Decoding Health Care

Part 26: Medical Education Part Three

Most physicians don’t stop their training after completing residency. Fellowships are the primary path to specialized training. Although I will speak mostly about Internal Medicine subspecialty training, the same specialization occurs in surgery. General surgeons have a fairly short list of operations they perform (except in rural settings). Breast surgeons, GI surgeons, and vascular surgeons have all claimed a piece of the general surgeon’s domain of times past.

American medicine is largely run by fellowship trained specialists. Most fellowships last 2-3 years and involve a deep dive into a medical specialty, like oncology or gastroenterology. If the subspecialty involves a procedure (like colonoscopy) a lot of time is spent perfecting technique. As medical care has become more sophisticated, more focused training in a subspecialty can be pursued. For example, a gastroenterologist might pursue further training in hepatobiliary or a cardiologist might pursue further training in electrophysiology (arrhythmias). This added training will usually last another year or two.

When all of the training is completed, the qualifications of the subspecialist trainee is often established by board certification. Board certification indicates mastery of the subject matter. Patients are told that board certification is a mark of a well-trained physician. Hospitals and insurance companies often require it for credentialing. It is the Good Housekeeping seal of approval.

Board certification is controlled by the medical specialty board; in the case of internal medicine and its subspecialties, that is the American Board of Internal Medicine. The ABIM, founded in 1936, accredits training programs and administers an exam to graduates of internal medicine residencies as well as graduates of fellowship programs. The ABIM is led by a group of academic physicians usually involved at their respective institutions in graduate medical education. Although the leadership is no longer just a bunch of old white guys, it’s certainly composed of fairly conventional career academicians.

The ABIM is very influential. More than 80% of specialist physicians are board certified. When I became board certified, the certification was life-long. However, in 1990 the board moved to time limited certification with a need for recertification every 10 years. Too bad it is every bit as out of touch as the medical licensing exams we give to medical students.

The test is difficult. And it is composed of the same trivia presented in a gotcha format as the NBME exam. Fellows spend a lot of time studying for the exam and 80-90% pass the test the first time they take it. That is encouraging. But it doesn’t really test problem solving, and it certainly doesn’t test the ability to use readily available resources that are so widely available to today’s physician. It tests the ability to memorize all the translocations you are likely to encounter in a patient with acute leukemia. Now that is a good thing to know, but I can look that up in about 2 minutes. But since that is what fellows eat, sleep, and breathe they pass. Disregard the fact that it doesn’t mean very much other than that you can memorize trivia.

When recertification became required real controversy arose. Previously board certified (and by all accounts competent) physicians were given the same sort of exam. And they didn’t keep memorizing new facts because they figured they could look the answers up. Plus the test didn’t really capture what they had learned over their last 10 years experience of practicing medicine. Plus they needed to take time off to study for and take the exam. Plus it was really expensive.

The ABIM retreated and has tried numerous times to respond to these concerns. They have not succeeded. There is still a lot of controversy and nobody know how this will be resolved. One thing is certain: there is no way recertification tests whether or not you are a good physician.

At the heart of the matter is how to ensure physicians stay up to date. Most doctors argue that by meeting requirements for Continuing Medical Education (CME, required by many state licensing boards) that they are keeping up. CME is earned by attending conferences at your hospital, taking courses on-line or attending medical meetings. For whatever reason, the ABIM has rejected this approach. But to be fair, CME credits don’t really measure whether or not you know how to take care of a complicated patient, which resources to consult, and when to seek extra help.

What has also driven doctors nuts is how expensive these recertification tests cost. The cynics suggest that the ABIM test question writers need to pay for those junkets at nice resorts where they sit around a table and write questions to trick those fools taking the exam. But the ABIM is big business and to be frank it is ossified. It needs to change and it doesn’t want to.

Fellowship is actually an excellent learning experience. Just as with internship and residency, the learning curve is very steep. But there is no question that the education a fellow gets during fellowship is incomplete. Fellowship is best suited to train academic physicians. For a long time, at many programs, a year or two doing basic science lab research was a key component. But if you are going into practice you learn next to nothing about how to run a practice. There is a good reason for that. Very few of the faculty ever ran a practice. A simple but profound change that could be immediately implemented in fellowship training is a requirement for a real world practicum where fellows learn about Medicare, Medicaid and commercial insurance, practice staffing models, physician reimbursement, private practice vs hospital based practice, etc.

We also still need to face the challenge of making sure that doctors don’t age out of competence. Should there be a mandatory retirement age for physicians? Do we need to worry about declining skills in the senior physician? This is a very real problem. The physician workforce is aging with almost 25% older than 60. And with the medical manpower shortage, arbitrary age restrictions could be catastrophic.

The answer to this question is far from clear (https://journalofethics.ama-assn.org/article/competence-not-age-determines-ability-practice-ethical-considerations-about-sensorimotor-agility/2016-10). How important is experience? How about the amount of time which has lapsed since training? One study suggests that there is a statistically significant increase in patient mortality as the physician ages (https://hbr.org/2017/05/do-doctors-get-worse-as-they-get-older). But the differences are really small, and the study was done in hospitalists caring for medical inpatients, and the age differences disappeared if the older hospitalist was really busy.

The evidence is even more confusing when you examine different specialties. Older surgeons have better surgical results than younger ones. Younger internal medicine physicians adhere more to clinical guidelines than do older physicians. The truth is that if we eliminate physicians with obvious cognitive and physical limitations the difference is likely very small. Nonetheless, it is becoming increasingly common for health systems to do their own thing when it comes to evaluating the older physicians. Based on a recent publication (https://www.acpjournals.org/doi/10.7326/ANNALS-24-00829), every institution has their own methodology. They vary tremendously. It is unclear if these policies work, but the institutional leaders are happy with what they have put in place. Very scientific.

The mass media has been interested in this topic for several years. A recent op ed in the NY Times offered a balanced discussion from a middle aged physician (https://www.nytimes.com/2022/11/28/opinion/doctors-aging-competency-test.html). He is in favor of some form of competency testing of older physicians. But I would propose that we make such competency testing uniform over all age groups. There is no doubt that age isn’t the only factor that determines competency.

I suppose the ABIM recertification aimed to perform that competency assessment. It has failed miserably. A big reason it has failed is that the ABIM (in both initial certification as well as recertification) has followed in the footsteps of the NBME; both organizations are excellent at asking questions about arcane facts in tricky ways. At this point, the ABIM has lost the confidence of many older physicians. Time for a change. The competency exam should accurately reflect how a good physician takes care of their patients. It should be case based, encourage efficient use of all of the information available, and capture the reasoning process. It should mirror how doctors do their jobs. As a consequence, real doctors should help write the exam as opposed to lifelong academics who do one day of clinic a week with residents and fellows at their beck and call. And it shouldn’t cost $2200 over 10 years, plus another $700 for the exam for each certification.

Physicians undergo extensive training. From their first day in medical school, it is a minimum of 7 years and more typically 10+ years until they are really in the workforce. But a lot of doctors become disillusioned fairly quickly. Burnout is common. I believe some of the problem lies with how we train physicians, but there are other factors involved. I will tackle the issue of physician burn-out in my next post.