A Shameful Silence Over Physician Exams

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.

The Arora Board Review's principal, Rajender K. Arora, MD, has surrendered his certification to perform the tests, according to the ABIM. In a court filing, ABIM alleged that Arora and other associates improperly disseminated copyrighted test questions. Physicians paid between $1,000 and $1,495 for the Arora Board Review courses.

The questioning in the ABIM's board certification process evaluates what it terms the "knowledge, skills and clinical judgment" of participating physicians and "assures that those who are certified have demonstrated the requisitive expertise to deliver excellent patient care in internal medicine."

"Every single one of these questions is like a precious jewel," Cassel says. "We get a group of experts from all over the country who come together to write these questions and then edit, and have them have them pre-tested and tested to make sure everything is valid," she says. "It takes two years to make one question that works. It's a huge amount of staff time. Every one of those questions is very valuable, and hundreds of questions were exposed."

A sample question used by ABIM, and provided to HealthLeaders Media, begins:

A 14-year-old boy noted swelling of the right arm and had 15 minutes after shop class . . . "

The Arora question starts:

A photograph of a white 14-year-old boy is shown with swelling of his right forearm that developed after attending a class on wood chopping . . .

Generally, investigators for ABIM found in this question and others that the Arora question "is almost identical to the ABIM question and contains the same unique fact pattern."

Physicians who solicited or shared questions from Arora Board Review could be suspended for at least one year or more, based on the seriousness of the offense.

"Thousands of physicians go through the test every year and almost do it honestly by studying and learning what they need to know," Cassel adds. "It made me feel dismayed and sort of sickened, because it's my profession that I care deeply about and we set a standard for ourselves, what we are doing for patients and the public."

The heartache may not be over, though.

Because of what happened, the ABIM is conducting an investigation of other testing services, Cassel says.

"We have ongoing surveillance," Cassel says. "We have increased this. We do scan all the review courses as well as the blogosphere. We do have ongoing investigations of a couple of additional programs, but nothing to suggest anything like this."