The Docs of Innards: Is It Cheating To Pass Along Memorized Questions From Exams?

The American Board of Internal Medicine (ABIM) has taken some sort of disciplinary action against 140 docs who cheated on their ABIM certification exams. In a lawsuit that the ABIM had filed previously against Arora Board Review, a company that does exam review courses for certification, the discovery process yielded information that proved to be more damaging for the docs than for Arora.[1]  The documents in the now-settled case included e-mails and other correspondence from the docs to Arora.[2]  The e-mails and correspondence revealed that the docs knew many of the questions and, indeed, followed up by sending along memorized test questions from their own certification exams to Arora in order to help the cert-docs-in-waiting along.

The dynamics of the question transfer are fascinating because there are some things lost in translation.  Here is one example from the Wall Street Journal’s June 10, 2010 healthblog, an example drawn from the pleadings in the litigation in this matter.  After reading this question see if you don’t find yourself asking, “Why did they need the review course?  I knew the answer to this one without a lick of medical school let alone a board certification review course.” 

ABIM question: A 72-year-old man comes to you for evaluation before undergoing cataract surgery to be performed by an ophthalmologist at your hospital. The patient has been under your care for 11 years for diabetes mellitus and hypertension, both of which are well controlled. He has never had any vision problems, and he says that he reads himself to sleep every night. You refer the patient to a second ophthalmologist who finds no cataracts. Which of the following is the most appropriate action to take regarding the first ophthalmologist? A. Call your colleagues and advise them not to use this ophthalmologist; B. Contact the state medical board; C. Refer the issue to the peer review committee at your hospital; D. Urge your patient to call the Medicare fraud hotline

Board review question: An Ophthalmologist, who works in your hospital, refers you a 64-year-old patient for preoperative medical clearance for cataract surgery. However, your examination does not reveal any evidence of cataract. Patient has no eye symptoms and he reads books before going to bed every day. In the past, you have had similar experience [sic] twice with this Ophthalmologist and each time you had not found [sic] cataract in the patient. Besides getting a second Ophthalmological consult, what is your next step? A. Stop accepting patients from this doctor; B. Tell patient not to sign the consent for surgery; C. Place a call to this Ophthalmologist; D. Report to peer review

(Answer: peer review)[3]

This type of cheating ring is fairly typical.  When we were in junior high and had algebra first period, we would walk out and find the students from 2^nd through 6^th period waiting anxiously.  We would say, “It was hard,” or “It was hard, but if you studied, you will be okay.”  Some folks evolved to, “Well, it was hard and you better know ________.”  From there others moved along to, “Well, it was hard, and you better know _______, and there was this one question . . . “  From there students move along into assigning which questions to memorize so that they can be passed along.  Docs who took the board certification exam remembered exam questions, wrote them down, pooled their resources, and then sent them off to their board-review course. The board-review course then included those questions in their study materials for course participants.  A comparison shows that the questions are not identical, but they certainly did memorize the gist of them.

The docs do pay for the courses and the docs are dependent upon these courses because, well, aren’t we all a’feared of just studying?  We want a review course to take some of that pain away.  But, in the zeal to remove the pain some docs and their review courses have crossed over into just getting the questions.  Hence, the ABIM scandal. 

The docs do promise confidentiality when they register for the ABIM exam and are also reminded of that confidentiality and other pesky things such as honesty and not passing along test questions.  ABIM describes the confidentiality pledge and honesty reminder as follows:

Each physician who signs up for an ABIM examination is directed, in writing, not to discuss exam content. In addition, before each test, physicians sign a ‘pledge of honesty’ to not disclose, copy, or reproduce any portion of the material contained in the examination and are warned that ABIM will impose severe penalties on any physician involved in efforts to provide examination question content to others.[4]

 So, ABIM has disciplined the docs with a range of sanctions from letter reprimands all the way through varying discipline levels including revoking exam passage (for 1-5 years) and certification (also for 1 to 5 years and, for some, into eternity) to naming five of them as defendants in a suit by ABIM for copyright infringement and misappropriation of trade secrets, i.e., passing along the exam questions.  The five of the 140 were named as defendants because of the extent of their activity in dispersing the questions.[5]  There are always those in the ring who assume that purchasing questions is acceptable and profess innocence because, “How were we to know they were from previous tests?”  So, ABIM metes out justice via mercy, with just a drop of skepticism.  

Now, some would argue that certification is a nice pen in the pocket of a physician’s lab coat, but is not necessary, so what is the big deal? One doctor posted the following on the Regator blog, “But is it really cheating? College kids do it all the time.”[6] Others call the certification exam “antiquated” with “no correlation” between certification and improved medical outcomes. In tis group are those who argue that certification leads to more mistakes in patient care because docs rely on their “recently certified” minds in lieu of verification.  These folks want open-book exams.[7]  Oh, don’t we all? Still others, such as ABIM CEO Dr. Christine Cassel would argue, “Any high school kid knows that cheating is unfair.”[8] That’s where Dr. Cassel and I would part ways.  She is wrong about the high-school kids.  That’s where it started.  High schools are not doing a crackerjack job of reining in cheating. Docs don’t wake up one day and decide to cheat on a certification exam.  The Barometer suspects that the docs were using similar toes-to-the-line strategies throughout their career.  Dr. Cassel is just now beginning to see the graduates of a new culture of cheating.

 

 

[2] The doctor who ran the review course agreed to surrender his own ABIM certification and refrain from offering live review courses.  He and his company can, however, continue to sell review materials for the board certification.

[3] http://blogs.wsj.com/health/2010/06/09/abim-cheating-scandal-take-a-look-at-some-test-questions/.

[4] www.abim.org

[5] You can find ABIM’s press release on this matter at http://www.abim.org/news/ABIM-sanctions-physicians-for-ethical-violations.aspx.

[6] http://regator.com/whatshot/American+Board+of+Internal+Medicine/.

[7] http://www.kevinmd.com/blog/2010/04/recertification-doctors-improve-patient-care.html.

[8] Katherine Hobson, “Board Says Doctors Cheated,” Wall Street Journal,  June 9, 2010, p. A6.