An Out-of-Balance Seesaw: Physician Burnout and the ABIM Apology

On February 3, 2015, the American Board of Internal Medicine (ABIM) issued an apology to American physicians for subjecting them to an out-of-date and burdensome board recertification exam. The importance of this step cannot be overestimated. Of the ~850,000 active physicians in the U.S., over 200,000 currently hold ABIM certification, which is required of internists and most medical subspecialists. Starting in 1990 (the year I was unfortunate enough to complete Internal Medicine residency!), physicians have been required to take the exam every ten years to maintain their board certification. While the ABIM cites data suggesting that the exam improves quality of care, this has not been definitively established, and questions have arisen from a number of quarters about appropriateness of content, the expense, and whether the exam is contributing to early retirement, a major concern in terms of the growing physician shortage.  The ABIM apology focuses on making the exam more relevant to the practice of medicine, allowing CME credits to be used in place of the esoteric MOC (maintenance of certification) modules, and eliminating the onerous practice assessment and patient survey requirements. Board recertification is expensive, time consuming, and requires intensive preparation. In the setting of increased demands to see more patients in less time, decreased reimbursement, increased scrutiny, increased role definition by non-physicians, and the burdens of the EMR, board recertification is yet one more factor contributing to physician burnout. Physician burnout is a complex phenomenon and yet it can also be summed up with a very simple equation. X = all the things that buoy a physician up X equates to things like positive patient encounters, good relationships with support staff and colleagues, intellectual challenge, or picking up a tricky diagnosis.  X also includes meaningful personal relationships, adequate sleep, and personal health, in addition to a sense of meaning and accomplishment. Y = all the things that drag a physician down Y includes an EMR that is frustrating to use and eats away at precious time, unrealistic patient loads, having more and more administrative hoops to jump through, inadequate staffing, or not having time to just focus on the care of your patients. The math is simple: When Y outweighs  X, you get imbalance and physician burnout, almost like two sides of a seesaw. And board recertification is in the Y category big time. My own experience is telling. When I recertified in 2010, as a hospice physician out of touch with general practice, I prepared for over a year and a half, studying 3 hours a day for 3 months. I spent most “free” moments studying, I was completely drained, and my family was angry and alienated. Prior to that recert, my 13-year-old son had always proudly called himself Dr. Gazelle Junior. By the end of the experience, he said you couldn’t pay him enough to become a doctor. Now, at age 18, he’s planning on a career in engineering. Many things can be done to decrease physician burnout. Not having to spend time that you don’t have studying for an irrelevant test is one important one, but it is still just one factor. Part two of this blog series will discuss the growing body of knowledge on other interventions.