There is a business monster attached to the board certification process, and the monster is hungry for cash. In the past few weeks I have had the experience of directly observing the board certification business monster machine in action. My husband has signed up for the new American Board of Anesthesiology (ABA) certification examination in pediatric anesthesia to be administered in October. One of my junior associates, who has been with our group a little over a year, is scheduled to take his oral board exams in a few weeks. It’s painful to watch this expensive ordeal in action.
Let me say at the outset that I have no skin in this game. I was board certified in both anesthesia and critical care back when the certificate was not “time limited.” I took the voluntary recertification examination in 2009, the final time anyone could take that test without entering the MOCA system.
First, the pediatric certification exam. As you may know, the initiation of this subspecialty certification by the ABA was not without controversy. The ASA Board of Directors did not support the initial concept proposed by the ABA for pediatric subspecialty certification. Despite the ASA’s misgivings, the ABA chose to go forward with the process. Many in the pediatric anesthesia community—some with pediatric anesthesia fellowships, some with extensive practice experience, and some with a combination of both—chose to sign up for the first examination. Many pediatric anesthesiologists believe that if they don’t become subspecialty certified, they could be committing the equivalent of professional suicide, as hospital credentialing committees and other professional credentialing bodies look to the certification process to verify competency. This has created a large group of anesthesiologists in the later stages of their careers who are now preparing for this exam.
What are the economic consequences? In order to register for the pediatric anesthesia exam, one must first pay a fee to the ABA. Then, one must pay a fee to take the test at a test center. In the meantime, those individuals with ABA non-time limited certificates will discover that they are required to enter the MOCA system (whether they wanted to or not) and pay a sizeable fee to the ABA to do so. In order to study, one must pay fees for pediatric anesthesia educational review materials to the ASA or other CME sources. Lastly, there are long weekend review courses to attend, where lecturers in pediatric anesthesia, sometimes faculty giving one another’s talks, race through slides, stopping at every fifth one or so. There is a charge for the course itself, a cost to fly to Chicago or Dallas, and the cost of lodging and food, not to mention the lost income from time away from work. This adds up to thousands of dollars merely to take a brand new exam.
Let’s move on to the initial oral board certification exam. The business aspects of this process are perhaps even more egregious than the pediatric anesthesia examination. The physicians taking the oral examination tend to be young anesthesiologists, often just recently out of residency, at the start of their careers. There is now an entire process that many believe they must go through in order to be properly prepared for and pass the oral boards.
First, there are written materials with subject matter review and examples of oral examination questions. Next there are on-site review courses that last 3-5 days and include either multiple sessions of practice orals, lectures, or both, depending upon the course. These can run up to $2000 each for the course alone, before the cost of the travel and lodging at the course site. Finally, there is the week of the exam itself and the associated travel costs. If we factor in the loss of income for one to three weeks of work, the price of taking the oral boards can be astronomical for these young anesthesiologists. Fear appears to be the driving factor here; if “everyone” is doing it and believes it is necessary to pass the oral boards, then paranoia dictates that everyone else must do it as well. When their livelihood may depend upon becoming board certified, people will do whatever they believe it takes to pass.
It seems to me the board test prep system has run wild here. Certainly the intentions are good: to help physicians review and prepare for the examinations. However, there is a strong economic incentive for private companies and individuals to capitalize on the fear factor of not passing an exam. Perhaps it is time for the ABA board and the ASA CME division, in concert with the ASA liaisons to the ABA, to take a critical look at what is going on. I am not convinced that all this test prep leads to better and more qualified anesthesiologists; it may just give us better test-takers.
Is it time to abandon the oral examination system in favor of a more extensive and rigorous written exam? Once you have passed the exam, you could immediately enter the MOCA system with all the CME requirements, practice evaluation, QI projects and simulation that entails. Perhaps everyone should have a higher quota of mandatory annual CME, to include clinical cases similar to the Problem-Based Learning Discussions available at the ASA Annual Meeting,
I don’t have the answers but I certainly have a lot of questions. I believe that forcing people to throw large amounts of cash at an imperfect system is not a good answer. Let’s take a critical look at what makes good anesthesiologists and build ongoing lifelong learning programs to maintain their skills. Isn’t that what we are all about in the end—the best possible care for our patients?