Physician Exam Scandal Inquiry Raises More Questions

The American Board of Internal Medicine's proposed sanctioning of 139 physicians by the ABIM for passing along and receiving exam questions from a test preparation company is getting messier.

Here's why. A lengthy appeals process is underway, with potentially 80 lawyers involved, which always means complexities and various paths toward getting to the truth. And questions are growing, at least in my mind, about whom exactly the ABIM is targeting. One of those physicians cited for sanctioning includes someone who had taken the test at least two decades ago, sources tell me. ABIM proposed sanctioning this person, related to handling of the questions, and the potential is that the physician could lose his or her certificate.

Excuse me? 20 years?

No joke. Why the ABIM is involving this doctor is beyond me. What's the point? Is there a statute of limitations on this?
The individual has not been identified, and attorneys decline to discuss the matter.

The imbroglio over the testing began when the ABIM cited the 139 physicians in June for improper conduct over the testing. The board said it stripped scores of physicians of their board certifications for periods ranging from one  to five years. 

The major target of the investigation was Arora Board Review, a New Jersey test-preparation course that apparently for years shared information garnered from physicians who took the ABIM test with other would be test takers, according to ABIM. The principal of Arora Board Review has surrendered his certificate to perform the tests. ABIM also has filed court action against Arora personnel for improperly disseminating copyrighted test questions.

The ABIM has sent what some have dubbed "shame on you" letters to about 2,700 physicians who took the test. These doctors were not accused of wrongdoing, but the board believes should have known what was going on and possibly revealed the conduct to the board.

For those 139 physicians whose certificate faces possible suspension, the appeals process is beginning, and already seems drenched in bureaucracy and potential conflict.

As I've been told, there are several levels of appeals that can drag on for months until a final determination is made. The appeals reviewers include representatives of ABIM staff, which may be seen as a conflict of interest. An independent panel appointed by the ABIM will consider the final appeal.

In its inquiry, the ABIM has recovered 36 boxes of paper evidence, six computer hard drives and audio and video recordings from Arora that were used in the investigation of the physicians, according to the Wall Street Journal.

Indeed, although Arora Board Review was the primary target of the investigation, that certainly doesn't excuse doctors who may have inappropriately given answers or taken answers from others. I wrote about this on June 17, quoting Christine K. Cassel, MD, ABIM's President and CEO. She said each question crafted for the ABIM certification exam is "like a precious jewel."

"A couple of thousand people attended (the exam sessions) and not everyone stole questions, but no one alerted us," Cassel said. "If people see unethical behavior they should let us know."

Robert M. Wachter, MD, a member of the executive committee of the ABIM and professor and associate chairman of the Department of Medicine at the University of California, San Francisco, writes in a blog "Dr. Arora ran an ABIM board review course with a difference."

"Attendees of the Arora Board Review were allegedly shown actual questions form past exams, fed to Dr. A from prior test takers—who shared dozens, and in some cases, hundreds of questions," Wachter wrote.  He noted that the board is suing Arora and a "handful of the most egregious offenders for significant damages."

"When you took your boards, you signed an attestation or clicked a little box pledging that you wouldn't share the questions with anyone else," he writes. "It's a pledge worth honoring." Wachter could not be reached for comment, his secretary said.

Wachter is correct in what he is saying, to a degree. But it may be worthwhile for the ABIM to examine how it conducts its own investigations.

For instance, the board said it is concerned about the alleged copying or near copying of questions that were carried out over years. But my question is: why weren't there lots of new questions put forth every year? Why would a question that goes back 20 years be an issue now? Officials of ABIM have said that many months' work was put into determining the questions.
And there's another thing: why did it take so long, if word of mouth was so prevalent among the testing service, for the ABIM to figure out that people were getting answers or reviewing questions that had been used before. Were they so isolated that the ABIM couldn't find out about it—if it was going on for 20 years?

Some respondents to Wachter's blog cover the realm of reaction to what has been unfolding in the tests. One writer was very critical of the test takers: "I can't believe people have stooped so low and have so little self esteem that they are not willing to do what it takes to pass the boards."

Another agrees with the "pledge of honesty" that is signed before taking the exam, but notes, "I wonder how just attending the course makes you unprofessional and unethical when you have not taken the exam and you don't know the content."

All those questions may be answered over time.

There is some talk that the penalties may be too harsh, and that possibly the ABIM should consider education programs and other procedures for physicians who may be sanctioned, instead of certificate removals. The ABIM has questions for itself it should have answered as well.