Revenge of the Nerds, Part II

January 17th, 2013 By Steven Knope, MD
As some of you know, I recently went through the process of re-certifying with the American Board of Internal Medicine (ABIM). As a licensed physician, and previously board-certified internist, I am not required to re-certify to practice internal medicine. I’ve been an internist for two decades now, and I would still be an internist without the imprimatur of the Board. However, as I explained to my 14-year-old son, testing and being graded never really stops. When you no longer have teachers, it is important to put yourself into situations where you are challenged.Having said this, the process of becoming board-certified in internal medicine has become more than just a little bit bizarre. It would appear that the nerds in my profession have taken over. They appear to be on some mission of revenge. Let me explain.

The Old Days:

When I was a medical student from 1984-1988, we would frequently complain about many of the older private physicians who were not current with their medical knowledge. Patients would be admitted under a private internist’s name to the New York Hospital, but the less experienced, more current house staff would take care of them. The older docs would make social calls and pretend to be in charge, but the important decisions were often left to the younger interns and residents. Of course this was not true of our professors or many of the fine private doctors who did stay current. However, the problem was common enough that we complained about the incompetent geezers and mused about what we would do if we ruled the world.

In those days, to become board-certified in internal medicine, you had to pass a single, rigorous exam after the completion of your residency in internal medicine. However, after passing that exam, you were board-certified for life. This meant that you were “grandfathered in” and never had to take another test to remain board-certified.

I remember saying to one of my residents in the 1980s, “The ABIM should make these old guys re-certify every 10 years, to make sure they keep up to speed.” My resident agreed. And as the saying goes, be careful what you ask for, because beginning with my residency class the ABIM decided that re-certification was a fine idea indeed. From that point forward, all internists would receive temporary board-certification for a 10-year period. They would then have to re-certify. If you didn’t take the periodic exams to re-certify, you were kicked out of the club.

Taking the Exam:

For those of you who learned that I was out of the office recently, Bobbie may have told you that I was busy taking the re-certification exam. This was an all-day, proctored exam. As I entered the testing facility, I had to have my picture taken and have my palm electronically scanned, to make sure I was who I said I was. I needed two forms of picture ID. I was not allowed to go to the bathroom during the testing without raising my hand and asking for permission from a proctor. I could bring nothing into the examining room with me; no pencils or scratch paper to make notes, no car keys –not even my wallet. Yes, boys and girls, these people take themselves very seriously. During the process, I felt like I was trapped inside some bad sequel to Revenge of the Nerds. Who came up with these Draconian rules?

The test was long and challenging; much more difficult than the previous 2 exams I had taken to certify in 1992 and 2002. The exam was on the entirety of internal medicine, including all medical specialties; cardiology, endocrinology, gastroenterology, rheumatology, etc.

Over 5,000 internists across the country took the internal medicine boards in 2012. The exam was so difficult that to pass 78% of the doctors who took the exam, the passing grade was lowered to 366 out of 800 points. In other words, you only had to get 45% of the questions right to pass the exam. Even with a passing score of 45%, the Board still failed 22% of the doctors who took it. The cost of taking this sadistic exam? A mere $1,365! Wow, what a bargain!

So, twenty years after complaining that all internists should be periodically retested, this was what my grand idea looked like in practice: a bizarre ritual in which we were treated like criminals and forced to take a test so difficult that you could pass with a score of less than 50%.

But wait, there’s more:

The process of remaining board-certified involved much more than just taking this single, grueling, over-priced, all-day exam. To be able to sit for this exam, you had to complete multiple on-line exams, over a period of several years. Some of these exams were so ridiculously complex that you were allowed to ask any specialist or colleague to help you with the answers. However, when I asked my specialist-colleagues on two occasions to help me with a question, I realized that this was an exercise in futility, because the specialists couldn’t answer the questions either. So I had to go to specialty text books to find the esoteric answers to these clinically irrelevant questions. Such was this gauntlet of the nerds.

To sit for the all-day exam, I also had to participate in the evaluation of my medical practice and show that I improved it. I had to have letters of good standing from Northwest Hospital. Some of you, as my patients, were asked to fill out confidential questionnaires from the Board on my abilities and bedside manner. In total, this process involved hundreds of hours of reading, test taking and patient evaluations before spending a day of my life in test-taking hell.

My Exam Results:

I just received the results of all of this testing, and you will be pleased to know that your doctor did pass his boards. I am, once again, officially board-certified in internal medicine and will remain so for the next 10 years. For those of you who cleverly asked if I would be giving you a partial refund on your concierge fee if I failed my boards, the answer is no. You will not be getting a retroactive discount. However, I do appreciate the confidence you expressed in my abilities, along with the warm sentiments of your kind proposition.

The Psychopathology of the ABIM:

As of this date, the ABIM will only tell the public of a doctor’s status after the exam: A physician is either board-certified in good standing or he is not. However, there are plans by the new president of the Board to soon publish the actual test scores of every doctor who has taken the exam, so that patients can make a more informed decision about the “relative smarts” of a given physician. If you don’t believe me, read his words:

“Transparency is also on my radar. Today, the Boards deliver a dichotomous verdict: a physician is either certified or not certified. But we know more than that about our diplomats: everything from their test scores to how they performed on practice improvement modules. We may be irrelevant in the future if we maintain our traditional “Certified Y/N” stance. When people seek out a good doctor, knowing whether the doctor is board certified is just the beginning. As the popularity of sites like HealthGrades and Angie’s List illustrates, patients want far more information. I believe that if the Boards don’t provide it, others will.”

Apparently, to prevent the ABIM from being made “irrelevant”, the Board will soon post the actual test scores of all doctors for public viewing. Wow! So, to determine the best doctors, all you need do is look at their national test scores? I’m sure the public is waiting with bated breath. (Yes, ABIM, I have spelled “bated” correctly; look it up.)

My Scores:

Given that my scores will apparently be released in the very near future, I’ll save you the suspense and tell you that I scored in the top decile, or in the 90th percentile on this exam. If you want my raw scores, I will be happy to share those with you upon request. Having disclosed this information, what I am about to say will not be misconstrued as sour grapes.

Grading the ABIM:

If it is not too presumptuous, I would like to make a few recommendations to the nerds who wrote this exam, charged me $1,365, and treated me like a cheat. I will refrain from making any formal psychiatric diagnoses, which might explain the roots of their behavior. Instead, I will stick to some constructive and compassionate suggestions that may help them in their future endeavors:

1) First, buy yourself a puppy. Spend some time playing ball with that puppy. Try to get a little perspective on life. Stop telling everyone what you got on your SATs 35 years ago. Standardized test scores don’t define intelligence. They never did.

2) Go out on a date with a girl. No, your cousin or your sister doesn’t count. Practice your lines in front of the mirror before your date. It’s not that hard. You can do it! Really, trust me, just go talk to a real girl.

3) Stop treating your colleagues like unethical cheats. Use the honor system. Stop taking pictures of doctors and scanning their palms on exam day to make sure they are who they say they are. A simple display of a driver’s license will suffice. Don’t force doctors to ask permission to go pee-pee during the exam. Don’t worry about cheating. If a doctor thinks he can cheat on an all-day, comprehensive exam by going to the bathroom and pulling some notes out of his boxers, let him do it. He’s going to fail anyhow.

4) Finally, forgive those boys from your high school football team who gave you a wedgie that day in gym class. I know it was embarrassing, but it was a long time ago. Forget about it. It’s going to be okay; really…you are going to be okay…


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