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. 

Twitter within Academic Medicine

I have had the opportunity to do several presentations about Social Media in Medicine and Medical Education.  I am currently set to give a Grand Rounds for Neurosciences at the IU School of Medicine in just a few minutes at the hashtag #IUNeuroscienceGR, with audience members in neurology, neurosurgery, physical medicine and rehabilitation, and psychiatry.  We will be having a live Twitter feed broadcast to the audience.  I am excited to provide information about this topic to this multidisciplinary audience, but even more interested in learning from the audience about how Twitter is perceived within the neurosciences sphere of academic medicine.

A recent article about the use of Twitter at medical conferences highlights this phenomenon.  In addition, it was great to present at the Med2.0 conference back in September 2012 about our experience with Twitter at Grand Rounds within pediatrics at the IUSM.  I am aware of others beginning to delve into this area, including Eastern Carolina University within their Department of Medicine residency program.  Recently, one of our graduates, Dr. Joel Topf, now a nephrologist in the Detroit area, presented a similar grand rounds on the use of social media within health care.

In addition, two days from now, I have the privilege of participating in a Tweet Chat on the topic of depression, to take place on 12/14/12, at 3 pm EST, under the hashtag #IUHedu , with Dr. Joanna Chambers from our Department of Psychiatry.

It is exciting to see Twitter being used as a tool to disseminate information to health care providers and also to patients, and also that others are seeing the impact of this on how physicians and other health care professionals learn.  The more that we can get the word out about the power of sharing healthcare information in this venue, the better.  Now we just need to demonstrate improved patient care outcomes from it--that's the hard part!

Reflections on #AAMC12 - Social Media in Medical Education

It has been a very busy few weeks, but certainly one filled with learning, teaching, disseminating, and advocating.  The American Association of Medical Colleges meeting finished last week, and this blog is my attempt at some brief reflections after recovering from the onslaught of email after the meeting, followed by some great interviewing for the residency program.

Given my interest in social medicine within medicine and, specifically, medical education, it was a phenomenal opportunity to hear what others are doing, what others are thinking about, and how we can overcome challenges and turn them into opportunities.  During one of the plenary sessions, I had the privilege of meeting and tweeting with Dr. Bryan Vartabedian, who blogs and tweets about medicine and social media.

The plenary speakers were just wonderful, and provided provocative, stimulating ideas for the audiences.  I tweeted comments from a few of these during the meeting.

I attended great workshops on feedback and quality and safety within CME.  I facilitated a session on Research in Medical Education (RIME) session on Continuing Professional Development with some very eloquent speakers, and learned much of what others are doing to change behavior and improve learning.  I also heard from Dr. Kendall Ho from the University of British Columbia about his work in e-Health and m-Health, considering what is currently available in the current generation, as well as what may be the reality in the very near future. 

I had the great privilege of facilitating a workshop on Social Media in Medicine with my colleagues Dr. Ryan Madanick and Dr. Terry Kind.  Both of them were gracious enough to come to this meeting and provide their experiences to the audience.  Many faculty came to hear about this topic, and provided stimulating conversation about the challenges and opportunities.  We discussed professionalism, competencies, the meaningful use of social media for physicians, and specifically, for medical educators, and we had a challenging goal of teaching participants how to use Twitter.  Several of them were able to do so by the end of the session, and indeed sent out their first tweets.  This was great, and we felt that we accomplished our goal.  We also learned that it was hard to answer all of the questions while trying to get through the basics of Twitter, explaining hashtags, DMs, mentions, and the like.

In the very last session, I was able to hear faculty from Albert Einstein College of Medicine (Martha Grayson and Liz Kitsis) and Kathy Chretien from George Washington University speak about professionalism within social media, as well as a robust discussion on doing faculty development on social media.  Einstein received a Macy Foundation grant  to study this topic, and have embarked on a wonderful journey.

Also, I was able to meet Kelly Stazyk from the AAMC, who is integrally involved in the intersection of social media with career advising for medical students.  I also had a chance to spend a half day meeting with a group from the AAMC reviewing implementation science and how it links with medical education.   Despite the fact that very few of us knew each other, we came together to discuss, critique, and help each other in writings on implementation science.  What a collaborative group!

Since I have been back, it has been a time to reflect on what I learned, what I can take home and implement myself into my own work, and how we can optimize teaching of medical students, residents and faculty.

So how often do you really reflect on what you have learned and what you can do differently when you return from a conference?  I think it is an integral part of being a professional, even when many things await you upon return.  A time for a commitment to change has never been more important.

Teaching, Learning, Advocacy

I am currently in San Francisco at the Association of American Medical Colleges (AAMC) meeting.  This is a meeting of medical educators, and is a wonderful conference for my personal learning plan.  I have truly enjoyed my time, learning a ton about the field of Continuing Medical Education, catching up with old friends, and meeting many new friends.

I have had the opportunity to be on a panel, hearing Dr. Kendall Ho talk about e-health, what is here now, and what may come in the future.  I also had the great privilege of moderating the Research in Medical Education (RIME) session on Continuing Professional Development, with provocative speakers on a variety of subjects.  I had dinner with the leadership of the Indiana University School of Medicine yesterday, meeting other new medical students who are the future of medicine.

Today, I couldn’t be more excited to give a workshop with my colleagues Dr. Terry Kind from George Washington University, and Dr. Ryan Madanick from the University of North Carolina, on the topic of Social Media for medical educators.

Our message: we need to be in the digital space, to connect and communicate with patients, with learners, and with each other.  To teach, to learn, to advocate.  These are critical components of being a health care provider, and something I am proud to talk about.

To teach, to learn, to advocate.  As today is election day, and many will exercise their right to decide the future leadership of the United States, let us be reminded about the importance of advocacy, teaching and learning.  It is why many of us are here at this meeting, and how we re-energize our bases to go back to our institutions and care for patients to the best of our abilities.

Med2.0 (#Med2) -- An Annotated List of Blogs from Med2.0

It has been almost a week since Med2.0.  For those that don’t know, Med2.0 is a conference about using technology in medicine to further and improve patient care and education.  This was my first time attending this conference.  What a wonderful experience!  I had the opportunity to meet some of my physician colleagues whom I had previously not met in real life, but that I knew through Twitter.  In addition, there were others with expertise in other areas from whom I learned so much.

Since the meeting ended, many have written blogs about their experience.  Below is just a smattering of blogs written by a few attendees, reflecting on the awesome experience.

Specific Situations

Hallway Conversations. This blog from @kidney_boy describes the evolution of an educational resource tool, Dynamed, which occurred as a result of a hallway conversation.

Blogging: The “A-HA” Moment about Online Histories.  I wrote this blog halfway through the conference, after reflecting on a panel session on patient blogging and on the importance of asking patients about how they use the internet to search for health information.

Healthcare Needs Social Media.  This blog, by a well-known blogger and pediatrician, Dr. Claire McCarthy, describes the importance of relationships and communication in medicine and how social media aids in improving these.

Thoughts on QR Codes. This blog by @kidney_boy describes how placing QR codes into slide presentations worked well (and not so well) for participants.

Online communities This blog, by @colleen_young, describes how communities through the internet can support individual participants.  Colleen also won an award at the meeting for her work in this arena.  Congrats, Colleen!

At the end

SketchNotes: This blog, by @cassiemc , includes a wonderful pictorial sketch that is worth its weight in gold!

E-Patient  This summary, from Joe Graedon from @Peoplespharmacy summarizes take home points from Day#2 of the conference, highlighting the Society for Participatory Medicine.

General Reflections on the Conference

Student impressions: This blog by @HodaPharm , describes Hoda’s first-time experience at the conference, with reflections on many different presentations.

Gut Check:  This blog, by @RyanMadanickMD, a colleague of mine interested in the intersection of medical education and Twitter, summarizes how he learned from people with entirely different interests.

Summary of several individual sessions. This is a wonderful summary of many sessions attended by @kidney_boy, who blogged this piece for the AJKD at @eJKD .

I am sure that more will blog about their experiences, and hope that this summary provides helpful information for those there, as well as those who were not able to attend.  Please post any comments.  Thanks.

Alex Djuricich

The "A-HA Moment" about the OH ; Blogging

I am currently enjoying my time at the Med2.0 conference in Boston.  This great group of folks  is coming together to learn and disseminate how to leverage the power of emerging technologies to help improve patient care.  It is simply eye-opening to learn and understand some things coming down the pike which will help health care professionals care for patients in the future.

I attended a session on Blogging by patients which has me thinking.  One of the points that was brought home was that patients with chronic illnesses are blogging about their experiences with having certain health conditions, and that blogging has a powerful effect on how they self-manage their illnesses.  To me, this is VERY powerful.

In another session, a focus was on how many patients are searching for online information about an illness.  I have said this many times, and will say it again here.  The medical community has a duty and an obligation to dispel mis-information which is unfortunately so prevalent on the internet, and to provide simple, truthful, meaningful messages that patients can understand.  What better way to do this than through the use of social media.

One way to know about whether patients are looking online, or posting online through a blog, is to take on online history, or OH.  We should ask patients whether they do this, just like we should take a social history when we first meet them.  This can help us learn about how patients deal with their illness, and how we might be able to best help them.

This is my "A-HA" moment about the OH.  If you are a health care provider, you should consider the importance of the OH: it will be your A-HA moment too, and it will better help you get to know your patient.  Isn't that what the Patient-Doctor Communication is all about, after all?

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!