A Letter From a Miami Jail to the American Board of Internal Medicine

Sekeres is a leukemia specialist.

American Board of Internal Medicine (ABIM)

Philadelphia, PA

Dear ABIM,

In the spirit of Henry David Thoreau and Martin Luther King, Jr. — both of whom penned essays while they were serving jail time — and in follow-up to the previous letters I scribed from a Cleveland jail, I write to you from the dark and dank confines of emotional prison in South Florida, a victim of the poor choices I’ve made in life.

One of those was to opt in to the Longitudinal Knowledge Assessment (LKA) medical oncology exams that you offer.

True, I was between a rock and a hard place. My other option was to take your 10-year Maintenance of Certification (MOC) exam, an exercise in monasticism as I would have to spend hours alone, away from my family, patients, and my research to study for the test; in physical stamina, given the test’s length and uncomfortable chairs in my local Pearson VUE testing center, which I think may have been repurposed from the prison in Guantanamo Bay; and in futility, as over 90% of the questions have nothing to do with the patients I actually see in my specialty practice, and haven’t seen in over 2 decades of practice.

But your website made the LKA — which now has a registered trademark, perhaps to ensure that nobody else copies this testing innovation — sound so appealing! One doctor on your site wrote about how they were able to go on vacation with family and take time away from family during that vacation to spend hours answering LKA questions. There’s even an accompanying photo of the doctor, sitting alone with an open computer at one end of a long picnic table, presumably answering LKA questions, while their family spends time interacting with each other, like people do on vacation, at the other end of the long picnic table.

This strikes me as being completely tone-deaf in an era when physician burnout — in part due to the computer work we have to take home to complete — has led to a public health advisory by the Surgeon General.

I feel bad for that doctor, who clearly didn’t have time to squeeze the every 3-month test into a busy life of seeing patients and tending to administrative tasks. Answering LKA questions is certainly no vacation.

In fact, answering LKA questions is stressful. As you well know (since you made the rules), we have 4 minutes to answer a question, at which point a message erupts on our computer screen telling us that we are out of time, worthless, and weak, and should consider a career in The Law. In truth, it only tells us that time is up, but I believe the rest is implied.

Outside of very specific emergency scenarios, when do we ever have to make a decision within 4 minutes in medicine? I specialize in treating patients with leukemia, arguably the most aggressive subtype of cancer. I never have to make a decision within 4 minutes.

We do have the option of adding a minute to our question response time, but can only add 30 minutes from a “time bank” in a calendar year. So, add to that stress the calculus of whether an additional minute will truly provide the time to determine the best response, or if we should save the minute in our bank for a more deserving, yet to be determined question.

Don’t these sound like rules your older brother might invent to torture you by basically guaranteeing you will fail in some task, given the complexity of his hard-to-follow rules, and you will have to suffer the consequences of his purple nurple? Fess up, ABIM: did your older brother invent the LKA?

As usual with your exams, my favorite aspect is the “pretest question.” With these, we pay you large sums of money so we can fret over the correct responses to, and help you validate, questions that don’t count, and for which we might waste one or more of our precious 30 extra minutes. In one LKA assessment session, these accounted for one out of every six questions I answered! And like with the 4-minute timeout on questions, a message pops up at the end informing us that we just spent 4 minutes worrying unnecessarily about a poorly worded question, or potential answers that didn’t quite make sense, and that we are worthless and weak and should consider a career in The Law.

Again, I’m blaming your older brother for this one. It’s like the time he told you that you were in trouble with your parents and had to behave extra good to keep from getting punished, including doing his chores and fetching him the food and beverage of his choice, only to find out later he had made the whole thing up. And then, he still gives you a purple nurple.

Finally, as with your 10-year MOC exam, having to answer 30 medical oncology questions — of which approximately 48 are about patients with breast cancer — is an exercise in futility for someone who specializes in rare hematologic malignancies like me. Admit it ABIM: if, God forbid, your older brother developed leukemia, you would want him seeing a specialist like me, right? I’m sure you will agree, my knowing the appropriate therapy for a post-menopausal woman with stage III, triple-negative breast cancer won’t help me treat his leukemia any better.

Nor will the purple nurples your LKA exams keep giving us.

So, here’s my advice, ABIM, delivered as a kinder, nurturing older brother might dispense advice: make maintenance of certification relevant to our specialty medical practices; eliminate the nonsensical time limits for responses; and stop treating us like your gullible, younger siblings. We deserve better.

Sincerely,

Mikkael A. Sekeres, MD, MS

Board Certified, Participating in MOC

Mikkael A. Sekeres, MD, MS, is chief of the division of hematology and a professor of medicine at the Sylvester Cancer Center at the University of Miami. He is author of the book Drugs and the FDA: Safety, Efficacy, and the Public’s Trust (The MIT Press).

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