Dr. Asher A. Tulsky reflects on his time as chair of the Internal Medicine Board & ABIM Council

Asher A. Tulsky, MD, is Associate Professor Emeritus of Medicine at the Boston University Chobanian and Avedisian School of Medicine. He also directs communication skills training at the Boston Medical Center Solomont Simulation Center. He is the immediate past chair of the ABIM Council and of the ABIM Internal Medicine Board and served for eight years on the ABIM Internal Medicine Board Exam Committee. He is also an active member of the Association of Program Directors of Internal Medicine.

What do you consider your greatest accomplishments as chair of the Internal Medicine Board?

I don’t think I can take personal credit for our accomplishments, but I believe the Specialty Board has done some pretty amazing things during my tenure. The first that comes to mind is the change in procedures requirements. Up until about four years ago, every internal medicine resident successfully completing residency had to have successfully completed a number of different procedures regardless of whether or not they were going to be using those procedures in practice. Thoracentesis, paracentesis and lumbar punctures were not procedures every internist going into practice would do. In fact, most do not. Further, we were concerned that the minimum number of five successful attempts per procedure didn’t actually guarantee that they were actually qualified to do them. But it was a requirement that all program directors had to attest to.

As a former program director myself, I know how difficult it was to get people to do them. And then it was particularly challenging because knowing that these were things that people would never do again just felt really disingenuous. After soliciting input from all of the stakeholders including program directors, fellowship directors and professional societies, we changed the requirement to one procedure of relevance to their future practice that the program director would attest to. So, I think eliminating that requirement was probably the greatest accomplishment that the Specialty Board did early in my tenure.

I think our second accomplishment was creating the Internal Medicine: Inpatient assessment. Up until last year, there was the Focused Practice in Hospital Medicine program, which allowed those diplomates who did mostly inpatient care take their assessment on inpatient medicine content only. We discovered that only a small minority of hospitalists were actually participating in the program, choosing to take the traditional program that was more outpatient-based, possibly related to some of the requirements of the program. Participation required a number of things, including a letter from the CMO or someone similar at the institution and attesting you took care of a certain number of patients over the year. After vetting with all the stakeholder societies, we decided to sunset the Focused Practice in Hospital Medicine pathway and open up the inpatient assessment to anyone who chose to do it. And what’s interesting is since we’ve done that, we already have more people participating in that than the total number already certified in what was focused practice in hospital medicine. So, I think those two things were probably the things that I’m most proud of as a Specialty Board that we accomplished.

How has ABIM changed since you’ve been on Governance?

I was on Governance for eight years and it’s been just incredible to see how the organization has evolved. Of course, a lot has been in response to the concerns and the criticism from the diplomate community. What I’ve seen that I find particularly inspiring is how every effort is made to get input from the stakeholders before any major decisions are made.

For example, before we made the procedures change and created the inpatient assessment, we connected with every major society, with program directors, special fellowship program directors for the procedures and individual diplomates. We made sure everybody was on board before making it a fait accompli.

I think the other thing that has been really impressive over the last few years is the commitment to health equity and diversity. And I’ve seen this through the recruitment of its governance members, advisory committees, as well as in the approach to item development. ABIM is making a real effort to make sure that there’s no bias in test items and looking at test performance to determine if questions have an effect on how different groups of people respond.

ABIM made great strides in making sure that Governance reflects the makeup of the diplomates and that it includes more people and more diversity. We have been extremely successful in that, particularly on the Internal Medicine Board. I think we’re really intentional about not only having a number of different ethnicities, but we also have people from private practice, primary care, university, rural, as well as urban settings. I think we really do reflect the diplomates at large and more importantly, the community of our patients at large.

I think those are the biggest changes I’ve seen in the time I’ve been here. I have to tell you, it is just an amazing group of people from the staff to the other members of Governance. They’re just amazingly wonderful, committed individuals.

How have you grown as a physician because of your interactions with ABIM?

I’m much more thoughtful about the bigger picture because of my experiences with ABIM. When you’re with a patient in the office, it’s kind of one-on-one. And I think that it’s useful to step back and look at the bigger picture of this one individual among many others. I’m more thoughtful about getting input from others. I try always to include my patients in the decision -making, which has been a standard for me. But sometimes, it’s really making sure that I’ve gotten all the information that I need before I have these conversations. And I think ABIM has made me better about that.

I think the process of staying current means more to me now. I’ve maintained my certification throughout this, throughout all my time in governance and as an item writer. But I think I take a different approach to it now. It’s not just about the testing anymore but actually making me a better doctor. I’ve learned how much data there is supporting the value of being certified in terms of the performance one does as a physician, in terms of outcomes of their patients. And I take that to heart. And for me, staying current is a priority.

Do you have any advice for physicians who are thinking about joining ABIM?

I would say really think about joining an item-writing committee. I think it’s one of the best learning opportunities that one can have. And in fact, I’ve used the item writing process as a way to help residents learn by having them write questions because that process walks you through the thinking process. You have to think about what is the support for the right answer? What are the other answers that could be correct but aren’t and why they aren’t? And it really makes you think more deeply.

Being a part of ABIM is not only about the assessment, it’s also about having an impact on the guiding of internal medicine training. We collaborate with other societies and look at ways to be innovative. And I think the Longitudinal Knowledge Assessment (LKA®) was one opportunity to do that. I would just say to anyone thinking about joining ABIM that you should come with an open mind. Listen to all the people you’re with. Never make snap decisions. I think that’s something I learned. ABIM does important work. Despite the critiques and all the criticism, I think we can make this something that people really feel has value for them.

Do you have any parting thoughts?

I think my biggest parting thought is just gratitude. It’s gratitude for the opportunity I’ve had to work with the amazing staff from ABIM to develop the leadership that I’ve been able to do with just amazing role models. And that goes from the CEO, to my colleagues on the board and the ABIM staff. And I will say honestly, this has been one of the highlights of my professional career and I will be very sad to leave.