with the promises of genomic science, the hopes of personalized medicine, the revelations of Big Data, the titillations of electronic health records, and the efficiencies of accountable care organizations might, in fact, require much more application on the part of doctors than continuous MOC®.
In such an world of exponential change, taking care of patients may seem like an unnecessary distraction, and ensuring doctor competence could require nothing less than Total MOC™: the complete, perpetual, and exclusive commitment to relearning everything all the time.
3. If we don’t do it…
Finally, for masters of organizational politics, the collective “we” is an essential pronoun of doublespeak. Warning about the consequences of our failure to “self-govern,” Wachter draws attention to “what’s at stake:”
…we physicians are granted an extraordinary amount of autonomy by the public and the government. We ask people to disrobe in our presence; we prescribe medications that can kill; we perform procedures that would be labeled as assault if done by the non-credentialed. If we prove ourselves incapable of self-governance, we are violating this trust, and society will – and should – step into the breach with standards and regulations that will be more onerous, more politically driven, and less informed by science. That is the road we may be headed down. It is why this fight matters (emphases mine).
Likewise Nora describes the purpose of certification as “a longstanding component of the US medical profession’s system of collective self-regulation.”
But “self-governance” and “self-regulation” are terms applied to organizational systems on the basis of a loose analogy borrowed from the realm of biology. Only living organisms are truly self-regulated. A bacterium can, on its own, adjust its intake of glucose so as to maintain homeostasis. Likewise, in complex organisms, feedback mechanisms orchestrate the response of various organs for the survival of the whole body.
A trade association, on the other hand, can use the analogy of the organism only so far. For the purpose of public relations, it may be necessary and convenient to claim E pluribus unum, but the fact remains that any organization of human beings is a collection of autonomous individuals. Among those individuals, some must make the rules and others must agree to obey them. The “self” in self-governance is purely metaphoric. Without voluntary submission to the rules of the organization, the metaphor of the “we” becomes harder to conceal.
And as far as the danger that they might “step into the breach” with measures that are “more onerous, more politically driven, and less informed by science,” well some of us simply beg to differ.
Board certification was not a response to public demands, cannot plausibly be correlated to the pace of medical advances, and should not be assumed to represent the will of physicians.
Board organizations must contend with two major problems. The first one is epistemic: how do they know a given physician is competent, when the very concept of competency is conveniently left undefined? The second one is juridical: how can they claim legitimate authority to adjudicate competence if physicians en masse begin to look for alternative representations?
Wachter is correct in fearing a “race to the bottom.” The certifying exercises designed by the American Board of Medical Specialties and its member organizations serve the profession only to the extent that professionals voluntarily choose to abide by its rules. But as physicians increasingly threaten to jump ship, lobbying the government to coerce doctors into compliance may be the only resort left to keep up the charade and maintain the MOC®kery.
1. Primary care physicians can thus trace their second-class citizen status to this position taken by the AMA and further promoted by the ABMS (an AMA progeny).