Maintenance of Certification Blues: All About Respect

The Maintenance of Certification (MOC) is spreading further into academic medical centers where our psychiatry residency training program directors are now scratching their heads over how to implement the Accreditation Council on Graduate Medical Education (ACGME) Milestones project. The Milestones program is yet another pseudopodium of MOC.

One of the Advisory Group members to the ACGME is the President and CEO of the American Board of Psychiatry and Neurology—which promotes MOC.  See my post, “Save Time for Patients” for more about Milestones at The Practical Psychosomaticist blog, Save Time for Patients – The Practical Psychosomaticist.

It will take a united front of doctors from all specialties to educate patients and policymakers at every level about our commitment to the principle of lifelong learning and the widely held belief that MOC will never be the vehicle which helps us achieve it.

The latest update in the lawsuit filed against the American Board of Medical Specialties (ABMS) in Federal court in late April 2013 by the American Association of Physicians and Surgeons tells the tale about the ABMS effort to promote the MOC agenda while choosing to ignore the image it is projecting to American physicians, AAPS Takes MOC to Court.

And the latest news about the growing number of state medical associations registering their support for lifelong learning though opposing MOC and MOL as vehicles for achieving it is the Florida Medical Association House of Delegates’ approval of a resolution opposing MOL and MOC. Furthermore, they also adopted another resolution in favor of the American Medical Association submitting a similar resolution for national consideration, Florida
opposes MOC Maintenance of certification | IP4PI – Independent Physicians for Patient independence

You don’t have to try to read the entire 50 page brief the AAPS legal counsel makes in response to the ABMS motion to dismiss the lawsuit. However, I encourage you to read the first 9 pages in order to get the main point of the lawsuit.

This issue is in many ways about respect, respect for doctors and respect for patients. I read a couple of interesting articles recently about the culture of disrespect in health care [1, 2]:

Perspective: A Culture of Respect, Part 1: The Nature and… : Academic Medicine

Perspective: A Culture of Respect, Part 2: Creating a Cult… : Academic Medicine

What about the apparent disrespect that I believe large organizations like the ABMS demonstrate by using processes like the MOC, allegedly not in an honest effort to improve the ability of physicians to provide competent health care, but to make large sums of money, as anyone can see by looking at their tax forms (see the link above about the MOC lawsuit)?

If disrespect is the main attitude problem in rank-and-file physicians, I think the ABMS and other boards should be role models we can respect. It’s difficult to do that when there is so much evidence for their disrespect for American doctors.

I have been trying to give the ABMS the benefit of a doubt because there is good data to show that large organizations make good faith efforts to do the right thing by patients and to give hard-working doctors credit–and unintentionally get results that undo those efforts.

One recent example of this is the “denominator bias” that can lead to some hospitals getting credit for identifying and managing mental health and substance abuse issues by using screeners for quality indicators when maybe they shouldn’t get credit and vice versa [3]. This can lead to bias just because of the sensitivity of the screening tool. Have you wondered why delirium occurrence (especially when not Present on Admission) may not be linked to a quality indicator at your hospital?

Bradley and colleagues call for avoiding positive-screen-based quality indicators because of the bias they can cause. This takes courage.

By the same token, I’ve often mused about how much courage it would take for the ABMS to let go of the MOC. I’ve even dreamed about how we as physicians might help the ABMS find a face-saving way to give up that wasteful program which has no real evidence base to support the claims ABMS makes for it.

I have tried to respect the ABMS. What makes it so hard for the ABMS to respect me?

Please consider signing my petition to support lifelong learning and opposing Maintenance of Licensure (MOL) in Iowa at

“…And we must build a culture of humanistic clinical excellence.”—Jamos the Elder
“…And we must build a culture of humanistic clinical excellence.”—Jamos the Elder


1. Leape, L. L., et al. (2012). “Perspective: a culture of respect, part 1: the nature and causes of disrespectful behavior by physicians.” Acad Med 87(7): 845-852.
A substantial barrier to progress in patient safety is a dysfunctional culture rooted in widespread disrespect. The authors identify a broad range of disrespectful conduct, suggesting six categories for classifying disrespectful behavior in the health care setting: disruptive behavior; humiliating, demeaning treatment of nurses, residents, and students; passive-aggressive behavior; passive disrespect; dismissive treatment of patients; and systemic disrespect.At one end of the spectrum, a single disruptive physician can poison the atmosphere of an entire unit. More common are everyday humiliations of nurses and physicians in training, as well as passive resistance to collaboration and change. Even more common are lesser degrees of disrespectful conduct toward patients that are taken for granted and not recognized by health workers as disrespectful.Disrespect is a threat to patient safety because it inhibits collegiality and cooperation essential to teamwork, cuts off communication, undermines morale, and inhibits compliance with and implementation of new practices. Nurses and students are particularly at risk, but disrespectful treatment is also devastating for patients. Disrespect underlies the tensions and dissatisfactions that diminish joy and fulfillment in work for all health care workers and contributes to turnover of highly qualified staff. Disrespectful behavior is rooted, in part, in characteristics of the individual, such as insecurity or aggressiveness, but it is also learned, tolerated, and reinforced in the hierarchical hospital culture. A major contributor to disrespectful behavior is the stressful health care environment, particularly the presence of “production pressure,” such as the requirement to see a high volume of patients.

2. Leape, L. L., et al. (2012). “Perspective: a culture of respect, part 2: creating a culture of respect.” Acad Med 87(7): 853-858.
Creating a culture of respect is the essential first step in a health care organization’s journey to becoming a safe, high-reliability organization that provides a supportive and nurturing environment and a workplace that enables staff to engage wholeheartedly in their work. A culture of respect requires that the institution develop effective methods for responding to episodes of disrespectful behavior while also initiating the cultural changes needed to prevent such episodes from occurring. Both responding to and preventing disrespect are major challenges for the organization’s leader, who must create the preconditions for change, lead in establishing and enforcing policies, enable frontline worker engagement, and facilitate the creation of a safe learning environment.When disrespectful behavior occurs, it must be addressed consistently and transparently. Central to an effective response is a code of conduct that establishes unequivocally the expectation that everyone is entitled to be treated with courtesy, honesty, respect, and dignity. The code must be enforced fairly through a clear and explicit process and applied consistently regardless of rank or station.Creating a culture of respect requires action on many fronts: modeling respectful conduct; educating students, physicians, and nonphysicians on appropriate behavior; conducting performance evaluations to identify those in need of help; providing counseling and training when needed; and supporting frontline changes that increase the sense of fairness, transparency, collaboration, and individual responsibility.

3. Bradley, K. A., et al. (2013). “When Quality Indicators Undermine Quality: Bias in a Quality Indicator of Follow-Up for Alcohol Misuse.” Psychiatr Serv.
OBJECTIVE Valid quality indicators are needed to monitor and encourage identification and management of mental health and substance use conditions (behavioral conditions). Because behavioral conditions are frequently underidentified, quality indicators often evaluate the proportion of patients who screen positive for a condition who also have appropriate follow-up care documented. However, these “positive-screen-based” quality indicators of follow-up for behavioral conditions could be biased by differences in the denominator due to differential screening quality (“denominator bias”) and could reward identification of fewer patients with the behavioral conditions of interest. This study evaluated denominator bias in the performance of Veterans Health Administration (VHA) networks on a quality indicator of follow-up for alcohol misuse that used the number of patients with positive alcohol screens as the denominator. METHODS Two quality indicators of follow-up for alcohol misuse-a positive-screen-based quality indicator and a population-based quality indicator-were compared among 21 VHA networks by review of 219,119 medical records. RESULTS Results for the two quality indicators were inconsistent. For example, two networks performed similarly on the quality indicators (64.7% and 65.4% follow-up) even though one network identified and documented follow-up for almost twice as many patients (5,411 and 2,899 per 100,000 eligible, respectively). Networks that performed better on the positive-screen-based quality indicator identified fewer patients with alcohol misuse than networks that performed better on the population-based quality indicator (mean 4.1% versus 7.4%, respectively). CONCLUSIONS A positive-screen-based quality indicator of follow-up for alcohol misuse preferentially rewarded networks that identified fewer patients with alcohol misuse.