Reflections in Medicine and Medical Education 2014

2014 has been a tumultuous year, especially in medicine.  Frustrations with electronic health record systems, the Ebola virus, reactions to the Ebola virus, response to the new MOC requirements, burnout, and many others all contributed to the complexities that exist in medicine.  In medical education, questions like "what do the milestones really mean?" are common thoughts emanating from educators.  I'm not even touching Entrustable Professional Activities either!

Our school also passed a new conflict of interest policy.  I was privileged to lead this effort in 2014, and, despite unanimous approval of the policy in less than a year, I continue to get more questions "what about my situation?  Is that ok?"

In short, it is a tough time to be in medicine, no doubt.  Increased fear of being sued, decreased reimbursement, more regulatory requirements, and the uncertainty of exactly where medicine is going make for challenging times.

So how do people cope with this?  

Some choose to go "nose to the grindstone" and work harder.

Some decide to "call it quits" and leave medicine.

Some opt to "fight back", through advocacy in the form of blogs saying "enough is enough".

Some take a step back and say "at least I have a job and job security".

Some are put off by the "it's a job" phrasing, opting for "it's a profession, and unfortunately it is slowly eroding".

I know that resiliency is a helpful trait to handle all the changes, but still, I don't have all the answers.  I strongly believe that in the end, what I do matters, to learners, to patients, and to future learners and patients.  What trainees do matters.  What doctors and other healthcare professionals do matters.

That, coupled with blessings of continued good health, allows me a little peace in a hectic world moving at a frenetic pace.  Just try to search for your own similar peace.

Happy Holidays to All!

Alex

Maintenance of Certification and Quality: There Are Two Sides

I had written a previous post on this subject earlier, but with two articles out this week in premier journals (the New England Journal of Medicine  and JAMA), I am seeing some interesting chatter on Twitter from well-respected physicians describing the downsides of Maintenance of Certification, or MOC.  Here are two previously written blogs (#1  and #2) outlining these “downsides”.  It is clear to me how these physicians feel about the MOC process.

There could be many ways to discuss the issue of MOC in this blog.  I will try to focus on simplicity: “for” and “against”, along with literature that highlights each of these arguments.

Arguments challenging the current process of MOC

1.       It takes physician’s time away from direct patient care.

2.       It is a “bureaucratic scam”, due to the fact that it is very costly, with the beneficiaries of monies being the leadership of the Boards comprising the ABMS (American Board of Medical Specialties).  [Interesting that this article is not referenced in PubMed, but can be found through standard non-medical search engines.]

3.       It is out of touch with the current practice of medicine.

4.       It has not been shown to benefit patients or patient care.

Arguments in favor of the MOC process

1.       If not the current ABMS MOC process, then there exists the possibility that other regulatory agencies (such as OSHA) could dictate how physicians should practice (see quote in article by Dr. Robert Wachter). 

2.       There exists a correlation between higher scores on MOC examinations and quality of care. (Article 1 and Article 2).

3.       Physicians who spend the majority of their time in practice, not just “academic types”, validate the content of MOC examinations.

4.       The farther out a physician is from training, the lower is the quality of care provided.  While this seems to be a pretty harsh statement against the “there is no substitute for experience”-argument, the current literature does support this position.

I am sure that there are many other arguments for and against MOC.  This blog is not intended to be a mathematical "weight comparison" of articles on the topic.  My own opinion on this is simple: physicians need to engage in lifelong learning (Article #1 here and Article #2 here), under the “Practice-Based Learning and Improvement” competency.  Whatever the ideal process should be for this, I cannot say with certainty, but I would much rather have those within my own specialty, who also understand educational methodologies, regulate ongoing physician certification, rather than others that are removed from the day-to-day challenges of the current practice of medicine.  The current leaders in my specialties, who dictate the regulations as they currently stand, are the ABIM and the ABP.  This was summarized in my Annals of Internal Medicine letter to the editor earlier in 2012. 

So what do you think about the process of MOC as a way for the ABMS to hold physicians to a standard acceptable to the public?  Is it working well?  If not, what could be improved?

In full disclosure, I am not employed by the ABIM or any of the ABMS boards.  I personally know one member of the ABIM, from his days as a former program director.   I have not written examination questions for the ABIM or the ABP.  I get no royalties from the ABIM, the ABP or the ABMS, and have no stock in these companies or any of their subsidiaries. 

Maintenance of Certification

Board certification as a marker of competence of the medical knowledge necessary in each medical field has been touted for a long time.  Residency programs stress the importance of passing “the boards”, and provide education to residents in the form of didactics that are commonly geared not only to clinical care, but also towards this examination and the skills needed to pass it.

What does it mean to be board certified?  The official term is “Diplomate of the American Board of ___” (depending on one’s specialty).  What it means is that the physician has completed training in her/his area of expertise, and has passed the initial certifying examination (or set of written and oral examinations, for some specialties).  Currently, this certification expires after a certain time period (ten years, for example).

In the past, physicians had to sit for and pass a “recertification” examination, although now the process has changed significantly.  Physicians are now required to demonstrate a valid license to practice medicine, complete an appropriate set of practice questions to demonstrate lifelong learning, pass another certifying examination, and also complete a performance or quality improvement project.  Together, these four parts are known as “Maintenance of Certification”.  An excellent explanation of this process, from the American Board of Pediatrics, is noted here.

There are some physicians who feel that this process to “recertify” is onerous, and not necessary.  There are others who feel it is absolutely essential to demonstrate a minimum standard within the specialty.  I personally fall into this second category.  There are a select few who “grandfathered” in, meaning that their original board certificate was lifelong, thus indicating that they were never required to recertify if they so choose.  This “grandfathering” process is not done anymore in any of the specialties, but there are obviously those who still hold such certificates.

An interesting point-counterpoint as to “should someone who is grandfathered go through maintenance of certification” has been noted.  Those in favor of pushing for everyone to recertify cite this article and others, which showed that those who maintained their certification provided improved processes of care for certain populations than those who did not maintain the certification. 

The American Board of Medical Specialties is soon making public the information around whether a diplomate is undergoing or has undergone maintenance of certification.   I applaud this reason, as I believe that patients deserve to know whether their physician has or has not met this “minimum standard”.  Others do not feel the same, citing multiple reasons why maintenance of certification is onerous, costly, and takes time away from direct patient care.

What do you think?  Should maintenance of certification be public information for all to see, or not?  Should we push physicians who have not maintained their certifications to do so, or to not be permitted to practice their craft?