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. 

Computers in Patient Care

I’d like to start this blog with a comment that I am a strong proponent of using emerging technologies to help improve patient care.  I believe in the power of mobile computers to help us with patient care.  I believe that we should use technology to augment the care we provide, not replace it.  However, I had an interesting hallway conversation with one of my fellow attendings earlier this week, which caused me to reflect on this topic, and ultimately write this.

Electronic medical records are touted to help improve efficiency, to be able to collect information to help us improve the care we provide, as well as other positives that are well-described.  The government is even providing incentives to health care systems and physician practices for “Meaningful Use”.  I have believed in the power of computerized physician order entry, or CPOE, for a while, having had it at one of our training hospitals when I was training in 1994 – 1998.

However, the discussion I had the other day made me really think.  Trainees (and attendings, as well; we are not any different) spend so much of their day on the computer, and this appears to be coming at the expense of face-to-face time with the patients.  This article suggests that direct time with patients is not ideal for residents on call, and that much of the time on call is spent in front of a computer.  12% of the time was spent in direct patient care.  12%!  I am concerned about this, and I bet patients would also have similar concerns.

This article, with a drawing by a child highlighting what they see with regards to doctors and computers, pretty much sums it up: even children are noticing that doctors are “tethered” to the computer.  This has to change! 

I do believe that we can fix this.  It starts with acknowledging this “elephant in the room” (or, more aptly, the “computer in the room”).  I am currently spending a few weeks on the inpatient service at our county hospital, and had the chance to discuss this with our medical students.  We made sure that rounds on patients including going to see the patients and interact at the bedside, not just exclusively sitting around a table discussing the patients.  We discussed motivational interviewing (and demonstrated it) and getting to know patients as people.  We reflected on why all of the students went into medicine, and none said “to type information into a computer.” “Stop and smell the roses” was the take-home message of the day, the roses being, among other things, time with patients.

Please, please make sure that staring into a screen doesn’t replace sitting at a patient’s bedside.  Please make sure to talk to your patients, to look them in the eye, to ask them what they think, and to answer their questions.  It will help the patients, and it will promote the humanism that is at the heart of the patient-physician relationship.  Yes, computers and mobile tablets can help us care for patients, but in my opinion, there is a bond between a patient and a physician which should never be replaced by a computer.  Let’s not break that bond!

Medical Administrators – Should They Still Care For Patients?

I have been relatively absent from social media for the past week or so.  I have been doing inpatient duties on a general medicine service, and really enjoy working with medical students, interns, residents, pharmacists, and inpatient floor nurses.  It has been a wonderful opportunity to experience the day-to-day activities involved in hospital medicine, and of course, to see and care for patients.

The time on the inpatient service is demanding, both physically and emotionally.  Managing ill patients, long hours caring for complex patients and updating their families leave little time for my other duties in overseeing a CME office and a residency program.  I am trying my best to juggle all of these duties, but for now, the patient care priorities do come first.

As I was arriving one day this week, I saw the chair of another department coming in, and mentioned that I was on service doing inpatient work.  He remarked: “So good to hear that you are continuing this great work, and that you are still actively involved in patient care.  Keep it up!”  That made my day.

So I have been pondering this: should physicians who have major administrative duties and oversee programs, and thus have major time devoted to such activities, still care for patients?  Should they still remain clinically active in order to have “street credibility” with their mostly clinical colleagues? 

I think the answer to this is “yes”.  As busy as it is, I still believe that it keeps me fresh.  It allows me the opportunity to reflect on why I went into medicine in the first place.  It allows me to still remember what it is like to talk with a worried family member about a loved one, to see the gradual changes when a patient improves from hospital admission to discharge.  It allows me to also see the trainees doing what we want them to do: learn to care for patients.

The more I become involved in overseeing administrative programs, the less time I can devote to direct patient care.  But I still really enjoy doing the day-to-day patient care, and working with trainees as they learn the art and science of medicine.  I still haven’t forgotten the old adage by Francis Peabody: “The secret in the care of the patient is in caring for the patient.”