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Harmed by MOC | Email From Nicholson, Laura 2018

From: Nicholson, Laura MD
Date: Saturday, November 10, 2018 9:23 AM
To: Teirstein, Paul S. MD
Subject: Recert misery

Hi Paul,

I recently gave in and took the recert exam a year late, and wrote the question below after weeks of prep and then post-test PTSD. I thought I must have early dementia during the exam, but my younger colleagues only 10 years out are telling me they are feeling equally terrible, having trouble sleeping, etc. Anyway, I was trying to submit it to an ACP commentary or Medscape or some such, maybe as a joke with a cartoon, maybe as a serious letter, and I can’t seem to find the right forum. Thought I would ask you, as a leader (however unsolicited) in this area, whether or where I should send it. (Feel free to ignore if you’re sick of this chapter in your professional life.)


A 54-year-old female hospitalist prepared for her Maintenance of Certification exam. She received excellent scores in past years by studying MKSAP, so she used the same strategy, completing MKSAP Board Basics and 1400 questions, many of them twice. She learned UpToDate would be available for all exam sessions but continued her intense studying, including 2 weeks of vacation time away from clinical and teaching duties. During the exam, she found the questions long and complex compared to prior years, with surprisingly little use of media such as CXRs, EKGs, or blood smears. As in real life, she decided to check UpToDate on patient scenarios that were uncommon to her practice, assuming that to be the intention of the open book exam. She found UpToDate opened slowly, occasionally not loading at all, and that it could not be left open between individual questions. She developed low grade nausea and tachycardia, which has progressed to anorexia and insomnia.

What is the most important next step in her treatment plan?

  1. Physical therapy referral for cervicalgia
  2. Employee Assistance Program evaluation for burnout and imposter syndrome
  3. Office ergonomics assessment for coccydynia
  4. Application to Mira Costa Community College to teach freshmen biology
  5. Attendance at Southern California ACP to commune with other casualties

Dear ABIM:

I have always enjoyed studying — quiet hours to fill my mind with the human biology I love so much. I have taken the boards 6 times now if I count medical school, plus 1 specialty board, but this time I witness terrified, exhausted colleagues sending $1000’s to ABMS and spending $1000’s more on preparation, desperate for the right to continue their own professional livelihoods. My senior colleagues tell me they were there when these recertification requirements were conceived and that “it was always about money.” I now feel my own professional societies — ABIM plus ACP with its expanding collection of expensive study materials — are willing to break me on behalf of enriching themselves, and that it’s an abusive relationship I should end. Their leaders are failing “recertification” in professionalism, respect, and empathy.

Laura Nicholson, MD, PhD
Scripps Clinic Hospital Medicine Division
Associate Program Director, Internal Medicine Residency
Director, Resident Research
Director of Education, Scripps Research Translational Institute
Clinical Professor, UCSD Volunteer Faculty