So we’re just days away from the Iowa Medical Society (IMS) Policy Forum and I can tell you that the majority of Iowa physicians support my Policy Request Statement on opposing Maintenance of Certification. I have to admit I’m a bit nervous about how the discussion will go on September 25, 2014 starting at 12:30 in room 5181 of the Medical Education Research Facility at the University of Iowa Carver College of Medicine. That’s because there’s one important difference so far in the pre-Forum discussion from the IMS House of Delegates resolution I sponsored last April on supporting the principle of lifelong learning and opposing Maintenance of Licensure (MOL).
The difference is that there is some dissent from a few Iowa doctors, who apparently believe that there’s more to lose from not supporting MOC. However, the dissenting opinions also acknowledge the obvious and well-known weaknesses inherent in MOC. I’m fairly confident the policy will be adopted although I’m also doubtful about what influence it will have on preventing further pernicious repercussions of MOC.
The whole idea behind PRS 14-02 is to oppose mandatory Maintenance of Certification (MOC) for licensure, hospital privileges and reimbursement from third party payers. But the problem is that these are already happening, with the exception of MOL…so far. And this unfortunate fact forms the main argument of the opponents of PRS 14-02. This is what I call the “fait accompli position.” In fact, MOC was promulgated by the American Medical Association (AMA), despite their current position opposing it, and that led to its being embedded in the Affordable Care Act tying it to physician reimbursement from the Centers for Medicare and Medicaid Services (CMS).
So right about now you’re probably asking, why is the geezer so energetically pursuing opposition to MOC and MOL? A quote from a recent paper about medical professionalism by Wynia, et al, who take great pride in announcing that they worked closely with the American Board of Medical Specialties (ABMS), might help:
The authors argue that while making lists of desirable professional characteristics is necessary and useful for teaching and assessment, it is not, by itself, sufficient either to fully define professionalism or to capture its social functions. Thus, the authors sought to extend earlier work by articulating a definition that explains professionalism as the motivating force for an occupational group to come together and create, publicly profess, and develop reliable mechanisms to enforce shared promises-all with the purpose of ensuring that practitioners are worthy of patients’ and the public’s trust .
The word “enforce” sticks in my craw. And I don’t like anyone telling me that I need to prove I’m “worthy of patients’ and the public’s trust.” I am worthy and I don’t need anyone enforcing regulations that purport to make me worthy. In fact, I have never believed that you can enforce integrity into a professional or anyone else. I think integrity is a quality which must be cultivated from the inside out by honest reflection on one’s own attitudes, beliefs, and behavior based on ethical principles. And I suppose every reader by now knows that I’m suspicious of anyone who is fraternizes with the ABMS professing to know anything about professionalism while forcing the wasteful travesty of MOC down the throats of hard-working physicians.
Leach wrote a commentary about Wynia’s view, saying that he agrees with his position, but with an important additional remark, “…and at the same time hope they are right.” This correctly casts doubt framed in humility on the regulatory capture model, a quality I find lacking in the ABMS pronouncement about the need for enforcement. Leach notes that Wynia, et al are silent about forgiveness in their definition of professionalism . I find the ABMS approach particularly unforgiving, dictatorial, highhanded, and wrongheaded. I also think Leach is on precarious ground by conveying his faith that the ABMS can preserve trustworthiness by using the MOC model. I also think he tacitly disagrees with the ABMS’ approach:
“Professionalism is not organically expressed by answering multiple-choice questions correctly, or even by responding correctly to simulated challenges, as helpful as those tools are.”
I think Leach would agree with my position opposing MOC, though he expresses his doubt about the enforcement with political correctness. He is gentle. I am not. But he says what I would say if I could be as eloquent as he is:
How can we develop the heart in our work? We might begin by working with human nature. All humans come equipped with 3 faculties: the intellect, the will, and the imagination. The object of the intellect is truth, of the will goodness, and of the imagination beauty. This applies directly to the work of medicine. The task of the good physician is to discern and tell the truth, to seek what is good for the patient and place it above what is good for the doctor, and to find beauty (i.e., harmony) in clinical judgments, harmonizing the best generalizable science with a deep understanding of the particular context of a given patient and making a judgment that is in fact creative and beautiful. Good professionalism is a habit, a habit that can be fostered by systematically answering three questions at the end of each day: how good a job did I do discerning and telling the truth, doing what was good for the patient, and making clinical judgments that were practical and wise?
Leach knows that the busyness of medical practice today, to which MOC contributes, doesn’t leave time for the private reflection that leads to the deep wisdom which can never be achieved by trivial Performance in Practice modules and multiple choice exams focused on minutiae. The ABMS approach leads to physician burnout about which I know a great deal. But to “…deepen reflective practice, to find time for solitude and good conversations…” we need to “…recognize and create nourishing communities.”
MOC and MOL divide the medical community and fail to encourage the healthy solitude we need for truly wisdom-nurturing reflection. And that is why I would rather fail in my opposition to MOC and MOL than succeed in falling into line with those who take the fait accompli position.
1. Wynia, M. K., et al. (2014). “More than a list of values and desired behaviors: a foundational understanding of medical professionalism.” Acad Med 89(5): 712-714.
The term “professionalism” has been used in a variety of ways. In 2012, the American Board of Medical Specialties (ABMS) Standing Committee on Ethics and Professionalism undertook to develop an operational definition of professionalism that would speak to the variety of certification and maintenance-of-certification activities undertaken by ABMS and its 24 member boards. In the course of this work, the authors reviewed prior definitions of professions and professionalism and found them to be largely descriptive, or built around lists of proposed professional attributes, values, and behaviors. The authors argue that while making lists of desirable professional characteristics is necessary and useful for teaching and assessment, it is not, by itself, sufficient either to fully define professionalism or to capture its social functions. Thus, the authors sought to extend earlier work by articulating a definition that explains professionalism as the motivating force for an occupational group to come together and create, publicly profess, and develop reliable mechanisms to enforce shared promises-all with the purpose of ensuring that practitioners are worthy of patients’ and the public’s trust.Using this framework, the authors argue that medical professionalism is a normative belief system about how best to organize and deliver health care. Believing in professionalism means accepting the premise that health professionals must come together to continually define, debate, declare, distribute, and enforce the shared competency standards and ethical values that govern their work. The authors identify three key implications of this new definition for individual clinicians and their professional organizations.
2. Leach, D. C. (2014). “Transcendent Professionalism: Keeping Promises and Living the Questions.” Academic Medicine 89(5): 699-701 610.1097/ACM.0000000000000211.
Wynia and colleagues propose a definition of professionalism as a belief system by which to shape health care rather than a list of values and behaviors. The belief that professionalism is the best way to organize and deliver health care constitutes a promise to society. The notion that the medical profession as a whole as well as its individual members should be held accountable to standards of competence, ethical values, and interpersonal attributes developed, declared, and enforced by the profession itself is also a promise to society. The author argues that good promises offer a stabilizing influence over the inherent uncertainty in human relationships and may provide the ground for a lasting trustworthy relationship between the medical profession and society; however, the professionalism belief system itself is vulnerable if the promise is breached. The modern world has challenged the professionalism model of organizing health care, and individual practitioners as well as their professional organizations are seeking clarity about what professionalism means given current realities. This commentary reflects on these circumstances and provides some recommendations for developing a construct of professionalism.