The American Board of Internal Medicine (ABIM) has a tradition of playing a critical role in healthcare delivery in the United States. ABIM recently has taken on the issue of medical misinformation and how it has contributed to the deterioration of trust in medicine and science.
Richard J. Baron, MD, MACP, president and CEO of ABIM and the ABIM Foundation, discusses with SoundPractice host Mike Sacopulos the history and mission of the ABIM and a recent piece in The New England Journal of Medicine in which he and his co-author discuss the importance of the medical profession maintaining independence from political interference and the consequences of attempts to politicize medical issues.(1) Baron expands on how this issue is having an impact on physicians, their patients, and medicine.
As a bonus, Sacopulos and Baron discuss Baron’s undergraduate degree in English and how those studies helped his writing skills and his skills as a physician leader.
This transcript of the discussion has been edited for clarity and length.
Mike Sacopulos: Rich, can you please tell us about the American Board of Internal Medicine? What is the mission and history of the organization?
Richard Baron: Absolutely, and it’s a great place to start because it’s very relevant to what we’re talking about today. The mission of the board is to improve the quality of healthcare by certifying doctors who demonstrate the knowledge, skills, and attitudes essential to excellent patient care.
The whole idea is that the way we try to make healthcare better is by creating processes that recognize doctors who have demonstrated important skills for the practice of medicine. We used to call ourselves a standard-setting organization. Now, we say we are the vehicle through which the profession sets standards for itself.
The history of the board: We were created in 1936 by a joint action of the American College of Physicians, the internist organization, and the AMA. This happens in many industries. You get membership organizations that focus on education and advocacy who become apprehensive that people will degrade or threaten whatever the industry is by doing it badly, by not meeting a set of standards. And so, they create organizations that are independent to create standards and expectations and verify that they’ve been met.
A common example that people probably are aware of, but probably haven’t thought much about, is the organization NCQA. Those initials stand for the National Committee of Quality Assurance. The National Committee of the Group Health Association of America was an HMO industry membership and lobbying group that realized, hey, we need to have standards for the industry. And so NCQA spun out from the Group Health Association.
An older example that your listeners will be familiar with is The Joint Commission on Accreditation of Healthcare Organizations, which started as the quality committee of the American College of Surgeons in the 1900s.
It’s a common evolutionary path for a standard-setting organization to come out of a membership organization. That’s how and why ABIM was created.
Sacopulos: Well, thank you for that history. As you know, SoundPractice is the podcast of the American Association for Physician Leadership. And I’m interested in the path that brought you to physician leadership.
Baron: The honest answer to that, Mike, is self-defense. All I ever wanted to be was a clinical practicing doctor. I was in the National Health Service Corps; it’s how I funded medical school. And after training at Yale and Bellevue, I went to rural Tennessee, where I was the only physician in the western half of the county. And there I saw something I’d never seen before: the physician as member of their community. And I loved that.
I loved that the people I took care of in the office, I would be standing next to in the grocery store line or they would be involved in caring for our infant. And so, when I came to Philadelphia, I wanted to create a community practice, and I did.
After a few years in the Academic Health Center, I opened a community practice. And I needed a part-time job because I went from an environment as a salaried physician where no matter what I did every month, a certain amount of money appeared in my bank account, to running my own practice where no matter what I did in the office, at the end of the month, a certain amount of money disappeared from my bank account.
And I thought I needed a part-time job. And I stumbled into a job in 1988 as the 0.4 FDE medical director of a startup, Medicaid HMO. And that was a new thing, that HMOs were just getting started. There was no Medicaid managed care. It was all fee for service around the country. Of course, today, 80% of Medicaid is managed care. But then it was new and it was some teaching hospitals that got together.
And in retrospect today, you’d almost think of them more as an ACO. The mission of the organization was improving the health of a defined population within a fixed budget. And there I was, the 0.4 FDE medical director, and I was the 35th employee and we had maybe 4,000 members.
The plan was that when the practice got busy, I’d give up the part-time job and stay full-time in practice. But the organization had a compelling mission, had a wonderful CEO who was very supportive of me. And the organization grew and grew and grew, and I kept saying, “You should hire a real medical director.” She said, “You are a real medical director. Bring in whatever you need to bring in to keep doing this job.”
A decade later, I was still the 0.4 FDE person, but now I was the senior vice president for medical affairs of a 100,000-member Medicaid HMO and early Medicare Choices HMO. There were 400 employees — 100 of them reporting to me. And I was dividing my time between the community practice, which by then had grown to seven doctors, and the leadership in the HMO. People said, “With your practice you could influence 1,500–2,000 people, but if you become a medical executive, you’ll have an impact on hundreds of thousands or millions. You should do that.”
I didn’t want to do that. I didn’t go to medical school to become an executive. I wanted to stay in practice. But I have to admit, when I got a call, 30 years in practice, from Rick Gilfillan at the Innovation Center who said, “I got $10 billion and a bunch of get-out-of-jail-free federal regulatory cards. Are you going to stay in practice forever or do you want to come down here and fix American healthcare?”
Frankly, the hook was in. That’s a quick summary of how I wound up as a leader, but it really was about trying to take the insights of what I was experiencing in practice and the challenges and what worked and what didn’t, and bring that perspective into a leadership space where I could have some impact on structuring the way practice happened.
Sacopulos: Excellent. You and Carl Coleman recently wrote an article for The New England Journal of Medicine titled “Protecting the Legitimacy of Medical Expertise.” Why’d you write the article?
Baron: We are at this extraordinary moment in our society, in our country, where expertise is under attack, where people are coming to doubt the existence of facts, to contest things that we would have thought were factual. And whatever you want to say about medical practice, we earn our living by being experts, by studying deeply the science of medicine, the literature of medicine, really trying to gain a knowledge base and put it in service to our patients. That’s the core of what we do.
We put a sign out there that says, “If you have a problem that’s medical, come to see me, I have expertise, I have skills, I can help you.” And that help comes in the context of a broad community of clinicians, scientists, who together craft a standard and expectation of what it looks like to do it right. And now we find ourselves in a world where people are skeptical of expertise, they’re dubious of expertise, they wonder about the motives of experts.
And when you amplify all that anxiety with social media and the internet and the fact that anybody can find any so-called fact they want on the internet, they can find things to support whatever it is they want to believe. It becomes a very challenging environment. I think expertise is being threatened, and it’s incumbent on us as a profession, as leaders in a profession, to defend that expertise.
Sacopulos: Your article does not address nurse practitioners. NPs are taking on an ever-larger portion of primary care in the country with decreasing physician oversight in many states. Has the expansion of nurse practitioners eroded physician expertise in the eyes of the public?
Baron: I don’t think it erodes the concept of physician expertise. I believe patients and the public do understand the difference between nurse practitioners and fully trained physicians and their different roles.
What it speaks to is our collective failure to offer the public accessible primary healthcare. There are a lot of reasons for that, but at the end of the day, the reason I left my medical practice was to take Rick Gilfillan’s invitation and save American primary care. My wife said, “Why would you leave this practice that you’ve built? Why would you move from Philadelphia and go to Baltimore and Washington?” And my answer was, “Because I thought this was one of the critical problems facing the country.”
I almost felt like my father must have felt signing up to fight the Nazis in World War II. And I think we made real progress, and programs that I was involved in — like designing the comprehensive primary care initiative, which directed a lot more resources, financial resources to primary care — made a difference.
We helped broaden the scope of primary care practice around the country, but we did not succeed in saving American primary care. I believe we are in big trouble there. Patients are going to need somebody to answer the phone and see them when they’re ill. And if you just look at the numbers, you’ll see we don’t have enough primary care doctors. Various kinds of team-based care and expansions of practice are happening to meet an unmet need.
Sacopulos: Well said. Your article, which we will post information about accessing on the AAPL website, argues effectively that the anti-expertise perspective has moved to mainstream, and this is thanks, in part, you argue, to Google and Amazon. Can you expand a little on that?
Baron: Sure. Something that was shocking to learn as a matter of history is that at the founding of the Republic, only two states licensed doctors. And, people believed that disease was local. By 1830, all but two states licensed doctors. “Great progress,” you say. But by 1860, only two states licensed doctors.
What changed their minds between 1830 and 1860? Why did they think licensing was a good idea in 1830 and a bad idea in 1860? The answer is explained beautifully in Choose Your Medicine by Lewis Grossman, an American law professor and legal historian. He talks about what he describes as the medical freedom and liberty movement.
Between 1830 and 1860, people who opposed licensure characterized it as an infringement on freedom and liberty. Grossman talks about four different freedoms. First is freedom of bodily integrity. The argument centered on whether physicians used botanicals or other stuff. If you license the people who use the other stuff, you’re going to make me put the other stuff in my body and I don’t want to.
The second argument was commercial freedom. If you give doctors a monopoly, they’re going to get together and raise prices. Not only that, I should be able to hire anybody I want to be my doctor. And on the doctor’s side: What do you mean I can’t just go be a doctor? Why would you limit that?
The third argument was freedom of inquiry. If you license one group of doctors, well, the botanical folks are not going to go out and find the cure for cancer; you’re going to keep them from finding it.
And the fourth was freedom of conscience, that the state shouldn’t tell me who I get to pick as a doctor. It doesn’t tell me who I pick as a minister, why would it tell me who I pick as a doctor?
And what’s striking is that all four of those freedoms are actively in play right now in conversations in our country: bodily integrity, monopoly and commercial freedom, freedom of inquiry. Are we shutting down science?
Everybody who disagrees with prevailing medical consensus, all of a sudden they’re all Semmelweis, they’re all Copernicus, they’re all Galileo. They’re all brilliant people who see the thing that nobody else sees. I think most of us, physicians in practice and in leadership, take licensure for granted. We take for granted the idea that, of course we’re the only ones who can admit people to hospitals. Of course we’re the only ones who are going to get paid by insurance companies for medical services.
It’s important for us, as a profession, to realize that that unique privilege is a grant of civil authority that, as the story from 1830 to 1860 shows, is not guaranteed forever. And as we start seeing state legislatures getting involved in regulating physician practice, we realize that they can chip away at what it means to be a physician, what the authority of physicians is.
We all need to be thinking deeply about what gives us legitimacy, what gives us authority. A major part of it is science. But a huge part of it ultimately relies on trust, and that is something that I fear we are starting to lose as a profession and as a healthcare enterprise.
Sacopulos: Last night, I looked up the Surgeon General’s podcast, House Calls, and then I looked up a podcast that’s been criticized for providing false information related to COVID-19. As you’ll remember, in early 2022, Joe Rogan on his podcast, The Joe Rogan Experience, claimed coronavirus vaccines weren’t actually vaccines but were instead gene therapy. He promoted the taking of ivermectin as well. Our Surgeon General’s podcast had 55 reviews. Joe Rogan’s podcast had over 4,800 reviews and 11 million listeners per episode. Is this a problem of prioritizing entertainment over information?
Baron: Wow. First of all, Mike, those are chilling statistics. Thank you for putting them in front of your listeners and educating me about them because they really do illustrate the scope of the problem.
One of the things we know about misinformation is that lies spread faster than truth. There was a study that documented that lies spread 17 times faster on social media, and that gets exponentially magnified. We have to remember that the business model of the social media platforms focuses on engagement, not accuracy; they’re rewarded for what people look at, for what people are paying attention to.
If the platforms are prioritizing engagement, then they are prioritizing entertainment over accuracy and truth. It’s entertaining to read or hear an outrageous story, but that certainly doesn’t make it true. And we don’t want to live in a world where we’re crowdsourcing the truth. We may want to crowdsource our political leadership as we do with elections. We may want to crowdsource who we think the best masked singer is. But I don’t think we want to crowdsource the treatment of a lethal disease. We want to rely on sound methodology for generating evidence we can rely on. And it’s never 100%. When a study establishes a treatment, it says, “If you do this, you’re more likely to benefit from it than if you don’t do it.” That’s all it’s saying.
Sacopulos: It is frightening. Rich, there are fewer numbers of freshman college students around the country. As tuition rises, more of our fellow citizens take aim at higher education. Is the anti-expertise perspective that you talk about in medicine more a sequela than a disease?
Baron: I would say yes. In March 2022, Jill Lepore wrote a piece for The New Yorker about the Scopes trial, which was the contest between science and religion. She argues that, actually, the same issue is the center of controversy in schools today in the form of critical race theory and education. It’s parents saying, “I don’t want the state to tell my kid what’s true.” And again, it’s another guise of the freedom argument. It’s “I should get to decide.”
I believe the freedom argument leads to a bias against higher education because, well, what if people on campuses are educating people about what’s true? No, people should be able to choose what’s true. The late Senator Moynihan had a great phrase attributed to him, “You can choose your opinions, but you can’t choose your facts.” We do seem to be living in a world where people seem to want to be able to choose their facts. It’s very dangerous.
Societies that prioritize higher education tend to be societies that flourish and thrive, and societies that deprioritize it tend to struggle. I worry when I see the de-prioritization of higher education and the lack of higher education becoming coin of the realm.
Sacopulos: As a physician leader, I look to you and your members at the ABIM for solutions. Please offer me some hope. What’s the path forward, Rich?
Baron: I think the path forward has to be focusing on building and deserving trust, behaving in a trustworthy way as an organization. The American Board of Internal Medicine actually went through some very difficult times over the last decade. We were the subject of a sustained attack that had a lot of traction among the doctors. It was shortly after I started, and I’d like to think it wasn’t because I started.
But I came to believe that the challenge that we faced was we had moved from a lifetime credential that we issued at the beginning of career to a time-limited credential that said, you periodically need to demonstrate that you stayed current in the field, which made a lot of sense. But we did a terrible job explaining it to people, and we continued to behave like a group of arrogant people. We were the teachers; you were the students. We knew the answers; you didn’t.
We could get away with that when we were working with residents and fellows. But by the time I started in 2013, some of the people that we were saying that to were 50-year-old cardiologists, and they said, “Who made you the boss of me?” I realized that we had a 20- or 30-year legacy of having made no effort to build trust with them.
I discovered a document from 1980 where a practicing doctor said to the board, “I asked all my colleagues what they think of the board and they don’t know who you are, they don’t know what you do, but they’re pretty sure that whatever you do is different enough from what they do that if you’re going to set standards, you better do it with them and not to them.”
And that isn’t what we did. My leadership journey in the last decade at ABIM has been to try to become a more trustworthy organization with respect to the diplomates that we certify. That’s taken me to everywhere from financial transparency on our website to different kinds of communication, to changing the tone of communication, to changing the way we talk about what we do, and also to changing the program that we offered so that we would see it through the eyes of the doctors going through it, even as we maintain fidelity to the core value proposition of distinguishing doctors who’ve stayed current from doctors who haven’t, of doctors who met standards of expertise and knowledge from doctors who haven’t.
I think we’ve made real progress in that. But the journey wasn’t to stand up and say, “We’re right and you’re wrong.” It was to take seriously how we had allowed trust to erode and what steps we needed to take to restore it. And that was everything from changing the way we did business to changing the way we talked about ourselves, to doing a better job explaining how what we did was relevant to the needs of the people that we were serving.
And frankly, I came to believe that every healthcare organization out there is one step away from the journey ABIM was on, that we all think that we get the engagement of our patients, that of course they trust us. Of course we have their best interests at heart, and of course they come to us because we have science.
But as you look around and realize the counternarrative, what does surprise billing do to the story that we have their best interests at heart? What does it mean that medical bills are the largest cause of personal bankruptcy in this country? What does it mean when hospitals and health systems are harassing people and turning them over for collection?
And I get it, the no margin, no mission. But we have to stop assuming that we can do that, and it’s not going to have consequences in terms of how much people trust us.
A lot of the anti-vax narrative used to be focused on autism, and it didn’t have a lot of traction. Now it focuses on freedom and commercial exploitation like, “They’re making a lot of money on you in those drug companies and the government is abridging your freedom by making you do this.” Those narratives are much more resonant in the public, and we need to think of ways to talk to people who believe that, to assure them that the vaccine really does work. That’s not their concern. Their concern is that somehow it’s corrupt, somehow it’s an infringement on freedom. Our ability to build trust with patients will begin with recognizing what their concerns are and trying to deal with those instead of just trying to persuade them that we’re right.
Sacopulos: When I started practicing, most of the primary care physicians in my hometown had independent practices. We don’t see that nearly as much anymore. Physicians are in larger healthcare systems as employees. Do you think that the fact that they’re working for a larger organization depersonalizes them and maybe creates some of these feelings that you were just describing?
Baron: It certainly creates conditions under which that can happen, but I don’t think it depersonalizes them. In my opinion, the opportunities that physicians have to create authentic, meaningful relationships with their patients are as robust as they ever were. And what sustained me in 30 years of community practice was those relationships. I believe anybody practicing today has that opportunity to derive meaning from their work. People who are doing clinical work should think hard about how they can hang on to that in an environment that doesn’t reliably support it.
You’re absolutely right, though. Physicians Foundation did a study that showed that 72% of all doctors in the country now work for organizations not controlled by physicians. And that does create a new set of problems. In my own community practice, I got to hire and fire people. I got to decide what electronic health record we were going to use. I got to decide what purposes we would use that electronic health record for. When you’re working in a larger organization, you don’t have those degrees of freedom, for sure.
But what the organizations need to work on and physician leaders need to help organizations understand is that the organizations are losing trust with the physicians who work for them. The organizations need to think about what it takes to maintain trust. Whether it’s how people staffed for the pandemic or did or didn’t provide personal protective equipment or did or didn’t lay people off or did or didn’t whole variety of decisions that people made under great duress, that those decisions had rippling consequences in trust that staff had, trust that physicians had.
Everybody in healthcare needs to be thinking hard about how to rebuild trust. Organizations need to be thinking about rebuilding trust with their physicians and with their professional staff. And I think if physicians believe the organizational mission has moved to all about the money, they will not do a good job taking care of patients. They will not show up to work with patient’s welfare and clinical outcome top of mind. We’ve damaged that, and everybody needs to work hard to restore it.
Sacopulos: I was interested to read that your undergraduate concentration was in English. Could training in English or history help future physicians combat misinformation and relate better to patients?
Baron: It has certainly helped me. I think being an English major actually was one of the most important things in my career because when I went to medical school, I went with a belief that the activity of medicine was a fundamentally human activity, that it was fundamentally about the people, and that the science was a tool. It wasn’t the whole game; it was a way to meet the needs of people. And frankly, from the very beginning of my medical education, that wasn’t how they presented it. It was the science that I was supposed to learn, what I was supposed to be thinking about, what I was supposed to master.
I came to believe that we were being taught in medical school that patients were translucent screens on which a disease was projected. And our goal was to make the patient disappear so we could see the disease. I believe the humanities help us discover something, rediscover something, affirm that all of us have that human connection. That is what animates medicine. It has to drive medicine.
That’s where we find meaning: in the connection of the service that we get to provide as healers. That can get lost when you see it as an economic enterprise. It can get lost when you see it as a scientific enterprise. It can get lost when you see it as a technical enterprise.
The humanities help us discover ways that medicine continues to be a human enterprise. History helps us realize that what we have right now is not inevitable and could be something else, used to be something else, and will be something else. It helps us understand our work in a larger context. So, yes, I do think both of those things can help us be more effective in facing our current situation.
Sacopulos: Certainly, the practice of medicine is both an art and a science. And I think what you’re getting at is the art end of the equation, which may be beneficial for addressing problems that we’ve been discussing. The American Board of Internal Medicine is a busy and engaging organization. In our final minutes together, Rich, can you share some of the topics on the agenda for ABIM in the next year and beyond?
Baron: Absolutely. Over the last 10 years, there was an enormous amount of anger and some of the professional societies felt they needed to channel that anger, too, to represent their members with us. And we’ve done a lot of work to try to lower the temperature, to offer physicians who want to be in our program and want to hold our credential a pathway that fits into their lives.
We now offer something called a longitudinal knowledge assessment. Instead of having to show up and sit in a test center all day, they can do 30 questions at their convenience. This has been hugely successful, and we’re still able to make really meaningful judgments about whether people going through this assessment have stayed current. We haven’t lost our core value proposition, but we’ve helped this hit the ground in a more comfortable way.
We’re definitely trying to make the doctors’ experience dealing with us better, and that’s how we respond to queries about the program, making the rules a little more understandable, and trying to make the journey of the doctors through the program one that is educational and is not as intrusive and difficult.
We’re going to be looking at ways technology can help us do it better, just as every organization today is doing. And we’ll learn. Is there a role for simulation? Are there ways that we can pick up the digital artifacts that doctors are leaving today and use those to construct valuable assessments that would be less intrusive for doctors?
The core of the value proposition of being board certified is distinguishing a group of doctors who are practicing today’s medicine, who have mastered and stayed current with a body of knowledge from a group of doctors who just say they do.
We all are breathing the same air, we all are living in the same cultural environment. And part of why I wrote that article that you mentioned is that I think our colleagues should not take our position for granted. We should understand how contingent it is. We should realize that it’s at risk. And we should focus on behaving in trustworthy ways and helping our organizations behave in trustworthy ways.
If we lose the public’s trust, we are going to lose all of the privileges we have. And by privileges, I don’t mean social privilege, which we are blessed with as physicians. I mean the ability to command all the resources that we command as therapeutic physicians.
Today, we can sign off on drugs that require prescriptions. People who don’t have licenses can’t. We can arrange consultations and procedures and hospital work for patients, other people can’t. But that is a grant of authority that we have, and we need to earn it. We need to deserve it, and we need to behave in ways that persuade patients that we have their interests at heart and not our own.
Sacopulos: Very well said. For those interested in joining the American Board of Internal Medicine, where do they go to learn more?
Baron: Our website is abim.org. We are not a membership organization. The business model of a membership organization is such that you pay dues to the organization. And to join, you may need to be certified, you may need to already be in the discipline; sometimes you do, sometimes you don’t.
The business model of the American Board of Internal Medicine is that we are the vehicle through which the community sets standards for itself. Doctors pay a fee and then they go through our process. And if they successfully demonstrate in that process that they have maintained their skills, then they get a certificate, they get a credential.
As part of the broad attack on expertise, people say, “Oh, there’s no evidence this credential makes a difference.” That’s simply not true. We have on our website a series of infographics, as well as a bibliography, that describe all sorts of outcomes we care about that are better in board certified doctors than not board certified doctors. And that’s everything from risk of state disciplinary action against a license, to outcomes from heart attacks, to outcomes from cardiac procedures, to management of diagnostic error.
People who perform well on our exam are less likely to make diagnostic errors that injure patients and lead to unplanned hospitalization and death. There are a variety of very important clinical outcomes that board certification is associated with.
Sacopulos: Tremendous. Dr. Richard Baron, unfortunately, our time’s up. Thank you so much for speaking with me today. Continue the good fight, sir.
Baron: Mike, thank you. This is really one of the more thoughtful and reflective conversations that I’ve had with anybody in podcasting, so kudos to you for staying on the salient issues. I really appreciate it.
REFERENCE
Baron R, Coleman C. Protecting the Legitimacy of Medical Expertise. N Engl J Med 2023; 388:676–678. https://www.nejm.org/doi/full/10.1056/NEJMp2214120