The Disenfranchised Physician—The Revolt Against Certification

By Bob Sweeney

Our blog continues to look at those factors contributing to physician burnout and loss of faith in the practice of medicine as a career.  Here’s a topic that every physician has to contend with: maintenance of certification.     

Certification is a multimillion dollar industry in addition to being a mechanism for insuring that docs keep up their skills and competency.  It’s been around in one form or another for decades, but today’s version is largely a product of the 1980s.  Back in that day, there was no internet, and the only sources of verifiable learning content, other than apprenticeship, were paper publications and meetings. Societies organized to set specialty-specific standards quickly established or captured the role of guardian or gatekeeper for what types of learning and testing results would constitute evidence of maintained skills and overall competency.  

In the absence of competition for content sourcing and without an online forum for consulting and vetting information and processes, a “cardinal’s college” of academic specialists became the high priests of certification.  They organized and structured the review and testing environment, the frequency of test requirements, criteria for remediation among unsuccessful test takers, and the sources blessed as specialty gospel.  In parallel, these organizations effectively set the price, both periodic and ongoing, to run through the certification and re-certification gauntlet.  

So what’s wrong with a system to insure maintenance of competency?  Nothing, in principle! However, the system devised by the specialty societies had and still has a gaping hole in its logic.  There is no substantial correlation between test results on their tests and knowledge gain or retention.   Here are two articles that articulate the frustrations of physicians dealing with the certification bureaucracy:

https://www.medicaleconomics.com/article/physicians%E2%80%99-battle-limit-maintenance-certification-requirements-continues-despite-testing

https://www.checkbook.org/national/doctors/articles/Does-It-Matter-If-Your-Doctor-Is-Board-Certified-2797

There are a lot of reasons for this gap between expectation and outcomes.  First, as educational psychologists can tell us, the test format used by these organizations does not do a good job of preparing the user for anything other than a test.  Learning retention is demonstrably not a benefit of multiple-choice test taking.  It turns out that retrieval and retention are improved more by short answer questions and answers or a mix of test formats, accompanied by remediation at the time of response.  

Here’s one of many journal publications on the topic:  https://pages.wustl.edu/files/pages/imce/memory/2007_kang.pdf

So why do the societies use a suboptimal format?   Here is why:  it’s much easier to write questions of this type and, of equal importance, to score them. In short, the test format evolved to meet the demand on the part of the test writers and testers for a simple and easy to score product.  

Physicians are not stupid.  For decades, it’s been common knowledge that CME and certification requirements are rife with commercial exploitation, conflicts of interest  (e .g., the pharmacy industry), and unverifiable practice benefits.   The revolt began with internists about five years ago and continues in every branch of primary and acute care.  Even in the surgical and other process-oriented specialties such as ophthalmology,  physicians have reacted with dismay at requirements to record and document dozens of procedures to validate their skillset to some review board.  

Docs aren’t rejecting the reasonable expectation by the public that they be able to demonstrate that their practice is still up to current par.  What they are objecting to are costly and time-consuming activities that have no proven connection with competency.    What we have today is an environment where hospitals, patients and other colleagues expect providers to maintain certification. However, the certification process that has come into being is not aligned with measuring competency.  It’s become just another time block and expense standing between the doc and practice time.

Physicians must contend with a hurdle of requirements throughout their careers. Let’s be sure that the things they are asked to do make sense.  The purpose of periodic competency assessment is to protect the public, not to generate a profit for a specialty society commercial enterprise. 

Bob Sweeney, Principal & Managing Partner
bob@globalhealthimpactfund.com