I will never do it again.
Last October I took the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) exam. It was hard enough to believe that, at age 67 (I went to medical school at 40, after a career as an attorney), I still had to take a high-stakes, 8-hour, very difficult, multiple-choice exam, full of the usual tricks and traps, no different from those I took in 1994 and 2004.
It was awful.
You go to a test center, check in as you would, I imagine, at a prison, complete with mug shot and fingerprints. I had to leave my watch, an anniversary gift from my late husband, in a locker, sit in front of a computer screen that filled my entire field of vision with one complex question after another, and concentrate, concentrate, surveilled continually by multiple silent eyes.
I passed, but it was a hollow victory -- although I crammed for 6 weeks, the questions had little to do with my practice. I am certain I have forgotten everything I "learned".
And then I realized that, in contrast to 2004, I was not finished! I did avoid the "patient satisfaction" surveys because I practice exclusively at a charity clinic where many patients are undocumented and wary of forms. I finished the module on "practice improvement" (a typical elaborate MBA technique grafted clumsily onto medicine) on New Year's Day, 2015, and found I was still required to do an actual project, generating crisp numbers demonstrating "improvement" in a month or two, using our clunky EMR [electronic medical record system]. Our clinic is funded entirely by grants to serve the poor -- I would not think of asking that resources be diverted for such nonsense.
I gave up.
There are many problems with American medicine today, but lazy, ignorant, indifferent internists are not among them. There is no meaningful evidence that physicians don't know everything they need to know to competently care for their patients, or that they are indifferent to patient satisfaction.
The ABIM, however, approaches internists as if they were adolescents who will only study if there is a test coming up, and will only improve their practices if they are supervised by the board for the rest of their professional lives.
Not surprisingly, some internists like me have revolted against such a condescending approach. We are mad as hell and won't take it anymore.
The ABIM's approach doesn't take into account modern medicine and 21st-century clinical practice. Important medical information is today expanding at warp speed. No one can know it all any more. The solution is not more frequent high stakes tests, but Watson, the IBM computer, and its progeny. Watson would have aced the MOC exam in a fraction of the time it took me (and I hardly aced it).
Physicians are still key -- only they can elicit critical information from patients, ask the right questions and know what to do with the answers, while providing empathy and comfort. But why struggle to be an imperfect Watson if we have the real thing or its surrogates available? Moreover, we learn from Watson, just as Watson learns from us.
The MOC exam was designed to test graduating residents on a standard curriculum and to separate the wheat from the "chaff." The test emphasizes memory and speed, skills important in surgery, but in ordinary cognitive practice, not so much. The exam is based on competition between individuals working alone; modern practice is based on cooperation and teamwork.
And requiring these retakes is unique to the medical profession. No one takes the bar exam twice (except those who fail the first time): universities don't require professors to periodically repeat their orals.
Finally, it's not clear how MOC is helping American medicine. The competition among health care providers -- hospitals in particular -- is intense, and a fully board-certified staff sounds good in advertisements. But this no more assures better care than an erroneous map points you in the right direction.
Indeed, MOC, along with other increasingly burdensome requirements, may induce some physicians to leave clinical practice altogether. The last thing America needs now, however, is to lose experienced internists.
If the ABIM wishes to be useful beyond residency, let it develop good ideas, like "Choosing Wisely." Physicians today look constantly for ways to improve their practice: persuade us, don't coerce us, and we will come.
, is an attorney and internist in Bethesda, Md. She is a former staff internist for the National Naval Medical Center, and currently practices medicine part-time at the Arlington Free Clinic in Virginia. She also consults for law firms on Medicare and Medicaid fraud.