Do We Really Need Physician Re-Certification Testing?

There has to be a better way.
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(Photo: Maksym Dykha/Shutterstock)

(Photo: Maksym Dykha/Shutterstock)

How many standardized tests do physicians take in order to become certified? Though it depends on the doctor and the specialty, let’s use my example. Starting from medical school, the tests include the United States Medical Licensing Examination Steps 1, 2, and 3, and the American Board of Internal Medicine internal medicine and infectious diseases board examinations. That totals five. Since my initial certification was after 1990, I have been required to take re-certification exams in both internal medicine and infectious diseases to qualify to maintain my certification. I recently completed my last exam.

Does requiring experienced physicians to cram for a closed-book exam in an anxiety provoking testing environment produce the doctor you want taking care of you?

As an academic physician, my days and weeks are filled with writing grants to start new projects; publishing papers to communicate findings to the scientific community and community at large; caring for patients; educating medical students, residents, and infectious diseases fellows; and administrating programs to allow for all of these activities to occur. In 2015, my infectious diseases certification certificate will expire, so I began this year with a pit in my stomach, knowing that I would once again have to revert to days of having my nose in a book. How would I fit in the necessary studying for yet another test?

How is my education at this point in my career aided by leaving the exam clueless only to get a score three months later, never knowing for sure the questions I got wrong and their correct answers?

The anxiety that these exams created is not unique to me. The practice has also led to the business of re-certification board review courses, books, and discs. For physicians in primarily clinical practice, days are filled with back-to-back patient appointments and the time-consuming activity of documenting each encounter in an electronic medical record. Dedicated time to review material for the exam is often the only way to be able to focus.

As I took the exam, I was confident I knew the answer on some questions. But as with all tests, there were those questions where I narrowed my answer down to two choices and wondered which one might be correct.

Let’s pretend now that the hypothetical patient from my re-certification exam was in front of me. Would I just guess and go for one of the two treatment options I had narrowed it down to? As a physician and patient, I believe I would much rather look up the absolutely correct answer.

And what about the questions where I didn’t even understand what they were trying to get at? How is my education at this point in my career aided by leaving the exam clueless only to get a score three months later, never knowing for sure the questions I got wrong and their correct answers? In our digital age of easily accessible resources and Wi-Fi everywhere, isn’t it more important that I recognize the clinical syndrome and look up details to make the informed decision?

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Once I completed the exam I tried to remember those questions where I was uncertain of the answers so I could look into them. But I could only remember a few clearly enough to identify the correct answer. What purpose does that serve? I think I learned more by practicing questions before the test, reading explanations for those that I got wrong, and recalling facts that I knew were once more readily accessible.

Many physicians, including Dr. Danielle Ofri, have advocated for abolishing the closed-book exam. In January 2014, the ABIM attempted to expand the scope of its re-certification process to all internists, not only those certified after 1990. This action infuriated many physicians, leading some to revolt and establish a rival certification board named the National Board of Physicians and Surgeons.

Physician groups, such as the American College of Physicians, have been leaders, advocating for reform of the re-certification system created by the ABIM. All of these efforts led to a bold statement on February 3 of this year by the ABIM stating: “We got it wrong and sincerely apologize. We are sorry.” The group has additionally stated that “by the end of 2015, ABIM will assure new and more flexible ways for internists to demonstrate self-assessment of medical knowledge.” Given the fiscal challenges that ABIM has and the gap that re-certification funds are aimed to fill, however, it is challenging to envision what changes they will make in such a short amount of time.

Although I had these assurances of possible change in the coming year, I decided to take the exam. I had two options, April or November. Professionally and personally, the April exam date was more convenient, and, God forbid I failed, I would have another chance to take the exam before my certification certificate expired.

Does requiring experienced physicians to cram for a closed-book exam in an anxiety provoking testing environment produce the doctor you want taking care of you?

To be sure, some may say my argument is self-serving. But I don’t want to get rid of standardized tests altogether.

These tests serve an initial purpose of identifying a core knowledge that is necessary for the practice of each field of medicine. Some may believe that having certain facts ever present in your memory should always be tested. But this is not the reality of the daily practice of medicine. Because each doctor specializes in certain fields, those are the facts that stay most present with them.

Competent physicians are human beings with families, the stress of everyday life, and the unique stressors of the practice of medicine. In the real world of medicine, we consult colleagues and other experts when we need additional advice. We read and look things up every day.

I would be happy to enroll in a program where every year I am required to complete a series of questions online with answers provided immediately. For those questions I get wrong, I can read the correct explanation and learn in the moment. I can repeat the exam until I answer all of the questions correctly. That process would only reinforce my knowledge base, and all the funds currently spent on maintenance of certification could be put toward such a program.

Personally, I spent $1,720 in 2010 to enroll in the maintenance of certification program and take the internal medicine exam (the current fee is $1,940) and another $775 to take the infectious diseases exam, a total of $2,495. Doesn’t it seem reasonable that the ABIM should be able to administrate a re-certification program that is more efficient and streamlined for that amount of money per person?

While I await my results, of course I hope that I passed the exam yet again. I do feel that some of those facts that were hidden deep in my memory have re-surfaced, but I’m not sure for how long. It isn’t clear to me that experienced clinicians with fleeting obscure facts are what we need most in our medical field today.

Many friends and family congratulated me on being free for another 10 years, but the reality is that I will have to take the internal medicine certification exam again for the third time six years from now. I’m hoping that the ABIM fully addresses the concerns of the medical community and acts on its recent assurances. Taking part in a yearly online review may be the solution. And not having to take another closed-book test in my lifetime, would, I believe, make me a better doctor.

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