Can ABMS Listen to Doctors’ Stories?

I read an interesting article about letting patients tell their stories. Doctors are under many pressures to bypass this empathic practice. Maintenance of Certification (MOC) is only one of them. The latest news in the struggle between the boards and rank-and-file physicians is the new American Medical Association (AMA) policy just adopted opposing MOC recertification exams.

Unfortunately, the American Board of Medical Specialties (ABMS) doesn’t agree, which was not unexpected. Most trainees I tell about this ongoing conflict see the ABMS and member boards as wrong. I’m sure some of them don’t share that opinion–probably because they’re simply not aware of the issue. The Pennsylvania Medical Society (PAMED) sponsored the panel discussion about MOC at the AMA meeting in Chicago June 13, 2016. PAMED has even issued a vote of no confidence in the American Board of Internal Medicine (ABIM). Newsweek’s Kurt Eichenwald has written articles critical of the ABIM MOC process.

Most of us who have been opposed to MOC have been skeptical of the effectiveness of the program at influencing patient outcomes. There is controversy about whether or not there is good evidence in the literature supporting it (see references).

I think the struggle between working doctors and the boards is indicative of trouble with the whole MOC process and suspect the main reason it isn’t dropped is because the boards make a lot of money out of it. And I also believe one of the major criticisms against it is that it takes an inordinate amount of time to deal with all of the modules and it takes time away from patient care. We don’t have time to listen to our patients’ stories partly because we’re doing MOC busywork.

We graduated several combined specialty residents last week, in the Internal Medicine/Psychiatry and Family Medicine/Psychiatry programs. We’re all extremely proud of them. I’m not worried about their competence. I’m worried they’ll become cynical about our regulatory system. It takes a great deal of work and dedication to succeed in these and the traditional psychiatric residencies. In my opinion, it’s scandalous to subject them to the MOC for the rest of their careers, which will be difficult enough.

I know the new alternative board, the National Board of Physicians and Surgeons (NBPAS) is making progress in being recognized as another certifying board.  I also hope that the leaders of the ABMS and member boards realize what bad press they’re accumulating and finally understand what it will take to persuade the next generation of doctors to be proud of their legacy. It won’t be the MOC.

It’s time for the boards to listen to the doctors’ stories now.

References:

Lee, T. H. (2014). “Certifying the good physician: a work in progress.” JAMA 312(22): 2340-2342.

Hayes, J., et al. (2014). “Association between physician time-unlimited vs time-limited internal medicine board certification and ambulatory patient care quality.” JAMA 312(22): 2358-2363.

IMPORTANCE: American Board of Internal Medicine (ABIM) initiatives encourage internists with time-unlimited certificates to recertify. However, there are limited data evaluating differences in performance between internists with time-limited or time-unlimited board certification. OBJECTIVE: To determine whether there are differences in primary care quality between physicians holding time-limited or time-unlimited certification. DESIGN, SETTING, AND PARTICIPANTS: Retrospective analysis of performance data from 1 year (2012-2013) at 4 Veterans Affairs (VA) medical centers. Participants were internists with time-limited (n = 71) or time-unlimited (n = 34) ABIM certification providing primary care to 68,213 patients. Median physician panel size was 610 patients (range, 19-1316), with no differences between groups (P = .90). MAIN OUTCOMES AND MEASURES: Ten primary care performance measures: colorectal screening rates; diabetes with glycated hemoglobin (HbA1c level) less than 9.0%; diabetes with blood pressure less than 140/90 mm Hg; diabetes with low-density lipoprotein cholesterol (LDL-C) level less than 100 mg/dL; hypertension with blood pressure less than 140/90 mm Hg; thiazide diuretics used in multidrug hypertensive regimen; atherosclerotic coronary artery disease and LDL-C level less than 100 mg/dL; post-myocardial infarction use of aspirin; post-myocardial infarction use of beta-blockers; congestive heart failure (CHF) with use of angiotensin-converting enzyme (ACE) inhibitor. RESULTS: After adjustment for practice site, panel size, years since certification, and clustering by physician, there were no differences in outcomes for patients cared for by internists with time-limited or time-unlimited certification for any performance measure: colorectal screening (odds ratio [OR], 0.95 [95% CI, 0.89-1.01]); diabetes with HbA1c level less than 9.0% (OR, 0.96 [95% CI, 0.74-1.2]); blood pressure control (OR, 0.99 [95% CI, 0.69-1.4]); LDL-C level less than 100 mg/dL (OR, 1.1 [95% CI, 0.79-1.5]); hypertension with blood pressure less than 140/90 mm Hg (OR, 1.0 [95% CI, 0.92-1.2]); thiazide use (OR, 1.0 [95% CI, 0.8-1.3]); atherosclerotic coronary artery disease with LDL-C level less than 100 mg/dL (OR, 1.1 [95% CI, 0.75-1.7]); post-myocardial infarction use of aspirin (OR, 0.98 [95% CI, 0.58-1.68]) or beta-blockers (OR, 1.0 [95% CI, 0.57-1.9]); CHF with use of ACE inhibitor (OR, 0.98 [95% CI, 0.61-1.6]). CONCLUSIONS AND RELEVANCE: Among internists providing primary care at 4 VA medical centers, there were no significant differences between those with time-limited ABIM certification and those with time-unlimited ABIM certification on 10 primary care performance measures. Additional research to examine the difference in patient outcomes among holders of time-limited and time-unlimited certificates in non-VA and nonacademic settings and the association with other ABIM goals may help clarify the potential benefit of Maintenance of Certification participation.

Gray, B. M., et al. (2014). “Association between imposition of a Maintenance of Certification requirement and ambulatory care-sensitive hospitalizations and health care costs.” JAMA 312(22): 2348-2357.
IMPORTANCE: In 1990, the American Board of Internal Medicine (ABIM) ended lifelong certification by initiating a 10-year Maintenance of Certification (MOC) program that first took effect in 2000. Despite the importance of this change, there has been limited research examining associations between the MOC requirement and patient outcomes. OBJECTIVE: To measure associations between the original ABIM MOC requirement and outcomes of care. DESIGN, SETTING, AND PARTICIPANTS: Quasi-experimental comparison between outcomes for Medicare beneficiaries treated in 2001 by 2 groups of ABIM-certified internal medicine physicians (general internists). One group (n = 956), initially certified in 1991, was required to fulfill the MOC program in 2001 (MOC-required) and treated 84 215 beneficiaries in the sample; the other group (n = 974), initially certified in 1989, was grandfathered out of the MOC requirement (MOC-grandfathered) and treated 69 830 similar beneficiaries in the sample. We compared differences in outcomes for the beneficiary cohort treated by the MOC-required general internists before (1999-2000) and after (2002-2005) they were required to complete MOC, using the beneficiary cohort treated by the MOC-grandfathered general internists as the control. MAIN OUTCOMES AND MEASURES: Quality measures were ambulatory care-sensitive hospitalizations (ACSHs), measured using prevention quality indicators. Ambulatory care-sensitive hospitalizations are hospitalizations triggered by conditions thought to be potentially preventable through better access to and quality of outpatient care. Other outcomes included health care cost measures (adjusted to 2013 dollars). RESULTS: Annual incidence of ACSHs (per 1000 beneficiaries) increased from the pre-MOC period (37.9 for MOC-required beneficiaries vs 37.0 for MOC-grandfathered beneficiaries) to the post-MOC period (61.8 for MOC-required beneficiaries vs 61.4 for MOC-grandfathered beneficiaries) for both cohorts, as did annual per-beneficiary health care costs (pre-MOC period, $5157 for MOC-required beneficiaries vs $5133 for MOC-grandfathered beneficiaries; post-MOC period, $7633 for MOC-required beneficiaries vs $7793 for MOC-grandfathered beneficiaries). The MOC requirement was not statistically associated with cohort differences in the growth of the annual ACSH rate (per 1000 beneficiaries, 0.1 [95% CI, -1.7 to 1.9]; P = .92), but was associated with a cohort difference in the annual, per-beneficiary cost growth of -$167 (95% CI, -$270.5 to -$63.5; P = .002; 2.5% of overall mean cost). CONCLUSION AND RELEVANCE: Imposition of the MOC requirement was not associated with a difference in the increase in ACSHs but was associated with a small reduction in the growth differences of costs for a cohort of Medicare beneficiaries.

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Comments

  1. Stephen Moe says:

    Dr. Amos:

    I appreciate your efforts on this matter. Here’s something I put together on the topic:

    Board Re-recertification and the Maturing Psychiatrist

    Having graduated with the initial class of residents who were not awarded lifelong board certification, I am among the first cohort of psychiatrists who face the prospect of board re-recertification; in other words, becoming certified for the third time. Building on the report of Sidney Weisman, MD that was published in the Psychiatric Times, there are a number of issues that I expect are very common in those at a similar stage in their careers, and which I share to foster further discussion.

    In the first place, as is common in any profession, there has been an evolution in my practice. Early career positions that called for general psychiatric knowledge have given way to a practice centered on treating and evaluating injured workers. As a consequence, I have been called upon to develop expertise in conditions that were largely extraneous to those I treated when I was first board certified, including mild traumatic brain injury, chronic pain, and psychological factors affecting physical conditions, not to mention various issues at the interface of psychiatry and the law. By dint of interest and necessity, I have obtained an abundance of continuing medical education during the past ten years on matters that I knew almost nothing when I was first board certified, and which were only part of my practice when I recertified a decade ago.
    Secondly, both the topics that are of interest to me, and the means by which I educate myself on them, do not lend themselves to the CME that is approved by the American Board of Psychiatry and Neurology (ABPN). Officially sanctioned CME is centered on conventional topics in psychiatry frequently provided extraneous to one’s practice, via conferences, on-line lectures, collected readings, or highly contrived self-assessment measures. Whereas one can obtain “approved” CME piecemeal, one hour at a time, the process is labor-intensive and time-consuming, relative to the education obtained.

    Thirdly, in keeping with recent writings of Thomas Insel, Allan Francis, and others, my 25+ years of experience as a psychiatrist has made me intolerant of much of the conventional wisdom of psychiatry. For example, the extreme heterogeneity and comorbidity of psychiatric constructs such as PTSD (citation re 640,000) has made me intolerant of talks that treat the condition as well-circumscribed condition. In treating depressed patients who are unemployed, in pain, with maladaptive personality traits and issues with substance abuse, studies of the pharmacology of “treatment resistant depression” leave me cold. The elimination of somatization, pain disorder, and histrionic personality disorder from DSM-5 makes it necessary to turn to the general medical literature to gain insight into what used to be termed “medically unexplained physical symptoms.” In witnessing first-hand the significant limitations of psychiatric nosology and treatment, I have gravitated to psychological studies that provide me context and wisdom. Consequently, combined with either the redundancy or irrelevance of much of what passes for “approved CME,” I find myself increasingly resentful that I am expected to spend 300 hours obtaining education in topics of uncertain validity.

    The net effect of the desire to remain on top of my profession while also satisfying administrative requirements is to, in effect, create two categories of CME. One category is captured in the extensive self-directed education that I have obtained over the past ten years, as reflected in the hundreds of academic papers I’ve reviewed and retained in files, the multiple books that I’ve read and kept on my shelves, and the clinical reports I have written. The other category is represented by the content from conferences and material I have purchased through the American Psychiatric Association and other, which I find significantly less useful. The latter category is also frankly difficult to obtain, given the time away that is required to attend conferences.

    Like others at this stage in their careers, I find myself highly conflicted over a situation in which official recognition of my expertise must be gained through a labor-intensive, costly process that I believe detracts from self-directed education motivated by my actual interests and professional needs.

    Liked by 1 person

    • Dr. Moe, thank you very much for your thoughtful remarks. I think it should be a stand-alone post to make it as visible as possible.

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