One Small Step For Physician Autonomy

Physicians have been oppressed in the United States for the past 30 years - nearly the entire length of my career. That is not rhetoric. It is a fact. The oppression has occurred at the level of federal and state governments and eventually the businesses that those governments actually support.  A lot of it is documented on this blog and I am not going to repeat it here.  The most recent twist on that oppression has been in the form of maintenance of certification (MOC) actively promoted by the American Board of Medical Specialties (ABMS).  All medical specialty organizations in the United States are members of the ABMS and are forced to abide by its rules.  Some specialty organizations  started their own MOC that did not involve ABMS procedures and they were told they had to all go through the same process.  That process involves testing and intrusive measures into a physicians practice.  It is a major departure away from life-long learning that physicians aspire to and use to shape their individual practices.

The move to MOC was initiated by ABMS on their own and well before there was any debate of the evidence.  As an example, I was board certified by the American Board of Psychiatry and Neurology (ABPN) in 1988.  There was no time limitation on the original certifications until 1990.  I was certified Added Qualification in Geriatric Psychiatry in 1991; but that certification was time limited 1991-2001.  I was re-certified in Geriatric Psychiatry ten years later and that certificate states Recertified 2000-2010.  I was also certified Added Qualifications in Addiction Psychiatry 1993-2003.

Somewhere around the time I was due for certification for Addiction psychiatry, I asked myself: "Why are you doing this?" It costs a thousand dollars to take the test.  The test did not confer any special status, privileges, or salary.  It did not change any study habits at all.  I was still attending quality CME courses, reading the literature, and incorporating it into my practice. I was teaching and that is always associated with needing to know a lot more about current debates in the field as well as the representative scientific literature.  Even though I have never failed one of these board exams, there is a ritual of needing to take time off and study material that may not be immediately relevant to your practice - medical and psychiatric trivia that is an essential part of standardized test gamesmanship.  So I decided no - I am a professional. I am at the top of my game and all indications are that things are going well.  Even if they weren't, a thousand dollar board exam or even MOC procedure is not remedial.  It does not provide any feedback. It is essentially a prep school exercise of jumping thorough another hoop.  You either make it or you don't.  At that time there had been 7 hoops* and that was enough.  I stopped the process at that point. 

My guess is that a lot of other physicians saw the light the same way that I did.  My further speculation is that the ABMS reacted by increasing their leverage first by not issuing lifelong original certifications like they gave me back in 1988 and then making those re-certifications as onerous as possible.  I am not being dramatic when I use the term onerous.  I thought about getting back into the current MOC stream about a decade ago at an APA convention and talked with the ABPN representative at their booth. At the time, he literally could not tell me what I had to do to resume the endless cycle of paying fees and taking tests only that there was even more to do than that.  Not an inspiration to get back into the process.

Since then the ABMS has become much more strident about the MOC process.  They were playing the odds.  Physicians and their professional organizations are generally politically clueless and ineffective.  The best evidence of that is their inability to prevent managed care advocates in both government and business from taking over the field and dramatically decreasing the quality care.  They made arguments about how it was necessary to maintain quality and knowledge in a field.  How does that happen by taking a trivial pursuit style exam with no feedback and a very high pass rate?  How does that happen by basically doing patient satisfaction surveys on my patients - a procedure that is rapidly falling into disrepute in clinical settings. 

In the interest of brevity, I am not going to point out all  of the logical errors or overt conflict-of-interest in the ABMS arguments.  There are many bloggers out there who have done outstanding job of that including Cardiologist Westby G. Fisher, MD, FACC and Psychiatrist Jim Amos, MD.  In the literature the standard bearer against the MOC process has been Cardiologist Paul Tierstein, MD who was instrumental in founding the alternate board certification process through the National Board of Physicians and Surgeons (NBPAS). 

My conclusion after wading through all of the politics for that past decade was to get re-certified though NBPAS for several reasons including:

1.  Meaningfulness -  the existential equivalent of that word meaninglessness has been with me since I read Yalom's classic book Existential Psychotherapy in 1982. Yalom referred to it as the fourth ultimate existential concern - right after death, freedom and isolation.  Becoming a practicing physician is an exercise in delayed gratification.  As an intern and a resident the term "busy work" is used to designate tasks that have to be done but don't seem to advance true knowledge or understanding. It is really not clear what your professional life is going to be like until you are in the field interacting with colleagues and patients and practicing medicine.  Physicians as a group are overachievers, overwork, and compulsively question themselves about their decisions.  They are not work averse at all.  One of the motivators to expend this kind of energy is doing meaningful work.  Dr. Tierstein emphasizes this on the last slide in his lecture.  MOC is busy work and its meaning is arbitrarily defined by outsiders. 

2.  It reflects the original ABMS process - we certify you to go out in the world, practice medicine, and keep up with the theoretical and clinical aspects on your own as a professional.  Working with very bright colleagues providing excellent care for 30 years validates that approach.

3.  It certifies my ongoing work - I hope it is apparent from this blog that I am not a casual reader of the psychiatric literature.  I study it at several levels. I have two rooms in my home that are covered from ceiling to floor with medical and psychiatric literature.  I correspond with interested colleagues around the world.  I attend conferences.  I am working on current research.  I teach. I consider all of this life-long scholarship.  At one point the ABPN suggested they were going to put an asterisk (*) next to the names of lifetime certificate holders unless they participated in MOC.  To me that is an insult to my current work and professionalism. It's like designating me as some kind of steroid user.

4.  The NBPAS certifies continuing medical education credits (CME) - my state medical board asks me to report the total number every three years.  There is a suggestion that they will audit all of my certificates, but in 30 years that has never happened.  NBPAS does not certify you until you meet their CME requirement and send them all of the certificates via their web site.  They have an excellent website that can accept uploads of at least 10 of these documents at a time.  So here is a powerful reason for every state medical board to use NBPAS certification.  It immediately means that CME requirements are met very 2 years and they are certified.     

5.  It reflects what I do in my clinical work - sub-specialization in any field is always controversial.  Does there need to be another division in the field?  Is there enough evidence that it is far enough away from what everyone else is doing to be a separate body of knowledge?  After 30 years of work - I say no.  I still see geriatric patients, patients with general psychiatric disorders, patients with addictions, and patients with medical problems every day.  It's not like I can go to a magical clinic somewhere and just see a patient who only has one problem affecting their brain.  To do a good job, you have to continue to know it all.  It is hard work and there are often not a lot of clear answers, but that's why it is called practice and that's why we love medicine.

6.  It is tremendously cost effective considering what gets certified - the financial incentives for the MOC movement are huge and funded by physicians.  Stepping out of the MOC loop makes a clear statement.

7.  It is view consistent with my political philosophy -   I am from blue collar roots and was socialized to suspect the motives of politicians, businessmen, and even union organizers.  Very little of my experience as an adult seems to counter that perspective.  I see health care being run by the same mechanisms as the financial services industry and not for the benefit of physicians or their patients.  NBPAS certification is an antidote to the ABMS Big Brother approach.  In Dr. Tierstein's video he points out why it is no accident that healthcare companies insist that any physician working for them have MOC.  It is all part of the conflict-of-interest driven ruling class approach to business and regulation that we should expect.

That is why I got the NBPAS certificate.  I understand that there are early career physicians locked into some HMO who are told they need to be in the MOC cycle or they will lose their privileges and job (further evidence BTW of what MOC really is).  I can't understand younger physicians who don't recognize splitting when they see it.  I have read their opinions about how some think they know more than older physicians and how they are more tech savvy and how they are not averse to managed care manipulations.  I will just say that being an expert takes more than writing a smart phone app or thinking that you know every thing in the field after passing the initial board exams.  The true innovators and experts that I know have been doing what they innovated for the past 20-30 years.

The bottom line for this post is irrespective of where you are in medicine, if you ignore the politics you do so at your own peril.

Currently MOC is at the top of that list. 


George Dawson, MD, DFAPA




References:

1: Teirstein P, Topol EJ. Maintenance of Certification Programs and the Interstate Medical Licensure Compact--Reply. JAMA. 2015 Sep 1;314(9):952. doi: 10.1001/jama.2015.8912. PubMed PMID: 26325571.

2: Teirstein PS, Topol EJ. The role of maintenance of certification programs in governance and professionalism. JAMA. 2015 May 12;313(18):1809-10. doi: 10.1001/jama.2015.3576. PubMed PMID: 25965219; PubMed Central PMCID: PMC4751049. 

3: Teirstein PS. Boarded to death--why maintenance of certification is bad for doctors and patients. N Engl J Med. 2015 Jan 8;372(2):106-8. doi: 10.1056/NEJMp1407422. PubMed PMID: 25564895.

Supplementary:

*  The 7 hoops included part 1, 2, an 3 of the National Board Exams to qualify for a medical license and the subsequent 4 certifications and recertifications by the ABPN.  After thinking about this there were actually 8 hoops because there were actually 2 ABPN ceritifying examinations for psychiatry.  Part One was a written exam on psychiatry and neurology including imaging questions.  Part Two was an Oral Board exam that consisted of two parts.  One half of the day was an examination based on an observation of a videotaped interview. The other half of the day was an examination based on your observed interview of the patient.  Part Two had a higher failure rate probably due to a high degree of subjectivity.  I knew people who failed it more than once. So that is really a total of 8 tests altogether.