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