The American Board of Bada Bing

You got a really nice place on the web here, it would be a shame if somebody messed it up.

Recently, I received an email from a company called Avvo asking if I had seen my physician profile on their website. I was happy to see that I had received a physician rating, as a rheumatologist, of 8.9 (out of a possible score of 10, “excellent” in their description). When I looked at my profile, I found that I could look up the ratings of some other rheumatologists in the area to see how I compared. Although I was better than some (admittedly, not many), I found a number of colleagues who had perfect scores of 10, which, of course, stimulated my competitive juices. But then I remembered that I don’t see patients so, really, what difference did it make?

When I tried to figure out how I got such a good (but not perfect) rating, I found that I got 4.5/5 on experience, 5/5 for professional conduct, but only 1.5/5 for industry recognition (they obviously haven’t seen my disclosure statement). Looking back at the ratings for some of my colleagues (who also don’t see very many, if any, patients), the big difference was industry recognition. Clearly, making the web listing of various pharmaceutical companies, as mandated by the Sunshine Act, will now be considered a selling point for online doctor ratings.

After a bit of reflection, I reconciled myself to a less than perfect rating but, just as I was getting over the shame and disappointment, I found out there was a new threat to my excellent rating. Somebody was offering me a “deal I could not refuse” in return for which they would not smear my name for online rating services like Avvo.

Offer We Can’t Refuse

The American Board of Internal Medicine (ABIM) has publicly announced their desire for all physicians to participate in the recertification program. The ABIM is developing an “education” program that I could—but did not have to—take that would be an equivalent of recertification for people of a certain age (like me) who took our boards before periodic recertifications were required. Although the ABIM could not suspend or rescind my boards, they would now note on their website that I was “cooperating” (or not) with their program. And the cost of recertification is not cheap.

Specialty and subspecialty recertification was an innovation instituted around two decades ago to insure that doctors would remain up to date in their fields. Many other countries (e.g., Canada, which has a general maintenance of certification program, but no specialty or subspecialty recertification requirements) have no requirements for recertification, and there is little evidence that care for patients with rheumatic diseases is inferior there. The requirement for recertification appeared at the same time as Continuing Medical Education (CME) credits, which are now required by most hospitals and some states for reaccreditation and licensure. The CME requirements spawned a very large industry (of which I am happily a part as codirector of a course), and the ABIM people must have thought they needed to expand their territory to compete.

What’s the Best Way to Get Results?

As members of a learned profession, we all strongly believe that continuing education is critical but, as we are now urged to be members of a data-driven profession as well, none of us have ever seen the evidence that CME courses or recertification have the intended outcome. Indeed, our best intentions have paved the way for the creation of a bureaucracy whose sole purpose is to protect us from the depredations of the pharmaceutical industry without any ability to ensure that the quality of the untainted information imparted at a CME course was high or that physicians will make the best use of it.

Medicare and other third-party payers have clearly discounted the value of continuing medical education in medical care. After years of doctors being taught that such things as a prescription of aspirin after a myocardial infarction or that people of a certain age need vaccinations, they noticed a compliance rate in the failing range (less than 70%). When these third-party payers simply declared that they will reimburse physicians less if these requirements are not met, physician compliance suddenly rose to the outstanding category. It is clear that these same third-party payers are trying to figure out how to enforce similar quality measures for the treatment of rheumatoid arthritis and other rheumatic diseases. While the shape of these requirements is not known, you can bet that the work is progressing.

So, as the ABIM tells physicians, “you got a really nice place on the web here, it would be a shame if somebody messed it up.” We should think about the cost for the American Board of Bada Bing to provide us with “protection.” the rheumatologist

Dr. Cronstein is the Paul R. Esserman Professor of Medicine and director, Clinical and Translational Science Institute, New York University School of Medicine in New York.