Archive for the ‘Medical Education’ Category

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.

This column ran first in the online magazine for medical students, “in-Training”

In case you were wondering — robots won’t replace anesthesiologists any time soon, regardless of what the Washington Post may have to say. There will definitely be a place for feedback and closed-loop technology applications in sedation and in general anesthesia, but for the foreseeable future we will still need humans.

I’ve been practicing anesthesiology for 30 years now, in the operating rooms of major hospitals. Since 1999 I’ve worked at Cedars-Sinai Medical Center, a large tertiary care private hospital in Los Angeles.

So what do I think today’s medical students should know about my field?

A “lifestyle” profession?

For starters, I have to laugh when I hear anesthesiology mentioned with dermatology and radiology as one of the “lifestyle” professions. Certainly there are outpatient surgery centers where the hours are predictable and there are no nights, weekends, or holidays on duty. The downside? You’re giving sedation for lumps, bumps, and endoscopies a lot of the time, which can be tedious. You may start to lose your skills in line placement, intubation, and emergency management.

Occasionally, though, if you work in an outpatient center, you’ll be asked to give anesthesia for inappropriately scheduled cases on patients who are really too high-risk to have surgery there. These patients slip through the cracks and there they are, in your preoperative area. Canceling the case costs everyone money and makes everyone unhappy. Yet if you proceed and something goes wrong, you can’t even get your hands on a unit of blood for transfusion. To me, working in an outpatient center is like working close to a real hospital but not close enough — a mixture of boredom and potential disaster.

The path I chose is to focus on high-risk inpatient cases. I especially enjoy thoracic surgery, with the challenges of complex patients and one-lung ventilation. You can bring me the sickest patient in the hospital setting — where I have all the monitoring techniques, resuscitation drugs, blood products, bronchoscopes, and anything else I might need — and I’ll be perfectly happy. The downside: a practice like mine tends to be stressful and tiring, and I never know the exact time that the day will end. Hospitals that offer Level I trauma and high-risk obstetric care are required to have anesthesiologists in house 24 hours a day, 365 days a year. There’s no perfect world.

What type of person is happy as an anesthesiologist?

Even though women comprised 47% of the US medical school graduates in 2014, only about 33% of the applicants for anesthesiology residency were women. I’d be interested to hear from all of you as to why fields such as pediatrics and ob-gyn tend to be so much more attractive to women, because I genuinely don’t understand it. But I do have a few thoughts as to the type of person who is happy or unhappy as an anesthesiologist.

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Dr. Margaret Wood, who chairs the Department of Anesthesiology at Columbia University Medical Center, has published a wonderful article titled “Women in Medicine:  Then and Now“, in the journal Anesthesia and Analgesia.

I think I speak for many of us in admitting that Anesthesia and Analgesia doesn’t occupy a prominent place on my bedside table. Many readers may have missed Dr. Wood’s article. That’s a shame, because it isn’t just about anesthesiology, and speaks to issues in medicine independent of specialty or gender. Here are some of my favorite passages about lessons she learned over the course of her long and successful career:

“1. It is important to have a passion for what you do if you strive for excellence. If you have that passion, then the efforts do not feel like a sacrifice and “burnout” is not an issue. I cannot imagine that Virginia Apgar spent a single moment talking, thinking, or worrying about burnout.

2. The current fashion to complain about “life balance” can be self-destructive; however, pacing oneself is critical. You can have it all, just not all at once. The Chairman of Anatomy gave the inaugural lecture to my incoming class of medical students. His thesis was that as a physician/medical student you could have (i) an active time-consuming social life, (ii) a family, and (iii) a career, but to be successful you should have no more than two of these at the same time. I believe this to be true and have followed this advice since.

3. Women should be careful not to fall into the trap of feeling entitled to special considerations or engage in special pleadings. Our patients want their physician to be the best, whatever his or her sex. There is no room for a physician of either sex who is less qualified or less committed because of outside responsibilities.

4. Women no longer need to “prove themselves” against the sea of doubters who dominated medicine 40 years ago. Fortunately, we are now past that point and such doubts, are I hope, antediluvian. Women are where they are today, however, because many of us felt that demonstrating that women really could “do it” was a moral imperative and one to which we were fully committed.

5. Parents need to manage their work and family responsibilities to ensure that both receive their full attention. This will often mean ensuring that they have excellent childcare to allow them to have the confidence to focus on work when that is required. This may be expensive, but it is a critical investment by both parents in their family’s future. Successfully raising children is a joint responsibility of both partners; what is critical to women is also critical to men, and vice versa. Women starting out on this journey can be assured that it is possible to raise well-adjusted children in a home in which both partners have challenging and successful careers, provided there is a true partnership in the family.”

Is Dr. Wood a curmudgeon, or perhaps a dinosaur? That could be, but I find her honesty refreshing.

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Dr. Sandeep Jauhar, a cardiologist, believes with good reason that many physicians have become “like everybody else:  insecure, discontented and anxious about the future.”  In a recent, widely-circulated column in the Wall Street Journal, “Why Doctors Are Sick of Their Profession,” he explains how medicine has become simply a job, not a calling, for many physicians; how their pay has declined, how the majority now say they wouldn’t advise their children to enter the medical profession, and how this malaise can’t be good for patients.

Dr. Jauhar gets it right in many ways, but the solutions he recommends miss their mark completely.

I was 100% in accord with Dr. Jauhar when he argued that “there are many measures of success in medicine:  income, of course, but also creating attachments with patients, making a difference in their lives and providing good care while responsibly managing limited resources.”

The next paragraph, though, I read with astonishment.  Does Dr. Jauhar really believe that publicizing surgeons’ mortality rates or physicians’ readmission rates can be “incentive schemes” that will reduce physician burnout?  Does he seriously think that “giving rewards for patient satisfaction” will put the joy back into practicing medicine?

If so, I’m afraid he doesn’t understand the problem that he set out to solve.

The truth behind “quality” metrics

There is no question that some physicians are inherently more talented, more dedicated, and more skilled than others.  In every hospital, if you speak to staff members privately, they’ll tell you which surgeon to see for a slipped disk, a kidney transplant, or breast cancer.  They’ll tell you which of the anesthesiologists they trust most, and which cardiologist they would recommend to someone with chest pain.  But none of these recommendations are based on simplistic metrics like readmission rates or even mortality rates.  They are based on observations over time of the physicians’ ability, integrity, and conscientiousness–all of which are tough to quantify.

Let’s take, for example, a common operation such as laparoscopic cholecystectomy:  removal of the gallbladder using cameras and instruments inserted through small incisions in the abdomen.  This is a procedure which most general surgeons perform often, with few complications.

When complications occur, there are almost always factors involved other than surgical error.  Patients with diabetes are more likely to develop wound infections, for instance.  Surgery on patients who have had prior abdominal operations may take longer and could cause bleeding or damage to other internal organs because of scar tissue.  Morbid obesity and advanced age are risk factors too.

The surgeon whose mortality rates are higher, or whose patients are more likely to be readmitted to the hospital, may be dealing with a much different patient population from the surgeon with the lowest rates.  An inner-city hospital may admit more patients as emergency cases, in more advanced stages of disease.

It’s difficult for statistics to reflect accurately the dramatic differences among patients that affect surgical outcome.  A noncompliant patient who doesn’t fill prescriptions and follow instructions is more likely to have problems, independent of the experience and skill of the surgeon.  Trying to distinguish among surgeons with “outcomes data” will only result in more surgeons refusing to operate on high-risk patients.

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This column was written on behalf of the American Society of Anesthesiologists, and was first published by KevinMD on December 22, 2013.

When you need anesthesia for surgery or a diagnostic procedure, of course you want to know who’ll be giving you anesthesia.  If you live in Texas, Florida, the District of Columbia, or 14 other states, you may be lucky enough to have an anesthesia team taking care of you that includes a physician anesthesiologist and an anesthesiologist assistant, or “AA”.  If you live in many other states–including my own state of California–care from an AA isn’t yet an option.

Many Americans have never heard of anesthesiologist assistants.  Even many physicians are unaware that the profession exists.  But for more than 45 years, AAs have worked alongside physician anesthesiologists in exactly the same way that physician assistants (PAs) work with a surgeon, internist, or pediatrician–using teamwork to deliver the best possible medical care to their patients.

Today, there are more than 1400 certified AAs in the U.S.  Why are they limited to practicing only in certain states?  It’s a complicated question.  The answer involves the fierce opposition of nurse anesthetists to the very existence of the AA profession, our complex American system of state licensure, and the economics of healthcare.

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