The MOC Controversy and the Seven Deadly Sins

Jim Amos MD 7I’ve noticed it’s getting harder to keep a sense of humor about the Maintenance of Certification (MOC) lately, especially since the publication of the 3rd Newsweek opinion piece by Kurt Eichenwald on the finances of the American Board of Internal Medicine (ABIM), “Medical Mystery: Making Sense of ABIM’s Financial Report.” You probably won’t get to read the article unless you buy a subscription. I was lucky and got to read it at least once. And then there was the rebuttal by ABIM President and CEO, Dr. Richard Baron, denying that he’s hiding anything about his finances, which is implied by Eichenwald.

After reading both pieces, I thought of the seven deadly sins, with pride, anger, and greed leading the list in this drama which is becoming increasingly embarrassing to American physicians, because they’re displayed on both sides of this controversy.istock-editorial-license_7-deadly-sins-medium-1

Comburg, pulpit cover by Balthasar Esterbauer (1715) - Seven deadly sins: pride

Comburg, pulpit cover by Balthasar Esterbauer (1715) – Seven deadly sins: pride

Pride is considered the worst of the seven deadly sins. I can see it in the arrogance of board leaders who think they’re immune to criticism and, despite Baron’s apparent belief that his apology to ABIM diplomates makes him a paragon of humility–nobody believes him. On the other side, the pride of rank-and-file physicians makes many of us believe that whatever we’re currently doing for professional self-development is sufficient, or worse, that we don’t need to do anything beyond collecting CME activities.

Hey, I encounter physician incompetence every day–including my own. We need a more systematic way to stay current with medical knowledge and patient cares skills. But I still don’t believe MOC is good enough to embody the principle of lifelong learning. The recent JAMA article on professionalism and regulation included an article on Revalidation, the United Kingdom version of MOC (more accurately Maintenance of Licensure or MOL since the process is tied to physician licensure) [1]. The authors are frank about the reasons why Revalidation cannot yet be evaluated on its ability to improve patient care outcomes. And they also admit that it will probably not uncover the few doctors out there who are basically criminals.

I believe that if the medical literature could be made available to all working physicians, for example, through PubMed, most of us would use it more frequently than MOC to engage in professional development, comparing our practice to reviews and published studies–because we want to improve from the inside out.

Comburg, pulpit cover by Balthasar Esterbauer (1715) - Seven deadly sins: wrath

Comburg, pulpit cover by Balthasar Esterbauer (1715) – Seven deadly sins: wrath

Anger is another deadly sin that both the board executives and front-line, working doctors evince. Anger is evident in Eichenwald’s tone and anger is everywhere in the comments following his article. The President and CEO of the American Board of Psychiatry and Neurology (ABPN), Dr. Larry Faulkner, cautions against reacting to the MOC with anger–yet obviously he was willing to try and make the Part IV clinical module optional, probably because he recognized how angry it makes physicians because almost none of it is relevant to what most of us do day in and day out as psychiatrists and neurologists.

Comburg, pulpit cover by Balthasar Esterbauer (1715) - Seven deadly sins: gluttony

Comburg, pulpit cover by Balthasar Esterbauer (1715) – Seven deadly sins: gluttony

Gluttony in the broad sense of over-indulgence is characteristic of both board executives and front-line doctors. Why exactly do CEOs have to be paid as much money as they typically get? I’m not sure what that means. You can see how closely related greed and gluttony are. It’s harder to see how this might apply to diplomates, but think about gunner medical students, the grind of residency, and the seemingly endless work of being a doctor. And then we allow ourselves to be taken advantage of by the boards. Why couldn’t we be described as “gluttons” for punishment?

Comburg, pulpit cover by Balthasar Esterbauer (1715) - Seven deadly sins: envy

Comburg, pulpit cover by Balthasar Esterbauer (1715) – Seven deadly sins: envy

Envy is one of the sins working doctors must deal with. How can I not envy Dr. Faulkner’s $843,591 salary? Let’s see, what would board executives envy about rank-and-file physicians? Maybe they envy our daily connection with our patients, the daily drive for creativity and excellence we bring to clinical care. Dr. Baron did that, he says, for some 30 years before giving it up to make an awful lot of money. It’s too easy to say the money makes up for the loss of what most of us aspired to when we entered medical school–integrity, humanism, the reward of hard work for its own sake, the opportunity to help others heal and to teach the next generation of doctors our skill, our hard-won wisdom, and respect for the curiosity to seek new knowledge…and to respect the need for stewardship of the old ways because our patients need and want to see us as the paladins we have always sought to be for them.

Comburg, pulpit cover by Balthasar Esterbauer (1715) - Seven deadly sins: lust

Comburg, pulpit cover by Balthasar Esterbauer (1715) – Seven deadly sins: lust

Lust is not always synonymous with sex. It can be the drive for power and fame. We don’t often think of legacy in this way, but there can be a lust for legacy. It’s not hard to see how board executives might lust to leave a legacy by using MOC as a vehicle. And in our turn, the foot soldiers of medicine may lust for the legacy of being the champions of the resistance to MOC, to be remembered as the heroes who toppled the tower of greed, pride, and gluttony.

Comburg, pulpit cover by Balthasar Esterbauer (1715) - Seven deadly sins: sloth

Comburg, pulpit cover by Balthasar Esterbauer (1715) – Seven deadly sins: sloth

Sloth can be the charge of the board CEOs at the doctors who balk at participating in MOC. The message might be that we are failing to live up to the principle of lifelong learning and continuous self improvement. On the side of diplomates, the view is that the boards are failing to work hard enough to find alternatives to what are perceived to be empty time-wasting Performance in Practice (PIP) modules. Don’t we have more important ways to use our time?

So here we still are, no closer to resolving the seven deadly sins than we were years ago when the MOC debacle started, probably with good intentions but somehow becoming corrupted along the way. The boards are widely viewed as corrupt, yet despite the impression Eichenwald gives of them being criminal, even he finally says that ABIM is doing nothing illegal. But then in the next breath, he says that the Department of Justice should investigate them. And he says doctors should grow a backbone and fight the MOC with mass noncompliance–something MOC opponents have been saying for years. Interesting that Eichenwald should challenge physicians to grow a backbone, after he spent many paragraphs vilifying the identified enemy—the ABIM. I would say I have a strong enough backbone because I’m still standing under all of the pressure the boards are pressing on my shoulders.

Saying doctors don’t have backbone, whether it’s done by the press or by doctors, really sounds like more of the anger that keeps us all spinning. Backbone is not what’s lacking.

We spin this way because there doesn’t seem to be a way out of the MOC controversy. We can let our certifications expire–and then what? The belief that certification means the difference between good and bad doctors is widespread amongst the Joint Commission, the Centers for Medicaid and Medicare Services (CMS), hospital credentialing committees, private insurance companies–and many doctors. Patients? Not so much, which is ironic.

So where will all of this anger, pride, greed and the rest of it lead? I sure don’t have the answer, but I have this hope which may not be in vain, that someday we’ll all remember the 7 virtues: Humility, Charity, Kindness, Temperance, Chastity, Diligence, and Patience.

Maybe we all need to relax for a little while, take a break, appreciate how far we’ve come and not ruminate so much on how far we have to go, like the Storyshucker says.

We will not give up the search for a better way to implement continuous professional self-development. But let’s spend a little time in the garden. Play Matball.

References:

1. Marcovitch, H. (2015). “Governance and professionalism in medicine: A uk perspective.” JAMA 313(18): 1823-1824. URL http://jama.jamanetwork.com/article.aspx?articleid=2290641&resultClick=3
Professionalism was assumed and governance scarcely existent, with individual physicians holding themselves to account, loosely regulated by a statutory body run by the powerful General Medical Council (GMC). The GMC was established in 1858.

http://en.wikipedia.org/wiki/Seven_deadly_sins 

Image credits for the 7 Deadly Sins: http://commons.wikimedia.org/wiki/User:Hermetikerhttp://creativecommons.org/licenses/by-sa/3.0/

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Comments

  1. Hi Jim,

    I think that backbone is half of the problem.

    The other half is not realizing how all of the hucksters and grifters have taken over.

    What happened to the serious clinical medicine that we were all trained to do? I trained in clinician settings where there were administrators but they did not tell physicians what to do. We would work hard but it was for a reason. That reason was that we were trying to apply the latest clinical science to improve the lives of our patients. We did not work hard because we had managed care companies wasting our time and hospital case managers forcing discharges to beat the length of stay on a particular DRG. We did not work hard just to make notes that look good for billing and coding. When I trained on surgical rotations the average progress note was two handwritten lines long and to nobody’s surprise, longer notes don’t result in better quality care.

    The whole idea of intensive and expensive MOC was flawed from the start and those flaws suggest an agenda other than education. One of the largest unstated flaws is that there is a uniform body of knowledge that all psychiatrists or specialists need to know in order to practice safely. Since when has that been true? There are a handful of specialists out there who prescribe antipsychotics for schizophrenia and bipolar disorder. There are a handful of inpatient specialists. There are a handful of addiction specialists, geriatric specialists and CL specialists. These are all areas that adult psychiatrists can move into, get up to speed and function quite well on their own. As far as I can tell, no adult psychiatrist really needs to know any more about children and adolescents than they learned in residency unless they decide in a shortage area that they will do that work. The surgical news this week was that some systems are now banning surgical procedures in hospitals where they are not done frequently enough. Specialization in non-surgical care also occurs and speaks to the idea that at some point we can all stop taking the exams we took in medical school and for the National Boards.

    And what about people who are reading and studying non-mainstream areas like neuropsychiatry, movement disorders, and neuroscience? Is that somehow less relevant to their practice of psychiatry? Should they be expected to take two weeks off and take some crash course in psychiatric trivia in order to pass a non-relevant exam? I don’t think so. Part of being a professional is knowing what you need to know and not wasting people’s time.

    Board oversight seems like a prep school exercise for the uninitiated who are trying to get into some Ivy League school rather than working professionals. Anger keeps people focused on the problem and it is these boards, their attitude, the lack of value they bring to the table, and their political rhetoric.

    I never, ever want to hear again that the public wants us all to hop through a series of board hoops for the purpose of maintaining some imaginary standard when that same public has absolutely no idea what a psychiatrist does.

    Like

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