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MOC Ins and Outs: Interview with ABIM Chair Suresh Nair, MD
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Released: June 28, 2024

John Marshall
John Marshall, MD
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MOC Ins and Outs: Interview with ABIM Chair Suresh Nair, MD [00:20:53]

So as promised, I have a world's expert on how we get board certified in oncology, and we're lucky enough that Dr. Suresh Nair has agreed to spend a little bit of time with us. Now, if you don't know who he is, you should. He's an important guy. He was the physician in chief at the Lehigh Valley Health Network and Pennsylvania, just north of where I'm sitting. When I look through his resume, the guy likes Pennsylvania for sure. He's been from the east side to the west side with all of his training, and he's trained in some of the best places in the world, and he has dedicated himself to building just an incredible practice there. Part of his busy life as well has been to be involved in the ABIM. The process and certifying us all for our licensure. He's an oncologist, and in 2022, if my numbers are right, he actually took on the leadership role in the ABIM structure over medical oncology and having somebody like that to give us a few minutes is really special.

So, Suresh, let me first say thank you and welcome.

Suresh G. Nair, MD: John, I feel honored. Thank you so much. And to be, as I said, being with a legendary oncologist who I respect highly. Thank you.

John Marshall, MD: Well, I get in trouble a lot, as you know, so hopefully we'll keep each other out of trouble on this one. Because for the first time, this was number 4 for me on going around on, on a, on a getting recertified and I thought I had been doing it right. But it was December 15th of 2023 that I realized that I wasn't doing it right. My CMEs weren't MOCs, for example. And so, I had to very quickly figure out how I was going to do everything by the deadline so that I maintain my board certification. So, I had a panic moment here as a senior doc.

I wanted to talk a little bit about my choice, for example, to take the test. Sitting down formally number two pencils, no longer, versus the orderly tests as a way to maintain and just to get your high level that those of us in oncology are doing this. Who's doing what? Everybody, or is it a gemish all over the place?

Suresh G. Nair, MD: I've been on the ABIM med onc board for the last five years, and as you said, the last two years as the chair. So, I was there as the board responded to diplomats that sometimes the 10-year exam took time out of practice to go to courses, and it was very stressful. And especially I feel like in oncology where things are changing, you know, by the week, by the day for some of the questions. I know you probably had the same experience, the areas that I spent a lot of time in like melanoma, kidney, I was getting some of the questions wrong because the test questions were written five years ago. And they have to go through verification and standardization and all of that. So, the longitudinal knowledge assessment (LKA) was launched. We have about 14,000 board certified oncologists, 85 percent of them are engaged in the LKA, once they become eligible for it, and about 15 percent are choosing to do the 10-year. I also did the 10-year exam about two years ago. I've decided to do the 10-year in oncology and I'm doing the LKA in hematology and in internal medicine. I don't practice much hematology anymore, but I was originally boarded in that at the University of Pittsburgh, and I thought I would try it out, and it's been a bit humbling, but I'm gradually—I have a barely passing score and continue to improve in that. We are finding that, we're continuing to listen to the diplomats and we're looking at making some changes because, I too, the week of Christmas and the new year was reading a lot of up to date to get my MOC credits because I too had a deficit and, you know, I didn't have the hundred that was needed and So at the board level, we're looking at giving—there is credit for the LKA. You do get MOC credits for that, which I think more and more a lot of diplomats are going to, but we're working with ASCO, working with thought leaders in all facets of CME and maintenance of certification credits.

John Marshall, MD: Yeah, no, I think that's really great. And it's, it's, you're having to live it yourself. You know what it feels like when all of us are out there, because you and I are pretty specialized. A lot of generalists might do better on some things, but still need the props you know, resources and source things to help with the questions. When I first started, I did really badly on the first 30.

I have to share with you that the four minutes was stressful to me. I kept watching. I wasn't. very good actually at looking things up. And as I've done this now for a year or more, I actually realized that I've gotten better at looking things up. Now what I'm not sure of is, is that making me a better doctor or not? I mean, I can find the answer what's being asked, but I don't necessarily have any familiarity with What I'm talking about so I can match the words up to get the right answer But how much feedback have you had in that way that people because I do feel smarter I actually used to dread the time when I was doing The questions to now sort of looking forward to it because I do leave knowing more than I did before. What's been the feedback so far to you at your end?

Suresh G. Nair, MD: The feedback's been very similar to you John in that the four minutes is stressful. There is a time bank that you can click on for extra time for certain questions. I, I too, on, on the hematology, which I don't practice as much and I'm doing it for pure learning I didn't do that well in the first two, and now I've been engaged in about two years and keep getting better.

One of the things it's made me do is areas that I feel weak, and I do when I have some time read up on that area a little bit. And I'm noticing my scores going up and getting expertise. We are, you know, kind of wrestling with certification versus education. So, it's not a pure education tool. When we go to ASCO and we sit at the education sessions, that's a pure education tool. This is also a summative assessment, and there's a lot of science at ABIM. I've been very impressed with the test gurus there. There's a lot of science that basically about 96 percent of us end up being certified, but it is stressful to some degree. But I think all of us believe in lifelong learning. And there is, there is some science that when, when the test has some stakes. We actually learn at a higher pace.

John Marshall, MD: No question. My juices go up on when I'm doing those questions. No, no, I totally they do. And, and I believe I take away things that I wouldn't normally have ever learned if I hadn't come across the question.

Let me come back to the, you know, you miss questions, I miss questions, but in our own field, right? So, I'm getting the leukemia questions right, but I missed, there was a question the other day, where it was a resection of a colon met in the liver, and the question was, do you give chemo afterwards? Well, I happen to know there is zero literature to tell you what to do one way or the other. And when I got the answer wrong because I said to observe the patient and done in the subtext was the reference was NCCN guidelines. So, I went to the NCCN guidelines and saw that said, well, consider this. And so of course, you know, you know too much, right? And so, it's a frustrating moment. How do I miss that question? When I know the literature there and you and I talked a little bit before about How does the ABIM keep up to date? Where are the sources of the questions and that sort of thing?

Suresh G. Nair, MD: So, so we have a test writing committee and a test approval committee, and our board has given feedback for instance in the LKA, okay, there's 30 questions. There's usually at least one or two that the standard of care has changed, even if the question was written, you know, two years ago. I think a clear case would be in melanoma at the plenary, the neoadjuvant change from pembro to, you know, ipi/nivo now the two doses and our, our, we have a, you know, there, there's been test questions that, that If you do what we heard at ASCO, what's in the New England Journal, you probably could get it wrong. So, so one of the, one of the suggestions at our last board meeting was to have a group of experts. Literally, the, the, the week of go live of LKA go through with it with the fine-tooth comb, because it is very frustrating to diplomats.

John Marshall, MD: But I was thinking to us in my head was like, could you put the date up there? Because I remember we were talking about. You know, if I go on a Google search for something, and if I find an answer I like, but it's an older answer, it might not still be correct, but it's what I was looking for. And so, I don't keep looking. I'm done. I validated what I thought I knew, and then I move on. And, and so, as you say, we're, this is assessing a moving target. So, there is a time, but I think your strategy is perfect. It's just making sure that folks, Have a good look.

That still wouldn't have solved my problem.

Suresh G. Nair, MD: No, and we acknowledge that there's just some bad questions. That that question you were you were right, you know, based on the literature based on studies. And NCCN sometimes it's just more opinion rather than studies. And so, unfortunately, there are on the board, you know, so they are looking continuing to look for more test writers. We are starting to get a good number of applicants. And then what one other important direction that the board is going and based on listening to the ASCO survey of the diplomats is to tailor the exam so that 70 percent of the exam will be general content, 30%. We can't hit every narrow specialty, but the major specialties that we have that physicians in the future could say, I specialize in GI, or I specialize in lung, and so, so it can be more tailored to them. Because this is a summative assessment and the science has to be intact, right now we're working on what's called practice profiles and kind of focused assessment and we'll be having the fall meeting where our committee will present a lot of stuff to us.

We have Furman McDonald is the new CEO and president of ABIM. You know, had a distinguished career at Mayo Clinic was at Penn and really is, is a strong listener and I heard his vision at the ABIM Council last week. There was always this feeling the board was a bit tone-deaf to the diplomats and I, I see that changing. I'm a practicing community oncologist who has been lucky enough to have partnerships and stay involved in NCI trials. I'm supposed to be 40 percent clinical, but I ended up being 80 percent clinical in my 40 percent time. So, so I hope I bring the practicing physician perspective to the board. The board has been receptive and sometimes it does seem like it’s turning a plane around. Because they have to keep the science and the validity that the board certification means, you know, that that it means something to the public. One of the things we want to do is to celebrate maintenance of certification but continue to evolve.

And one of the areas we're grappling with now is the, you know, quick adoption of AI. Now Siri soon going to have AI on our phones you know, pretty much any, any Google search, you know, there's an AI running in the background. We know we can't run away from societal innovation. So, we just need to continue to see, you know, what's the most important thing to try to test. And more and more we're actually finding, it goes back to John, how you started, I think trust and being able to trust your physician because patients are going to be confused, there's going to be misinformation, there's going to be a lot of things. So how do, how do we test for, you know you know, trust and, and, and the things that makes a human physician different from a, from a robot.

John Marshall, MD: Totally right. I'll be quick, but the AI thing you mentioned, there was some complicated gene in one of the questions and I, instead of typing it, I tried to swipe and copy it and this alarm went off and it basically says, if you do that one more time, we're going to do something bad to you. So, I haven't done it again. Okay. But anyway, you have put some checks and balances on the ability to just cut and paste that question over and put it in AI and see what the answer is. But listen, I know you've had a busy day already. And you're giving us extra time on short notice to talk about a really important question about how do we keep up to speed and you are the sort of overseer of truth in many ways. And, like you. I am proud of my certification, and I am proud to be part of that club. We were all worked very hard to get the 1st one, and so we should continue to maintain that. And I think it's great to hear how both receptive you are, but at the same time, holding our feet to the fire to make sure that we're providing the public with a trusted human on the other side who knows what they're talking about and knows when they don't know what they're talking about. Maybe more importantly and knows how to figure it out for the patient in front of us.

So, Suresh, thank you so much for this. And good luck as you continue in your leadership role.

Suresh G. Nair, MD: John, I really appreciate it thank you so much. All right. Thank you.

John Marshall, MD: Thank you all for joining us for episode three of Oncology Update, where we focused on the whole concept of how do we stay up to date. I'll see you in a couple of weeks for episode four.