Maintenance of Certification: Point-Counterpoint

By now, many doctors have seen the JAMA viewpoint article in support of Maintenance of Certification (MOC) but you might have missed the rejoinder on MedPage Today. See my tweet below:

I read the JAMA viewpoint by Dr. Welcher and colleagues and I was trying to think of a response. Then I discovered the MedPage article “State Legislatures Wade Into MOC Debate” by Cheryl Clark. Supporters and opponents of MOC have, of course, been talking past each other for the last decade.

This reminds me of a point I tried to make about negotiating in Consultation-Liaison Psychiatry and in politics a few days ago based on a paper recently published in Psychosomatics (Siegel, A. M. and H. R. Bleier (2017). “The Role of Negotiation in Consultation-Liaison Psychiatry.” Psychosomatics 58(2): 187-190). This was linked to case report which highlighted the use of negotiating tools promoted by authors Fisher, Ury, and Patton in their book “Getting to Yes: Negotiating Agreement Without Giving In.” The companion book often cited along with it is “Difficult Conversations: How to Discuss What Matters Most,” by Stone, Patton, and Heen. Surprisingly, both books are available on line in their entirety. Isn’t there a copyright law against that?

I suppose this approach could be applied to the MOC debate. While I’m not the best person to be a cheerleader for it, given that I’ve been a regular critic of everything about MOC, it still makes sense to try to listen to the other side and be aware of one’s own confirmation bias. What makes me more aware of this is the constant bombardment of readers and viewers of the rampant political divisiveness by journalists who are themselves politically biased.

Now add to that a very interesting special article in the Spring 2017 issue of The Journal of Neuropsychiatry and Clinical Neurosciences:

Mario F. Mendez (2017). “A Neurology of the Conservative-Liberal Dimension of Political Ideology.” J Neuropsychiatry Clin Neurosci 29(2): 86-94.
Differences in political ideology are a major source of human disagreement and conflict. There is increasing evidence that neurobiological mechanisms mediate individual differences in political ideology through effects on a conservative-liberal axis. This review summarizes personality, evolutionary and genetic, cognitive, neuroimaging, and neurological studies of conservatism-liberalism and discusses how they might affect political ideology. What emerges from this highly variable literature is evidence for a normal right-sided “conservative-complex” involving structures sensitive to negativity bias, threat, disgust, and avoidance. This conservative-complex may be damaged with brain disease, sometimes leading to a pathological “liberal shift” or a reduced tendency to conservatism in political ideology. Although not deterministic, these findings recommend further research on politics and the brain.

Needless to say, the authors acknowledge the many limitations of generalizing from the limited literature on the topic. But it’s fascinating, nevertheless, to think we may be hardwired to be hard-nosed. If our political views are lateralized in the brain, maybe that’s what gives us “political-handedness” that makes us more likely to say “Talk to the hand!” to those who disagree with us.

It’s isn’t far-fetched to compare the MOC controversy with liberal vs conservative battles. Recall the origin of the model legislation against MOC? We owe that to what some would call the right-leaning Association of American Physicians and Surgeons (AAPS). Incidentally, current Secretary of Health and Human Services R-Tom Price is a member of the AAPS–and was criticized by some journalists for that.

What if opponents and supporters of MOC actually sat down and talked to each other instead of past each other? I’ve always supported the principle of lifelong learning. I just don’t think MOC embodies the principle well enough. And let me point out that there are conflicts of interest in at least one of the authors of the JAMA MOC supporter article:

“Dr Hawkins reports being the co-editor of a textbook on the evaluation of clinical competence for which he receives royalties from Elsevier; being a salaried employee of the American Board of Medical Specialties from February 2009 until December 2012.”

Does that completely invalidate their position? Many would say so based on the millions of dollars the MOC machine makes for board members. See how easy it is for me to fall into the anti-MOC tirade? I’ve been doing it for years.

On the other hand, I agree that patients deserve to know their physicians are keeping up with medical knowledge and skills. I don’t understand where the evidence is which supports private insurers requiring participation for reimbursement. I applaud boards for at least trying to make the MOC processes less burdensome. However, even the AMA has adopted a policy that sounds very similar to those being approved by many state medical societies:

“Any changes to the MOC process should not result in significantly increased cost or burden to physician participants (such as systems that mandate continuous documentation or require annual milestones).

The MOC program should not be a mandated requirement for state licensure, credentialing, reimbursement, insurance panel participation, medical staff membership, or employment.”

How do we get to yes?

Separate the people from the problem–You don’t have to be a conservative or a liberal to love or hate MOC. The issue is how do doctors, young and old, engage genuinely in lifelong learning and reflective personal practice assessment?

Focus on interests, not positions–Would focusing on our mutual interests include how to make sure we’re paying attention to developing all the attitudes, knowledge, and skills that help doctors help patients heal and thrive?

Generate options for mutual gain–Would it make sense to validate other methods as alternatives to MOC for staying competent and achieving excellence as physicians, being role models for medical students and residents, and acting as empathic, humanistic clinicians?

Agree on using objective criteria–What would be acceptable to patients, doctors, and regulatory boards to use as objective markers for successful application of medical core competencies as identified in the medical literature?

Sound good? Down with MOC! Oops, sorry, that was a slip. Let’s all calm down and contemplate what happens in the natural world where politics doesn’t matter and survival does.

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Comments

  1. Reasonable perspective as usual Jim.

    I will read the Mendez article (I worked with him for a short time) but the neuroscience of political preferences is highly speculative at this time.

    I like the anthropological observations myself. In that regard, I consider Keeley’s small book War Before Civilization to provide the basis for most political interaction. Keeley points out that from the beginning of time man has had group conflict that originated based on the dynamic of contempt for members of opposing tribes and generally violent action based on that contempt. For example, ancient villages would attempt to obliterate a neighboring village over what was often a fairly minor transgression.

    That pattern has played out a million times since. Thankfully – typical political conflict can be more symbolic than actually violent these days. The lesson is that very few people seem to be capable of overcoming that polarizing bias – even when they know all of the facts. All of this plays out with Congress and the Trump administration every day.

    I think it is quite reasonable to not compromise at all with the ABMS when they come up with arbitrary requirements, inadequate justification, and have conflict of interest that greatly exceeds that of 95% of the physicians in this country. Playing the patient accountability card is also not cool. I am still surprised that many of the physicians I talk with do not know about the NBPAS. If that movement got more traction and passed enough legislatures to be an alternative to ABMS MOC – any negotiation or ongoing confrontation would be unnecessary.

    George

    George Dawson, MD, DFAPA

    Liked by 1 person

    • Well said, George. I think it’s pretty clear that greed drives the ABMS MOC program. We should be able to elect board leaders and vote them out when they don’t represent us.

      Liked by 1 person

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