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A Shameful Silence Over Physician Exams

Joe Cantlupe, for HealthLeaders Media, June 17, 2010

Each question crafted for the American Board of Internal Medicine board certification exam "is like a precious jewel," says Christine K. Cassel, MD, ABIM's President and CEO. It sometimes takes two years to form the questions, with the right precision and nuance that elicits medical knowledge sought, she says.

Cassel's not saying it's an easy test, but that if you study, you've got good chance of passing, with data showing that 88% passed the first time in 2009. That's only one of the reasons why she's "sickened and dismayed" that the ABIM has had to suspend or revoke the certifications of at least 139 physicians who "solicited and shared examination questions." The tests occurred over several years, and hundreds of questions were compromised.

What further troubles Cassel is the silence of potential exam takers, among the thousands of physicians who might have known the questions were shared and did nothing about it.

Following a six-month investigation, the ABIM cited the 139 physicians, but many others weren't cited, but may have known what was going on, and kept the information to themselves, Cassel told me. You know, the classic case of car accident scenes, where witnesses don't come forward. But here's the rub: these are physicians who didn't come forward. They were witness to something potentially wrong and did nothing about it.

"A couple of thousand people attended (the exam sessions) and not everyone stole questions, but no one alerted us," Cassel says, expressing clear disappointment in her voice. "If people see unethical behavior they should let us know." Of the people who took the tests "actually see and sign documents that they will respect the intellectual property and agree not to share any of the material of the exam," she says."It's not subtle."

The conduit for the improper action, she and other ABIM officials say, is Arora Board Review, a New Jersey test-preparation course, which apparently received copies of the ABIM test questions for several years from physicians who took the tests. Eventually the company posted test questions on its Web site. .

An " investigation revealed that (Arora) course operators repeatedly told participants that they were receiving actual ABIM questions and requested participants to send questions to the course operators after their exams," according to an ABIM statement. "As a result, any physician who ABIM has reason to believe took the course will receive a letter expressing ABIM's concern about their failure to notify ABIM about the questionable activities."

The 139 people were sanctioned for "unethical and unprofessional behavior," says Loris Slass, spokeswoman for ABIM. The ABIM's action mostly "applies to what (the physicians) did with the information after taking the exam and that undermined the certification process," Slass says.

Slass says the organization sent letters to as many as 2,700 physicians who were Arora customers who apparently did not come forward with any suggestion that actual ABIM test questions were part of the Arora Board Review list of questions. The spokeswoman would not reveal contents of the letters.

The overwhelming number of physicians weren't reprimanded, though, with Cassel believing that a line needed to be drawn to single out the particular egregious offenders, those who potentially shared dozens of questions from previous ABIM tests. There were press reports that some physicians eventually came forward, but Slass said the ABIM began its investigation through internet surveillance and not from information from Arora customers.

There were other ramifications, beyond the physicians. The ABIM, a non-profit independent evaluation organization based in Philadelphia, was forced to have workers spend day and night crafting new tests, spending countless hours and money to undo the damage. The Arora Board Review has suspended operations, and also agreed to pay undetermined damages to the ABIM.

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