Both hate tests and homework, but neither can avoid them; controversy surrounding the nature, frequency and value of testing, and homework for both grade school students and physicians reverberates from the home, classrooms, and physicians’ examining rooms through local and state governments to all 3 branches of the Federal government; we demand high-quality education for our children and high-quality health care for all.

Free elementary education and basic health care are universal human rights. Subjects and all sorts of organizations—families, tribes, religious and charitable institutions, business enterprises, and governmental units—have attempted to secure and protect these rights of education and health care since the very beginning of humankind. Indeed, the ability to develop, preserve, and transmit knowledge using written language differentiates homo sapiens sapiens from other sentient beings. Science would not exist if children did not learn the “3 R’s” and medicine would not be modern without regular testing to prove the worth of new therapeutic procedures and pharmaceuticals and to affirm the competence of our medical practitioners.

In a society that values few things more than the education of its children and the health of its citizens, a society that wants and deserves objective measures of the performance of its investments to support its teachers and physicians in their efforts to fulfill these 2 fundamental human needs, tests are here to stay. Testing, and preparatory coaching, review courses, and practicing for testing, begins for some in pre-kindergarten, so that a child may gain admission to the “right” kindergarten, extending through elementary and high school to college and medical school entrance examinations, now following us through decades of clinical practice, with mandates for repeated periodic formal testing and other compulsory exercises to maintain board certification. Grade school students and physicians take a lot of tests.

In testing as with many useful things, too much of a good thing can lead to bad outcomes. Too much food leads to obesity; too much medicine can turn it into poison; too much testing detracts from the time teachers have to teach and physicians have to spend with patients. Many elementary teachers and parents and practicing physicians think we have pushed testing beyond its useful limits in requiring that multiple, repeated high-stakes tests be administered to our young children, interfering with, rather than promoting learning, and to busy physicians, taking too much valuable time away from the actual care of patients, without proof that testing, test preparation courses, homework, and formal programs for maintenance of certification actually lead to better outcomes, better educated students, or healthier patients.

Outraged that some high school graduates could not read, write, or perform simple mathematical exercises, President George W. Bush signed into law “No Child Left Behind” requiring States to develop standards for the basic skills expected at various grade levels to qualify for Federal school funding. The National Governors’ Association introduced Common Core Standards Initiative, measures… robust and relevant to the real world, reflecting the knowledge and skills that our young people need for success in college and careers, enabling American students to compete effectively in the global economy. Deployment included frequent standardized testing, with penalties for underperforming students and their teachers, principals, and school systems, focusing classroom time on “teaching to the test,” without evidence that frequent testing actually improved education. Parents of many children “opted out” of the testing process, just as many physicians are “opting out” of board recertification. School choice, using public funds for private school tuition, mirrors proposals to privatize Medicare, issuing vouchers to patients to spend for health care as they choose, rather than the government taking responsibility for the quality of education or health care.

Two reports from the Institute of Medicine, To Err is Human and Crossing the Quality Chasm , heralded our current efforts to measure and improve the processes of health care, emphasizing safe, efficient, reliable, guideline-validated care. Evidence is accumulating that, although rewarding and punishing individual physicians have limited value, measuring the enterprise-wide application of principles outlined by the Institute of Medicine does improve patient outcomes. The Affordable Care Act and the Medicare Access and SCHIP Reauthorization Act, which replaced the sustainable growth rate, both use detailed performance metrics to control costs by bundling payments and paying value rather than using the traditional fee-for-service model.

Through our professional membership organization, the American College of Cardiology, we have created evidence-based guidelines, appropriate use criteria, and performance measures to improve patient care, and we contribute to “real-life” registries and databases to document patient responses and the effects of care in the community setting. We regularly participate in a multitude of continuing education opportunities and quality improvement exercises. We believe in the potential power of the electronic health record to help us better communicate, follow proved care protocols, and avoid errors. We comply with payer rules and pre-certification rituals. We attend team meetings, budget meetings, quality assurance meetings, and more meetings. We then have time left to spend with our patients at the bedside and in our offices.

Then the American Board of Internal Medicine (ABIM) announced that our “lifetime” board certification henceforth is valid for only 10 years, and we must participate in board-approved continuous “maintenance of certification” programs and activities. The ABIM, emphasizing its independence from professional membership organizations, declared “Thus, the true constituency of the certification boards is the public.” Among its many activities, the ABIM collaborates with Consumer Reports to directly influence patients with its Choosing Wisely product.

The American College of Cardiology regularly issues documents defining in considerable detail (185 pages) the specific competencies expected to be gained in both general cardiology and subspecialty cardiology fellowship training programs. A dozen distinct certifying examinations, many independent of the ABIM, have been developed to verify competency in various aspects of cardiology that are offered to physicians as they finish their fellowship training in cardiovascular disease, costing thousands of dollars in initial fees followed by yearly fees for maintenance of certification, and the opportunity to take special preparatory courses to assist in passing these examinations, with additional cost. Young physicians paying off medical school debt and older cardiologists, looking to retirement, are especially sensitive to these costs. Some believe ABIM’s movement into continuing medical education was based in part on visions of expanded influence and additional revenue rather than relevant educational expertise or public need.

It is our professional responsibility to participate in the testing process at all levels, helping construct meaningful tests, taking tests, constantly refining tests, and acting on the results of testing to improve our processes of education and health care. The profession itself must define what it takes to be a member of the profession, not some outside organization. Cardiology has evolved greatly since ABIM was formed, just as internal medicine itself has also changed to address growing needs for primary care and nonorgan-based specialty care, including hospitalists, intensivists, and geriatricians and traditional internal medicine specialists. Cardiology relates not only to all these but also to noninternal medicine specialists in surgery and radiology. The time has come for cardiologists to acknowledge that our professional home is no longer internal medicine but rather form our own distinct American Board of Cardiology.