Board Certification Brouhaha: Rads Cry Foul Over ABR’s Ways and Means

At the American College of Radiology’s 2019 meeting last May, speaker after speaker stepped up to the open microphone in the ballroom of a Washington, D.C., hotel to vent their displeasure with the American Board of Radiology (ABR) and its maintenance of certification (MOC) program.

This public display of disaffection supplied only a partial picture, however: An anonymous online portal had been set up to accommodate feedback from radiologists who might be fearful of blowback or reprisals if their identities were revealed.

More than a few posted comments, and the vast majority opted for the sub rosa route.

That snapshot from ACR’s annual showcase event is revealing in several ways. For one thing, it helped crystalize the widespread unrest among the radiology community with the ABR. The board is often perceived as a closed, opaque and monopolistic organization with virtually no peer-reviewed literature to show that its recertification and MOC processes actually improve patient outcomes and quality of care.

Indeed, radiologists have privately fumed for years at the board’s high-stakes, every-10-year examination process, which many consider overly complicated, costly and a drag on time they could otherwise be spending with their busy clinical practices. Yet few have publicly spoken out. Fear of reprisal from an organization known to play hardball has clearly dampened open discussion.

Which also may help explain why someone identifying as a radiologist has taken to Twitter under the handle @ExitABR. This person’s profile reads: “General rural radiologist, just looking for board certification I can trust ... not anti-trust.”

Last December the incognito tweeter conducted an anonymous poll for academic radiologists. The single question: “Do you feel safe (personally and professionally) openly and publicly raising concerns about the ABR?” @ExitABR reported that 451 individuals took part, responding as follows:

72.3%—No. Very fearful.

25.3%—No. A bit worried.

1.8%—Not sure.

0.7%—Yes. No concerns at all.

And not all the discontented at large are intimidated online. Ben White, MD, a neuroradiologist who blogs from Dallas, has been all but unguarded.

In a recent post on his site, benwhite.com, he commented that the ABR “functions within a meticulously crafted bubble with its own reality-distortion field preventing its leadership from seeing where things went wrong and where they’re going. It’s a few doctors doing things on behalf of constituents without their input and against their wishes, flaunting their mandate and appearing to profit in transparent and frankly embarrassing ways.”

ACR Takes Note  

But White is far from alone. In fact, one of the key takeaways from ACR’s open-mic session was that the muzzled frustration with the ABR and many of its 23 sister boards—all of which fall under the umbrella of the American Board of Medical Specialties (ABMS), the leading not-for-profit overseer of physician certification in the U.S.—may be giving way to bold action.

Witness the fact six class-action lawsuits have been filed against a number of ABMS boards, including not only the ABR but also the American Board of Internal Medicine (ABIM) and the American Board of Psychiatry and Neurology (ABPN).

The intricately detailed ABR suit was filed by radiologist Sadhish K. Siva, MD, who practices in Murfreesboro, Tenn. He charged that the ABR employed “various anti-competitive, exclusionary and unlawful actions” to promote its MOC program. The suit was dismissed by an Illinois federal judge in November 2019, but Siva’s attorneys have since refiled an amended complaint.

Another sign of the higher profile anti-ABMS/MOC movement is the growing number of states passing or considering legislation prohibiting MOC from being used as a precondition for hospital credentialing and insurance network membership.

“There’s no question that awareness around the American Board of Radiology is higher now,” notes one prominent radiologist who spoke with RBJ on condition of anonymity, “and that’s empowering more and more people to talk about it and take action.”

The American College of Radiology has joined the public discussion. In a January 2019 letter responding to the ABMS Vision Initiative Commission report, the ACR said it supported “a ‘moratorium’ in prevailing continuing certification to ‘provide the ABMS and its member boards the needed time to get all aspects of continuing certification right.’”

The letter, signed by ACR Chair of the Board of Chancellors Geraldine McGinty, MD, MBA, and CEO William Thorwarth Jr., MD, went on to state, “The ABMS Vision Initiative report both underestimates and understates the reality, robustness and energy of a growing grassroots ‘anti-board movement.’”

In January 2019, ACR formed its own task force on certification in radiology to examine best practices for credentialing and future trends in medical specialties and other industries, and to get feedback from its membership.  

“We wanted to put our ear to the ground to demonstrate to our members that we understand there is angst in the radiology population,” Thorwarth tells RBJ. “The [task force’s] goal is not to make any judgments but to gather as much information as we can and then use it to move physician self-regulation forward.”

A task force report is expected to be delivered to both the ACR’s board of chancellors and the college’s legislative body, the ACR Council, in May.

Costly Exams

Few physicians or, for that matter, members of the public would find fault with the conceptual framework of medical boards and their commitment to lifelong learning and continuing professional development of their licensed professionals. The way ABR certifies that its diplomates demonstrate “the requisite knowledge, skills and understanding of their disciplines to benefit patients” is through maintenance of certification.

After decades of providing lifetime certificates in diagnostic radiology, ABR decreed in 2002 that all certificates would be time-limited and that MOC participation through exams every 10 years was required for those certificates to remain valid. Radiologists who had previously been issued lifetime certification were not required to participate but were still encouraged by ABR to do so.

The process isn’t inexpensive for participants. At the per-radiologist level, the single sorest point of contention on costs may be the fees assessed residents and fellows—many of whom are already beset by student debt and low salaries. On its “Initial Application and Fees” page at TheABR.org, the organization lists trainees’ costs as follows:

  • Annual fee (charged every year that candidates are in the initial certification process): $640
  • Annual fee late payment (charged if annual fee is not paid by March 1 each year): $100
  • Re-exam fee (may be charged if a candidate does not fully pass an exam; this figure includes a nonrefundable administration fee): $640
  • Radioisotope safety exam application fee (to achieve authorized user eligibility): $220

By comparison, established rads pay a flat $340 per year to continue participating in MOC. As put by an experienced radiologist source who spoke with RBJ on condition of anonymity, the disparity “has made the ABR seem particularly unsympathetic to the very real financial burdens” it places on trainees.

“A lot of folks think that if the ABR is going to be getting $340 per year for, say, 30 years,” the source adds, “they shouldn’t be charging such a high rate for trainees—and probably shouldn’t be charging them at all.”

Immense Assets

And all of that stands atop radiologists’ increasing awareness of ABR’s considerable wealth.

The revenues ABR generates through exam fees helped the organization grow its end-of-year total board assets to $51.1 million, according to the board’s IRS Form 990 for the fiscal year ending March 31, 2017. That was up from $49.5 million in 2016 and $45.7 million in 2015.

(The 10-year process recently yielded to a less restrictive Online Longitudinal Assessment program—more on that below.)

ABR’s financial growth spurt has been part of a broader trend that saw the difference between assets and liabilities of ABMS boards soar from $237 million in 2004—around the time MOC-related fees were phased in—to $642 million in 2014. That’s according to a research letter published in JAMA Aug. 1, 2017 (Drolet and Tandon, “Fees for Certification and Finances of Medical Specialty Boards”).

The authors noted that these margins enabled member boards to grow at an annual mean rate of 10.5% over the studied decade.

While best accounting practices hold that nonprofit organizations need to maintain reasonable reserves to cover unexpected capital expenses, the magnitude of the American Board of Radiology’s assets has raised eyebrows.

Seth Hardy, MD, MBA, a radiologist in Lancaster, Pa., broached the issue with an ABR representative who was delivering a talk at the annual meeting of his state’s radiological society in Pittsburgh last September. 

“When he opened the floor to questions, I asked him what the board planned to do with this hoard of cash, and he refused to answer,” recalls Hardy. “He thought he was facing a friendly audience and wasn’t prepared for anyone to challenge him.”

Nor, apparently, were other members in the audience, some of whom reportedly gasped at Hardy’s perceived effrontery.

Appetite for Accountability

In an interview with RBJ, ABR president Brent Wagner, MD, said the reserve “was at a reasonable level to make sure we don’t have to adjust our fees every year. As a nonprofit, we can’t go out and just borrow money when there’s a need for infrastructure development, new software or hardware, or things that go into the programs we administer.” 

Wagner pointed out that ABR is running in the red for last year, this year and next due in large part to the ramp up of Online Longitudinal Assessment, and that the board’s reserve “is helping us to offset that loss.”

ABR’s total assets for the fiscal year ending March 31, 2017, placed it sixth among the ABMS family of 24 boards in 2017, according to data from wikimoc.org. Moreover, it ranked second in total number of employees (137); seventh in revenues ($16.9 million); and fifth in CEO compensation.

A review of ABR’s Form 990 for 2018 showed that its highest paid officer was Executive Director Valerie Jackson, MD, at $784,842, with $49,725 in additional compensation. Jackson, who is retiring from the post she has held since 2014, will be replaced in July by Wagner, who has served as president of the ABR’s board of governors since 2018.

Says Westby Fisher, MD, an internist, cardiologist and cardiac electrophysiologist with NorthShore University HealthSystem in Illinois, one of the most vociferous critics of medical specialty boards: “[These boards] are giving themselves incredibly high salaries and there’s no proof since the implementation of MOC that they’ve done anything to improve physicians’ ability to do their jobs—or to benefit patients.” (For more from Fisher, see accompanying article “One Physician’s David vs. Goliath Crusade.”) 

Who is responsible for managing and annually reviewing executive compensation and related polices for the ABR? Answer: the board’s executive compensation committee, which, under its bylaws, is comprised of the president, president-elect and at least one additional member from the board of governors appointed by the president, who chairs the committee.

What’s also drawn the attention of ABR critics who rail at the board’s lack of accountability is its annual expenditures for “conferences, conventions and meetings,” which the board’s 2017 IRS 990 report listed at nearly $1.3 million.

According to multiple sources, Hawaii has been a preferred destination for these executive-level board getaways.

Moreover, as White reported in a recent blogpost, ABR also reimburses board members for “companion’s travel.” In the board’s 2017 Form 990, an item labeled “travel” under functional expenses is listed at $640,464, which White points out could separately house companion travel expenses.

Unclear Outcomes

Beyond financials, what continually fans the critical embers is, evidently, ABR’s dogmatic approach to testing the competency and skills of its members.

“No causal relationship has ever been established between MOC and a beneficial impact on doctors, patients or the public,” charges the federal class-action lawsuit refiled in January by Tennessee radiologist Siva. The updated suit further states that ABR has “manipulated certification from a singular training outcome evaluation into a device requiring radiologists to take ABR-administered examinations and tests and partake in other meaningless required activities throughout their careers, despite the fact that MOC has not documented validity.”

Physicians across a host of medical specialties have taken MOC orgs to task for requiring participation if they wish to maintain their admitting privileges to most hospitals as well as their standing with health insurance plans and networks like Blue Cross and Blue Shield. The 2018 “Survey of America’s Physicians: Practice Patterns & Perspectives,” conducted by the nonprofit Physicians Foundation, found more than two-thirds of respondents disagreed or strongly disagreed with the statement that MOC accurately assessed their clinical abilities.

And when asked about physician burnout, 95% opined that MOC contributed significantly or very significantly.

Within radiology, a study published last December in the American Journal of Roentgenology cast additional doubt on the effectiveness of MOC. The authors found that, among the more than 20,000 radiologists studied, nearly all with time-limited certificates participated in MOC, but of those who had been grandfathered into the program, and therefore were not required to take examinations, only 14% chose to do so.

The study’s conclusion? “Low rates of nonmandated participation may reflect diplomate dissatisfaction or negative perceptions about MOC.” Lead author Andrew Rosenkrantz, MD, and colleagues add that, in other ABMS specialties, “there is only scant or equivocal evidence of benefit of MOC in terms of patient outcomes.”

One radiologist questioned the logic of a recertification program that exempts older practitioners who might be in clinical decline after years in practice and therefore most in need of monitoring and professional improvement.

The hammerlock ABMS boards exert on physician certification has created a high hurdle for competition. To wit, the National Board of Physicians and Surgeons (NBPAS), created in 2015 as an alternative to ABMS, offers a maintenance of certification product at lower fees than those charged by ABR for its MOC. But, as the Siva lawsuit points out, approximately 1% of hospitals nationwide had recognized the NBPAS product as of January, 2020, and no insurance company had accepted it.

Quit Teaching to the Test

The American Board of Radiology has not turned a deaf ear to the widespread grumbling over MOC. It recently replaced the high-stakes, every 10-year exam with Online Longitudinal Assessment (OLA), which requires radiologists to answer a total of 52 multiple-choice questions per year, with two made available each week. Participants have the flexibility to dismiss up to 10 questions a year, presumably in areas outside their practice or expertise.

Radiologists generally concede the new process is less onerous and demanding of their limited time, and that questions are often not unreasonable. But there is still no shortage of clinicians who question the effectiveness and even soundness of OLA, especially since the ABR has not told candidates what scores will be necessary to pass.

“This is 2020 and we’re still using multiple choice questions?” White asked rhetorically in an interview. “The idea that you could get meaningful information and insight into someone’s daily practice—like how conscientious and thoughtful they are, how well they focus after a long shift, how well they communicate with referring doctors—from 52 questions a year is absurd.”

Nor did an article lead-authored by radiologist Lincoln Berland, MD, professor emeritus at the University of Alabama and a member of the ACR board of chancellors, mince any words.

“Ironically, we believe that while purporting to be creating the ‘examination of the future,’ the ABMS and ABR have been mired in testing concepts based on decades-old thinking that do not apply to modern radiology and medicine,” Berland et al. write in “ABR Psychometric Testing: Analysis of Validity and Effects” (JACR, June 2018).

Instead of the psychometric testing principles that undergird ABR’s new examinations—principles that essentially “teach to the test” and discourage key learning activities like unknown case reviews—Berland and colleagues call for “authentic” testing incorporating human observation, collaborative and interpersonal skills, and the ability to access information electronically.

The Competition Cure 

Radiologist Hardy, a strong advocate of peer-to-peer learning, stresses the important role he believes this educational technique could play in the training, development and certification of imagers.

Peer-to-peer learning is gaining traction in the classroom and workplace, Hardy points out.

“It’s much more of a collaborative learning process, similar to what pilots do every two years to maintain their license to fly,” he says. “I firmly believe this process would be much more effective in the field of radiology than randomly answering multiple-choice questions on the computer.”  

In the view of many observers, competition among different purveyors of certification and continuing professional development could help thrust innovation into the learning and testing processes. Given a chance, some say, a market battle might not only ease the burden on doctors but also reassure the public of the quality and safety of their care.

“There’s not a lot of pressure on us as a profession to do things in creative new ways,” says White. “In fact, there’s a ton of inertia to maintain the entrenched status quo. But if our goal is to show the public that we are truly lifelong learners, then radiology has to work a lot harder to come up with meaningful change.”