By Westby G. Fisher, MD, FACC

What is it like for physicians to fail their ABMS Maintenance of Certification® (MOC) program examination? How does the largest member board of the ABMS, the American Board of Internal Medicine (ABIM), respond to doctors who fail their secure examination?

As I continue to confidentially collect information from physicians who have failed their MOC examination, I thought it would be important to publish an example of a physician letter I received. The psychological, social, and financial consequences of failure of Maintenance of Certification are real yet have never been studied by the ABMS and their member boards, including the ABIM. To me, this is both highly unethical and inexcusable. This lack of concern for the negative ramifications of the high-stakes ABMS MOC examination that is increasingly tied to a physician’s ability to practice medicine is alarming, especially when judgment is rendered by an unaccountable organization led by non-practicing physicians and scientists that benefit so handsomely from this program.  It is also very concerning in light of the high suicide rate among physicians.

I have also included an example of how the ABIM finally responded. The lack of timely response, transparency, and obfuscation of methodology and facts reflects very poorly on the ethics, scientific credibility, and legitimacy of the MOC program.

(While some physicians have granted me permission to use their name, I have elected to redact their personal information for this post.)

My name is *******. I practice Internal Medicine in ******. I’ve been in private practice for 10 years. 

I was devastated when I opened an e-mail from ABIM on Monday June 30, 2014. I knew it was the strangest, most difficult test I had ever taken, but I had no idea that I would be failed. I wanted to curl up in a ball and cry, but I knew I had to be strong for all the patients that needed me that busy Monday. I was in a state of functional depression for weeks. Crying whenever I was alone. The thought of studying all over again for a crapshoot exam was more than I could stand. Fortunately, I connected on Sermo and learned what was going on and that I was not alone. 

I wrote to ABIM 4 different times, once a week for 4 weeks. I want clear answers about the delivery of the test questions and scoring. I have not yet received a reply. 

I spent many, many, lost, precious hours away from my husband, children and grandchildren on weekends and evenings studying for my exam. I started studying hard several months prior to the exam. 

Cost: Loss of time with my family – Priceless, MKSAP books, ?$650, Test $750, MOC module $1600, Loss of revenue $ 3000+. 

Yes, I’m willing to co-author and fight for this cause, and yes my name can be used.

I announced my failure at the quarterly Int Med meeting a few weeks ago at ****** Medical Center where I admit. I’m lucky because they are going to grandfather me in, so I won’t lose my privileges. 

This is lame I know, but it can’t bring myself to tell my parents.

In August, 2014, the physician above finally received this response from Richard Baron, MD, the President and CEO of the ABIM: 

Dear Dr. *******:

Thank you for your e-mails to the American Board of Internal Medicine (ABIM). I apologize for our delayed response. I understand your disappointment in learning that you were unsuccessful on the Spring 2014 Internal Medicine Maintenance of Certification (MOC) examination. I appreciate the time you dedicated to prepare for the exam and that you were not expecting this result. I understand your concerns and I’d like to respond to your questions about the examination and how it is scored. I’d also like to let you know of a recent policy change we have made for physicians who, like yourself, were unsuccessful in their first exam attempt.

With regard to your inquiry about the specific questions each examinee sees, though ABIM uses multiple versions of the exam, we take steps to ensure all takers are on a “level playing field.” We do this by constructing equivalent versions of the exam in content and level of difficulty so that, regardless of the version taken, examinees faced the same challenge. In addition, scores for all examinees were converted to a standardized score in the scoring process. The scoring process, along with the use of equivalent examination versions, ensures the comparability of scores regardless of the examination version taken. We follow standard testing industry best practice throughout our processes.

Concerning your question about whether ABIM exams are scored on a curve, the answer is that they are not: ABIM uses an absolute standard – a specific level of performance one must achieve in order to pass our examinations. Rather than scoring on a curve where a fixed percent of physicians will pass and fail, the absolute standard is a more fair and equitable process in that each test taker must meet a threshold of performance that makes their performance totally independent of other test takers. Because of this, the pass rates for an exam can and do fluctuate naturally.

About your question related to pass rates dropping, the differences in the percent of test takers who pass the exam (pass rate) from one administration to another is not due to changes in the exam content or difficulty but to the natural fluctuation that occurs with using a consistent absolute standard with different groups of exam takers who may have different motivation, ability and training.

ABIM has made a recent policy change that I hope will be good news for you– because your Internal Medicine certificate expires this year and you were not successful in this exam attempt, ABIM will grant you an extra year to pass your exam, providing you complete the Self-Evaluation of Practice Assessment requirement by December 31, 2014. During the extra year, you will continue to be reported as “Certified, Meeting MOC Requirements,” provided all your other MOC requirements are being met. You will need to pass your exam by December 31, 2015 and once passed, your next MOC exam will be due 10 years from the last pass.

We hope that you find this information helpful. Again, I completely understand your disappointment and wish you success in your next attempt. If you need further assistance, you may reply to this e-mail or call us at 1-(800)-441-ABIM (2246) Monday through Friday, 8:30 a.m. to 8:00 p.m., and Saturday, 9:00 a.m. to 12:00 p.m. EST.

Respectfully,

Richard J. Baron, MD, MACP

President and CEO

American Board of Internal Medicine

This letter is important for several reasons.

First, there is no excuse why the ABIM should have had such a “delayed response” to any physician diplomat’s inquiry, given the high cost of their “program” and the millions of dollars spent to support this program.

Secondly, we now find doctors who sit for the MOC examination are not all given the same examination, but rather different ones deemed to be “on a level playing field.”  How is “equivalency” between examinations determined exactly?  Wouldn’t we all like to know?  Might there be bias created by such a process?  And what are “standard testing industry best practices?”  Shouldn’t doctors be enlightened on these?

Thirdly, there’s the issue of determining an “absolute standard” for physician knowledge.  Who decides this “absolute standard?”  How can an “absolute standard” be determined for a physician when a central authority is completely blind to a physician’s scope of practice? Is there some “industry best practice” that doctors don’t know about?  Is the “absolute standard” of a quality physician only someone who can cram facts and “pass” a computerized test based on an arbitrarily-determined knowledge base?

The ABIM leadership are masters at skirting these very real concerns of the MOC program.

Finally, the doctor’s question regarding the rising failure rates on MOC examinations was not acknowledged nor  answered by Dr. Baron.  Rather, Dr. Baron blames the rising failure rates on experienced physicians’ “different motivation, ability, and training.” That’s right: it seems the higher failure rates are the doctors’ fault.

Not surprising, though.

The American Board of Medical Specialties’ MOC® program, which has been exhaustively marketed and sold to physicians and legislators as a valid mechanism for assuring quality physicians, appears hopelessly mired in scientific uncertainty and conflicts of interest.  The process is also having profound emotional and psychological consequences to those adversely affected.  This is not a training or teaching exercise, but rather a punitive assessment technique based on an undisclosed set of centrally-predicated and non-transparent benchmarks that appear unevenly distributed.  And sadly, our own professional societies continue to support the program primarily because they profit handsomely from it.

As the veil is lifted on this Draconian process, it is becoming increasingly clear that the ABMS’s MOC program is deeply flawed. Yet for reasons that only its well-paid creators understand, the program is no longer a voluntary exercise for physicians, but increasingly tied to government physician payment formulas and credentialing.    

I have no doubt that the members of the ABMS and ABIM feel in their heart of hearts that such a centralized, top-down secretive system of physician testing carries nothing but the most enduring benefit to society.  McCarthyism was hatched from a similar line of reasoning.  

It is clear that the inconsistencies and self-serving nature of the ABMS MOC program is becoming increasingly destructive to our colleagues and profession.  Now we must ask ourselves, what should working physicians do to fix this mess?

At the present time, it seems the only viable alternative is mass non-compliance with the ABIM MOC program or legal action. For not only is the MOC program scientifically indefensible, it is now clear that it is potentially very destructive to many physicians.

-Wes

PS: Physicians who failed a MOC examination are still encouraged to confidentially submit their stories as I continue my efforts to expose all sides of the Maintenance of Certification debate.