ABIM's Labeling of Physicians is Unfair and Eroding Patient Trust

As the body responsible for certifying physicians and ensuring the highest standards of medical knowledge and practice, the American Board of Internal Medicine (ABIM) has long been a key player in shaping the landscape of healthcare in America. However, the ABIM’s approach to evaluating physicians in general, and cardiologists in particular, is flawed: its labeling system goes beyond the objective assessment of our clinical skills and medical knowledge, sowing plenty of controversy.

As a trainee about to begin my career in this contentious climate, I’m concerned.

As cardiologists, we dedicate years to the rigorous study and mastery of our field, and various subspecialties. We voluntarily participate in continuing medical education (CME) pertinent to our areas of expertise in order to remain current on the latest advances in medicine, but many clinicians today are facing the threat of being labeled as uncertified if they do not participate in the ABIM-specific Maintenance of Certification (MOC) program. This puts an undue burden on physicians, diverting our valuable time away from actual patient care and family responsibilities, while exacerbating burnout and potentially leading to physician loss.

The essence of a physician’s practice should be based on patient care and medical knowledge relevant to specific areas of expertise rather than financial obligations to a certification board. Labeling physicians as uncertified, solely due to their decision not to engage in ABIM-specific activities despite them participating in CME relevant to their areas of expertise, has far-reaching implications for the nation's healthcare workforce, with a detrimental impact on both physicians and, eventually, patient access to care.

A recent article published in the Journal of the American College of Cardiology demonstrated declining cardiology board pass rates. I am saddened to say the problem is worse than the article identified, as approximately 15% to 20% of cardiology trainees did not pass the 2023 ABIM initial cardiology board exam, me included.

In speaking with many of my peers, we all scored greater than the 90th percentile on the objective multiple choice test on the first day, yet inexplicably “failed” the subjective component on day 2. I am a former chief fellow who taught echo and ECG to my junior fellows and senior residents and a current interventional fellow who spent more than 60 hours per week studying coronary angiograms, but according to the ABIM subjective day 2 test—which does not reflect actual clinical encounters and is filled with images that are either wrong or have poor quality—I, along with 20% of other newly minted cardiologists, am “not competent to practice.”

In the aforementioned JACC article, the authors argue that “measures taken during the COVID-19 pandemic produced a new generation of cardiologists whose foundation for practice has weakened.” I wholeheartedly disagree with that sentiment, but it makes perfect sense that faculty burnout courtesy of the burden of ABIM-specific MOC requirements would negatively affect trainee education.

Labeling of cardiologists as “uncertified” or “overall fail” has the potential to erode trust in the certification system, much less the institution of medicine.

I am frustrated with the ABIM’s insistence on labeling examinees as "overall fail" despite their excelling in the objective component of the ABIM cardiology board exam on day 1. When contacted with a request for transparency as to how the day 2 test is scored, so far the ABIM’s only response has been: “ABIM data have been very consistent in demonstrating that the ultimate pass rate for the exam is above 98%, meaning that the vast majority of those seeking certification can do so within 3 years regardless of the first-taker pass rate on their original attempt.”

In other words, ABIM foresees people undergoing the entire exam at least three times—that’s $7,200 in exam fees excluding the cost of board prep materials. This not only poses an extreme financial burden on top of mental anguish, but also consumes valuable time that could be better spent on patient care or professional development in other areas.

Repeating the entire exam is an unnecessary and burdensome process with no proven correlation to clinical care outcomes. It seems to me—and others—the current ABIM certification system is a money-grabbing tactic, prioritizing revenue over the professional development and well-being of physicians, and by extension, patients. Labeling of cardiologists as “uncertified” or “overall fail” has the potential to erode trust in the certification system, much less the institution of medicine.

A more targeted approach to certifying doctors would not only be fairer, but also allow for these highly trained specialists to enhance their knowledge in specific areas of weakness. I’m not arguing to abolish the “overall fail” label, but rather reserve that exclusively for those who fail both components of the board exam, and instead designate those who pass only one component as "incomplete."

These controversies shed light on broader issues within the medical community regarding the role of certifying boards in shaping the careers of highly trained and competent physicians. Cardiologists have certainly made their opinions known. Already, the Society for Cardiovascular Angiography and Interventions (SCAI) has released a statement urging change and several other cardiology-specific organizations have joined forces to propose a new, independent medical board to certify cardiologists.

As the debate intensifies, the impact on patient care remains a focal point, with concerns that the way the ABIM labels physicians who don’t pass all components of its tests could undermine the public's trust. Moving forward, it will become imperative to reevaluate the certification process to ensure transparency, fairness, and a genuine commitment to maintaining the highest standards in cardiology and beyond. The potential financial motives behind ABIM’s practices raise ethical questions that warrant further investigation and discussion not just within the medical community, but also within society at large. Ultimately, the focus should be on fostering a certification system that benefits physicians and, by extension, ensures the highest quality of patient care.

As I prepare to take my board exams for the second time, with renewed focus on topics that I’m not sure will serve me or my patients in the most effective way possible, the medical community awaits ABIM's response and potential next steps.