In the interests of full disclosure, I acknowledge with delight that I have a non-time limited board certificate from the American Board of Anesthesiology (ABA), issued before the year 2000. I can just say “no” to recertification.

The more I learn about the American Board of Medical Specialties (ABMS) and its highly paid board members, the more disillusioned I’ve become. It’s easy to see why so many physicians today have concluded that ABMS Maintenance of Certification (MOC) is a program designed to perpetuate the existence of boards and maximize their income, at the expense primarily of younger physicians.

Lifelong continuing education is an obligation that we accepted when we became physicians, recognizing that we owe it to ourselves and our patients. That is not at issue here. We have an implicit duty to read the literature, keep up with new developments, and update our technical skills.

The real danger of MOC is this:  It is rapidly evolving into a compulsory badge that you might soon need to wear if you want to renew your medical license, maintain hospital privileges, and even keep your status as a participating physician in insurance networks. If physicians don’t act now to prevent this evolution from going further, as a profession we will be caught in a costly, career-long MOC trap. The only other choice will be to leave the practice of medicine altogether, as many already are doing.

What can be done?

The American Medical Association (AMA), to its credit, passed a resolution this year calling for the “immediate end of any mandatory, recertifying examination by the American Board of Medical Specialties (ABMS) or other certifying organizations as part of the recertification process.” Further, AMA policy states:

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.

Many physicians have rebelled against compulsory MOC and have succeeded in getting the attention of their state legislatures. The state of Oklahoma passed a law in April, 2016, stating that nothing in its laws concerning medical practice shall be construed to make MOC “a condition of licensure, reimbursement, employment, or admitting privileges at a hospital in this state.” Kentucky’s governor signed a more limited measure that forbids making MOC a condition of state licensure. Other states are considering joining Oklahoma as “Right to Care” states.

The California Medical Association (CMA) considered but didn’t pass an anti-MOC resolution at its October meeting. However, there is enthusiasm for pursuing the resolution again in 2017, and it appears to have a strong chance of passing. The title of the resolution is, “Maintenance of Certification should not be used as criteria to assess physician competence”, and it would direct CMA to work with the Medical Board of California to promote legislation prohibiting MOC “as a mandated requirement for physician licensure, credentialing, reimbursement, network participation, or employment.”

NBPAS: An alternative to the ABMS monopoly

If there were unquestioned proof that the MOC process improves patient care and outcomes, then the expense and time would be more justifiable. However, no such data exist. Initial board certification is associated with higher-quality practice, but recertification with MOC programs is not. As Paul Mathew, MD, commented in the November/December 2016 issue of Practical Neurology, “Literature regarding the evidence supporting recertification with MOC programs is weak at best, and most is written by conflicted authors who are executive board members of ABMS boards.”

A good example proving Dr. Mathew’s point is a recent editorial defending MOC in the New England Journal of Medicine (NEJM). The co-authors have close ties to the American Board of Internal Medicine (ABIM) and its foundation, which have been mired in financial scandal. It would be hard to defend a claim to scholarly objectivity.

Dr. Mathew and I are both unpaid, voluntary board members of the National Board of Physicians and Surgeons (NBPAS), an organization founded two years ago by Paul Teirstein, MD, a cardiologist at the Scripps Clinic in La Jolla. Dr. Teirstein’s frustration with ABIM’s expensive MOC requirements led him first to create a web-based petition that rapidly accumulated more than 19,000 physician signatures. He then founded NPBAS as a grass-roots physicians’ organization, offering a cost-effective alternative pathway for board-certified physicians to demonstrate their commitment to continuing medical education (CME) while bypassing the ABMS and MOC.

The challenge, of course, for NBPAS is to achieve recognition by hospitals and insurers, which is a slow process. But progress has been made, as thousands of board-certified physicians (myself included) have earned two-year NBPAS certificates, and thousands more are in the process.

The anti-MOC movement shows no signs of abating. An October, 2016 article in the Mayo Clinic Proceedings concluded that only 24 percent of physicians agreed that MOC activities are relevant to their patients, only 15 percent thought they were worth the time and effort, and 81 percent believed that they were a burden. These results were “pervasive, and not localized to specific sectors or specialties.”

The ABA and MOCA 2.0

To the credit of the American Board of Anesthesiology (ABA), it was one of the first boards to pay attention to the discontent of its diplomates. In May, 2015, it convened a two-day summit to consider redesign of its Maintenance of Certification in Anesthesiology Program (MOCA), and concluded that its ten-year “high-stakes MOC exam is not the most effective way to help its board-certified physicians learn and retain medical knowledge.” The ABA decided to embrace “multiple learning techniques”, and introduced the “MOCA Minute” program, where physicians must answer 30 online questions each calendar quarter or 120 questions annually. This new approach has not brought with it any decrease in cost to participants.

I might be tempted to enroll in the “MOCA Minute” program if I didn’t think that it would be equivalent to stepping in quicksand, and that extrication would be impossible.

After watching residents doing practice multiple-choice questions for years, I’ve reached the conclusion that their time would be better spent reading a good basic anesthesiology textbook and review articles in major journals. The inherent problem with all the multiple-choice questions is that the resident ends up reading three or four wrong answers for every correct one. No wonder they become confused. They would be better off reading only correct information.

I have a fundamental objection also to the ABMS “Six Core Competencies” as the bedrock of the MOC program. Some of them – practice-based learning, patient care, procedural skills, medical knowledge – are fine. But the last two are another matter:

“Interpersonal and Communication Skills: Demonstrate skills that result in effective information exchange and teaming with patients, their families and professional associates (e.g. fostering a therapeutic relationship that is ethically sound, uses effective listening skills with non-verbal and verbal communication; working as both a team member and at times as a leader).

Professionalism: Demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles and sensitivity to diverse patient populations.”

These are qualities that we all needed to learn and incorporate into our daily practice long before we were board-certified. If you didn’t have an inherent sense of ethical conduct and personal responsibility before you left elementary school, nothing the ABA does is going to change you. If you can’t communicate, a multiple-choice test won’t help. These topics are not properly the business of continuing medical education.

If MOCA is truly valuable, then the ABA should have enough confidence in its product not to make it mandatory. It should compete in the CME marketplace with meetings, journals, online materials, and every other CME product. Board-certified physicians should be able to choose among all these to demonstrate “lifelong learning” and renew their time-limited certification.

It’s time to make it clear to the ABMS that we’re not its indentured servants. The time to do that is now, before it gains any more ground in making our right to work dependent on surrender to MOC.

2 COMMENTS

Oren Bernstein

I could not agree more. I faithfully did my MOCA 2.0 activities for the past year to honestly judge their utility to me as a physician and to my patients. I thought the MOCA minute was a poorly-executed, low-quality activity. The ASA already publishes the ACE and SEE programs which seem to serve the same purpose. MOC has never been proven to improve outcomes. I stay current out of duty to the community I serve, not because a paternalistic board holds a financial gun to my ...Read More

Andrew

I agree. I also have non-time limited board certification, but feel that my younger colleagues are subjected to an overly burdensome, costly and ineffective process. Let's make our voices heard.

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Six-year-old Caleb Sears:  His death was preventable

I’m not a pediatric anesthesiologist. Most of us in anesthesiology – even those who take care of children in the operating room or the ICU every day – probably will never give anesthesia to a child in a dentist’s or oral surgeon’s office. So why should we care what happens there? Dental anesthesia permits and regulations, after all, are under the authority of state dental boards, not medical boards.

The reason we should care is that healthy children have died under anesthesia in dental office settings, children like Marvelena Rady, age 3, and Caleb Sears, age 6. Unfortunately, they aren’t the first children to suffer serious complications or death in our state after dental procedures under sedation or general anesthesia, and unless California laws change, they won’t be the last.

In 2016, officers and past presidents of the California Society of Anesthesiologists (CSA) have made multiple trips to meetings of the Dental Board of California (DBC) to discuss pediatric anesthesia. We’ve provided detailed written recommendations about how California laws concerning pediatric dental anesthesia should be updated and revised. We’ve explained in testimony before the Dental Board, and in meetings with lawmakers, why we believe so strongly that the single “operator-anesthetist” model (currently practiced by dentists and oral surgeons in many states) cannot possibly be safe.

The DBC on December 30 published new recommendations for revision of California laws pertaining to pediatric dental anesthesia, posted them on its website, and sent them to the Senate Committee on Business, Professions, and Economic Development. But these recommendations ignored many of our concerns, and don’t go nearly far enough to protect children.

What is a single “operator-anesthetist”?

You may never have heard of a single “operator-anesthetist” because such a thing doesn’t exist in medical practice.

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4 COMMENTS

Alan Schneider M.D.

The real shocking statistic is that there are not more deaths if Dentists, along with their assistants, are allowed to provide sedation to children. Because one thing for sure it will not be moderate sedation in a child. I am amazed they are even able to get the IV started I trained decades ago as a pediatric anesthesiologist, although supervise mostly adults now, but even my adrenaline would be pumping if I provided sedation to a child in an office setting
Unnecessary dental sedation deaths persist. The practice of single-operator anaesthetist should have been stopped many many years ago. Thank you for an excellent article.

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“I’m your friend,” Harvard Business School Professor Michael Porter, MBA, PhD, told a sometimes skeptical audience during his keynote address at the ASA’s annual meeting, ANESTHESIOLOGY 2016. “I’m trying to help you see a better way forward, and avoid the bad outcomes that may happen if we don’t transform healthcare.”

Porter is a well-known economist, an expert on business strategy, and the author of the book Redefining Health Care: Creating Value-Based Competition on Results. In his speech to the ASA, he argued the case for redefining health care by making “value for the patient” the unifying purpose, and he urged anesthesiologists to forget pay for volume.

“How should anesthesiologists engage in bundled payments?” Porter asked. “Jump on them!”

Explaining that he has spent the past 15 years immersed in studying health care delivery, Porter said that he looks on health care as one of the world’s “most fundamental and intractable problems.” He asked listeners to think again about anesthesiology practice, and its role and responsibilities in the future of health care.

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1 COMMENT

Richard Ogden

I have spent the best part of 26-years working in the operating theatres in the UK, alongside some magnificent anaesthetists; and I must say this article is rather a sad one. The Anaesthetist, from a rather prejudiced point of view, is by far more important than the surgeon: if not because they facilitate safe operating conditions for the surgeon, then because they are the patients brain (Dr A Vohra Cons Anaesthetist) whilst under anaesthesia. Moreover, the Anaesthetist has the ability to provide considerable skill and ...Read More

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Classic rock music lovers who think they don’t like poetry, and literary purists who think they don’t like popular music, may have been equally baffled to hear that Bob Dylan is a winner of the Nobel Prize in Literature. As an unrepentant English major, I’m delighted.

I can’t remember a time when Dylan’s music wasn’t a part of my growing up, from the rebelliousness of the anti-Vietnam era to the bittersweet maturity of “Tangled Up in Blue“, my all-time favorite.

When you think about it, any time you listen to a song — a current popular hit, a 1950’s oldie, or a centuries-old ballad like “Greensleeves” —  you’re listening to poetry, only with a tune. In ancient times, before most could read or write, people turned stories into poetry and sang them because rhyme and melody made the stories easier to remember and retell. Much of rap music is poetry (often crude, but still poetry) with complex use of rhyme and assonance, and the musical element reduced to a backdrop of pounding rhythm.

Poetry set to music can convey any and all human emotion. Love, of course. Jealousy — absolutely. Just pick a musical genre, and there’s a hit song about jealousy. In pop music, Taylor Swift’s “Blank Space” lets her revel in her psycho side. In country music, Carrie Underwood graphically explains in “Before He Cheats” what can happen when a woman wants revenge on her faithless lover, and takes it out on his car. And the still-creepy “Every Breath You Take“, the 1983 classic rock hit by The Police, blurs the fine line between devotion and obsession.

Then there’s the universal human experience of grief. There was a time when every parent expected to lose a child, or more than one, because children often died from pestilence and poor sanitation. When my daughter Alexandra died unexpectedly at the age of five months, I couldn’t decide which was worse — thinking that I wouldn’t survive, or being horribly afraid that I would.

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4 COMMENTS

Beautiful. When we practice medicine and when we practice life with vulnerability we often find just what we're missing -- inevitable connection.

Rick Novak

Well said. Dylan wrote love songs, angry songs, sad songs, uplifting songs, protest songs, long fable songs, and mystifying songs, . . . like no one before him.

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You may have read about the recent tragic deaths of two healthy children – Marvelena Rady, age 3, and Caleb Sears, age 6 – in California dental offices. Unfortunately, they aren’t the first children to die during dental procedures, and unless things change, they probably won’t be the last.

State Senator Jerry Hill has asked the Dental Board of California (DBC) to review California’s present laws and regulations concerning pediatric dental anesthesia, and determine if they’re adequate to assure patient safety. Assemblymember Tony Thurmond has sponsored “Caleb’s Law”, seeking improved informed consent for parents.

On July 28, I had the opportunity to attend a stakeholder’s meeting at the Department of Consumer Affairs in Sacramento, to hear a presentation of the DBC’s report, and to be part of the delegation offering comments on behalf of the California Society of Anesthesiologists (CSA). We hope this is the beginning of some long overdue upgrades to the current regulations.

By long-standing California state law, dentists and oral surgeons are able to provide anesthesia services in their offices even for very young children or children with serious health issues. They may apply for one of four different types of permits for anesthesia:

General anesthesia

Adult oral conscious sedation

Pediatric oral conscious sedation

Parenteral conscious sedation.

But the route of administration – oral or intravenous – isn’t the point, especially for small children, and oral sedation isn’t necessarily safer. Sedation is a continuum, and there is no way of reliably predicting when a patient will fall asleep. Relaxation may turn into deep sedation, and deep sedation into a state of unresponsiveness which is equivalent to general anesthesia. Oral medications have led to deaths in children, sometimes even before the dental procedure has begun or well after it has finished. There’s no logic in California’s lower standards of emergency equipment and monitoring for procedures done under sedation as opposed to under general anesthesia.

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11 COMMENTS

karen

Dear Dr. Silegy, Apparently the province of Alberta, Canada, disagrees, after a four-year-old ended up with brain damage: http://globalnews.ca/news/3036086/alberta-dental-association-suspends-single-operator-model-for-deep-sedation-anesthesia/ The second anesthetist could be one of your partners, or a dentist with additional training in anesthesia as required by state law. Again, it's all about having a second trained independent anesthesia provider whose only job is to watch the child's airway, vital signs, and breathing. Just as I would want for my own child. Best, Karen Sibert, MD

Dr. Tim Silegy

Dear Karen: As I stated in my earlier comment, there are no facts to support your argument that two provider anesthesia is safer than single in these particular cases. Your allegation of oral surgery assistants administering anesthesia is unsubstantiated and NOT factual. I take exception to your comment that my defense of the single operator/anesthetist model is financially self serving. Itinerant medical and dental anesthesiologists have much more to gain from potential new regulations than I do.

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