This is a story about a new medical intervention. It’s an important story because it affects all doctors—and therefore all patients.
1. It’s expensive. Of course.
2. There is no credible evidence that it works. But its marketing is aggressive.
3. The overwhelming majority of physicians disapprove of it.
4. Cheaper alternatives exist.
5. The company that makes the treatment is rich and influential.
It’s hard to believe something like this could be approved in the United States. But not only is this new intervention approved; it is being forced on physicians—and patients—by eminence-based fiat.
The treatment is the new board certification process, called maintenance of certification or MOC.
In the past, board certification was a term associated with competence. My doctor is “board certified.” Hospital privileges and in some cases licensure turned on being board certified.
Getting board certified meant passing a major test at the end of training. That used to be it. Then the board, which turns out to be a private non-profit organization run by mostly non-practicing doctor-executives, decided that medicine was changing enough to warrant re-examination every ten years. Few people objected. Doctors took time away, went to courses, and re-certified every decade.
Things changed. The American Board of Internal Medicine upped the ante. Closed-book testing every decade was not enough. ABIM came up with something called MOC—maintenance of certification, which includes onerous practice improvement modules. The very term practice improvement speaks to the hubris and nonsense: how does a group of executives who don’t take call or see patients regularly, come up with modules to tell real doctors how to do their job? With patient surveys? Really?
Dr. Paul Teirstein is a cardiologist in San Diego, California. He leads the anti-MOC movement. Yesterday, the New England Journal of Medicine published his essay, Boarded to Death — Why Maintenance of Certification Is Bad for Doctors and Patients. It’s available for free. I’d recommend reading it. It’s well written and persuasive.
Here is why this is an important topic. When you walk on an airplane and look left into the cockpit, there are fellow human beings that you hope are well-trained and competent. You depend on human pilots, just as you do doctors. What if you learned a large business enterprise of non-pilots was usurping pilot training? What if pilot training became onerous and distracting to the job at hand?
This is what may be happening to physician training. I am a real doctor who cares for real patients. I believe that caregiver distraction is one of the major dangers to patient safety. I see it every day. Doctor and nurses have become so inundated with the nonsense of medicine that important things, basic things, are being missed.
We would not stand for our pilots being distracted with unproven training methods. It’s time we felt the same way about our caregivers.
The ABIM has overreached. They have hoisted on physicians an unproven anachronistic brand of medical education.
Teirstein says it well:
Much of the U.S. health care system is now focused on value, and physicians are working hard to provide better patient care at lower cost. MOC provides the opposite — an activity with no proven efficacy, at a high cost.
The world is a different place now. I can look up medical facts in seconds. I used smartphone medical apps twice yesterday in the exam room. The digital world we work in is not closed book. Caregiver distraction, not MRSA or Influenza, are the major threats to patient safety. You would be safer if your doctor was focused on you, not spreadsheets, modules and white screens.
Physicians who actually practice medicine and physicians who administer medicine have grown apart. Working in the clinic and hospital is much different from work in the boardroom or cubicle.
Real doctors are a prideful and competitive lot. We care about our skills. Competence is the peg on which we hang much of our self-esteem. We want a meritocracy.
Our morale is low. This is in great part because of the things that impede our ability to care for people. Board certification in its current form is yet another impediment to patient care.
JMM
Dr. Wes says
John-
Couldn’t agree more. But there is much more to the ABIM story that remain.
Requests for audited financials by a main stream media were not honored by the ABIM in September of 2014. The request has reached the Pennylvania governor’s office. Hopefully a full disclosure will be forthcoming for practicing physicians and the public deserve a full accounting of the dealings of our regulators.
Dr John says
Thanks Wes. To my readers, Wes Fisher has been, and is, a tireless leader in the anti-MOC movement. He stands up for the working-stiff doctor. Thanks friend.
Henry says
I just watched my daughter and son-in-law (who are double and tripled boarded, “tops” in their fields, and the parents of two very involved children) go through this process. Not only is it a distraction from patient care, it also substantially encroaches on family time for two parents whose time is already stretched by the demands of busy private (non-hospital owned) practices. I’m a clinical pharmacist who has had direct patient care responsibilities since the 1970s and fully understand how the distractions from patient care and administrative obstacles can all but reverse the passion and commitment to our patients… and it is getting worse on several fronts!!
Dr John says
Thanks for saying Henry.
pgyx says
Once again I want to repeatedly scream “AMEN!!” from the rooftops after reading one of your posts. But that would make me seem like a crazy person so I’ll stick with sharing via e-mail and Facebook.
My fiancé is triple-boarded (main specialty + 2 subspecialties) and working on a 4th certification. I just took my first board certification exam NOT in internal medicine, but in a specialty that does use MOC.
My exam was a joke — a twisted combination of questions with answers taken from obscure single studies and beyond-easy questions that every person in my specialty should be able to answer during medical school or by end of first year residency. Very little of the exam addressed topics necessary for daily practice or even for rarely seen disorders.
I scored highly, so I’m bitter not because I disliked my score, but because of the major time and expense doctors take to prepare for this test which utterly fails in its stated mission to separate the incompetent from the competent docs. This makes it seem like a money-making racket by the certifying organization.
Dr John says
I think this will be my problem next year when I re-certify. I worry that I’ll want to question the standard answers. I’ve spent the last few years studying the evidence, and one thing that is clear: guidelines and prevailing opinion are often based on shaky evidence. There was a couple of pages in Hitchens’ memoir describing the time when he became a citizen and studied for the US citizenship exam. It was funny because, as he pointed out, the truly right answer was often the wrong answer.
pgyx says
I would like to quantify what percentage of guidelines have changed in the past 10 years. It would take time, but it seems doable if it has not already been done. I’m a new specialist but read a lot about many fields in medicine because I find it all fascinating. I have been following literature “Cliff notes” in the form of Journal Watch newsletters, Medscape, and other news sites since 2006. Based on this, I can say that the guidelines upheld as truth frequently change in response to new knowledge or old knowledge revisited.
Guidelines are made by panels of humans and based on imperfect research — how could they possibly be the “right” answer for 100% of patients 100% of the time? Sadly, if there is a bad outcome then the physician is legally at risk if he did not follow guidelines, even if doing so would likely have resulted in a similarly poor or worse outcome. It’s implied that following guidelines offers legal protection against litigation, even if guideline-based treatment results in over-testing, over-treatment, or even a bad outcome .
Why have we dis-incentivized good clinical judgment in favor of checkbox medicine? As their name suggests, guidelines should be a starting point to *guide* our judgment, not bind us to follow them regardless of evidence that might lead us to make other, more appropriate clinical decisions.
Joe says
Some observations from an outsider.
(1) It’s nice to see docs get excited and united about something. It would be nice(r) if the issue was defensive medicine, or hospital billing practices, or questionable pharma patent extensions (XR version, anyone?), but it is encouraging to see the profession rally around something.
(2) Absence of evidence is not evidence of absence. I’m sure that many parroting the ‘no proven benefit to MOC’ line understand this, but it would be a shame for an otherwise worthy cause sink under the weight of faulty logic. ‘You can’t prove it – where’s your large randomized double-blind study?’ is often the last gasp of a group that wants to deny a real problem (ie. tobacco, coal dust, sugary soda). I’d be careful about overusing that argument.
(3) Some of your colleagues have aged out of or drifted away from competence, and some of them are causing harm to patients. You know this to be true, even if it’s a small number and MOC is a terrible way to deal with them. Right or wrong, the profession has a reputation for not dealing with this issue, and we’re not hearing any possible solutions. That’s a problem.
(4) Many professions have been suffering from the same assault on professional autonomy for 10+ years now. I don’t say this to belittle the problem or excuse the issue. I just add this observation to help you understand why your non-doc friends and patients shrug their shoulders and change the subject when you bring up the issue. The ship sailed for many professions 10+ years ago.
Best of luck with the fight.
Dr John says
These are great comments. Thank you Joe.
Ofeigur T. Thorgeirsson says
Just to extend, and bend this discussion slightly. What about medical conferences? – No proven benefit in improving patient care, and thus no value in itself, or what? Should we stop attending conferences? I am told that about 7.000 docs are transported every day around the globe attending conferences/professional meetings. Just think about the environmental impact of this the useless activity. So, how about an anti-conference movement?
Dr John says
OTT, Thx for commenting. I think about that topic often. The difference with mefical conferences is that we attend them, or not, based on choice. Board certification has (had) become a requirement to earn a living.