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Letter From a Cleveland Jail to the ABIM: Redux

December 30, 2021

Dear American Board of Internal Medicine,

Remember me? I'm the guy who sent those other letters to you over the past couple of years, in which I channeled the spirits of Henry David Thoreau and Martin Luther King Jr., both of whom wrote passionate epistles while they were in jail — Thoreau for failing to pay his taxes and King for his role in a non-violent protest.

This time, I'm imprisoned behind the cinderblock walls of incredulity as I hear yet more stories from colleagues who had to recertify their boards, and from others who now have to fulfill the new maintenance of certification (MOC) requirements.

Loved the email I got from you the other day about biffing the MOC requirements! Did you write it after reading Paul Teirstein's recent Perspective on this in The New England Journal of Medicine, "Boarded to Death — Why Maintenance of Certification is Bad for Doctors and Patients"? It mentions a petition signed by more than 22,000 people against MOC, and another signed by 7,000 people taking a "pledge of noncompliance."

Wow, I guess I'm not alone. I think that adds up to 26,000 people who won't be sending you a holiday letter this year.

Dr. Teirstein went on to call the "research" supporting certification "inadequate" – citing a lack of studies showing an association between recertification and performance on quality measures – and accused you of being a bully. Quite a statement against a Board that prides itself on basing certification on evidence-based medicine. The author stopped just short of saying that your mother wears combat boots. Not that there's anything wrong with that, mind you. I'm sure they're quite becoming.

You're probably reading this from the overstuffed leather chair and ottoman in your office, which you purchased with some of the $55 million in fees you received in one year from physicians seeking certification. To be clear, you bought the chair, but were resting your legs on a man named Otto, an internist who so feared complaining to you and then being listed as "certified, not meeting MOC requirements" that he offered his prostrate services to better assist the venous return to your generous heart and brain so that you could think up more board questions that don't correlate to better patient care.

My favorite part of the Perspective was when the author raised the same point I've raised before to you: how relevant are closed book/computer/colleague consulting/smartphone tests in an era when “Magnum PI” isn't must-see TV? I mean, I'm sure Flexner was a huge fan of this method of assessing knowledge. I think he also voted for Roosevelt for President. Teddy, that is, not Franklin D.

In addition, think about just how humiliating the entire process is. We spend weeks or months shunning family, friends, and other social stimuli to memorize facts we could otherwise access within seconds in our clinic workrooms. The day of the dreaded exam, we huddle in a small waiting area in a building hidden within a larger industrial complex, along with our residents and fellows, to check in. Sometimes, the surly Pearson Vue employee behind the desk can find our names and sometimes, for a few stomach-plunging minutes, he can't. Then, to verify our identities over the course of the day, he scans our palms.

Scans our palms?

Since when did I volunteer to share the secrets my palm holds with the Pearson Vue Stasi agents? How will they use this palm information against me in the future? Is that why, soon after taking the recertification exam, I suddenly started receiving mailers advertising lotion for dry and flaky skin?

On the way into the testing room, the agent has us empty our pockets to prove they don't contain anything we might have on us every day when we see patients, like a smartphone. In my case, said agent made a nearly career-ending discovery.

"What's that?" The Pearson Vue Commandant asked me.

"Um, it's a ball of lint," I answered, holding it in my dry and flaky palm.

"You know you can't bring anything into the testing room," PVC said, glaring at me.

"I didn't know my pocket had lint," I answered, hoping this sounded innocent enough. It wasn't even big enough to write "Factor Xa" on, even if I had intended to use it for cheating purposes. "Are you going to tell my Mom I had lint in my pocket?"

"Just put it in the trash can," PVC responded, shaking his head in disappointment.

Then, we sit down to finally take the test, absorbing question after question like bullets on a firing range. Because we are doctors, we recognize the telltale signs of increased sympathetic tone indicating extreme anxiety (sweating, increased heart rate, and accelerated respiratory rate) as we try to convince ourselves that the truly perplexing questions are actually just questions the ABIM is piloting – that they don't really count.

Wait a second. We pay the ABIM millions of dollars a year to go through this Cold War experience so that we can test the psychometric properties of their own questions for them?

Are you kidding me?

Isn't that a violation of the Declaration of Helsinki? I suffer emotional and psychological trauma from trying to answer items that ask more than one question, or for which there may be more than one response, or that may have dangling participles or misplaced modifiers. Can't the ABIM at least use some of the $55 million dollars per year they collect from us to hire people to do this?

So, ABIM, given all the outcry against your requirements, I think it's time you reconsider what you are having tens of thousands of doctors do to try to satisfy you.

Here's a suggestion: Get rid of the sit-down exam. It's anachronistic. It's embarrassing. Its results only correlate with results on other sit-down exams. As MOC doesn't help patient care, why not just replace it with documentation of CME? We all genuinely want to learn throughout our careers to provide the best contemporary care to our patients. MOC gets in the way of that.

And, for God's sake, can you please let Otto go home to see his family, or spend more time with his patients, or conduct research that will cure terrible diseases – instead of wasting his valuable time trying to fulfill your requirements?

Mikkael Sekeres, MD, MS, Editor-in-Chief
Board certified through 2022

The content of the Editor's Corner is the opinion of the author and does not represent the official position of the American Society of Hematology unless so stated.

Have a comment about this editorial? Let us know what you think; we welcome your feedback. Email the editor at


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