Archive for the ‘Professionalism’ 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.

“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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Is there a direct connection between communication skills and the art of successful leadership? Most of us would agree that there is. But is there a direct connection between blogging and leadership? That may be more of a reach.

Can the process of writing a blog help to develop communication skills that will prove useful in leadership? In my opinion the answer is yes, but a qualified yes. Writing a blog won’t help anyone become a good writer who never learned to write competently in the first place. Perhaps even more important, writing a blog won’t help anyone become a thought leader who hasn’t developed any original thoughts.

Communicating a vision

To make a real mark in history, a leader has to communicate a vision that people understand. The vision must be powerful enough to motivate them to follow. In decades past, for instance, the men who became President of the United States typically were graduates of liberal arts education, trained in the arts of debate, oratory, and essay composition. They knew how to make their points.

No matter which end of the political spectrum you favor, most of us would agree that Presidents John F. Kennedy and Ronald Reagan were gifted communicators. Though obviously they benefited from the help of speechwriters behind the scenes, both were skillful writers on their own, as proved by their private documents and letters.

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Nothing brings out the mama lioness in me more than seeing one of my cubs not being treated as well as I think it should be.

Recently I had the unusual experience of accompanying my oldest daughter into an unfamiliar hospital for a minor surgical procedure. Now this daughter isn’t exactly a cub — she’s a full-fledged adult, with a master’s degree in health care administration, a husband, and two small boys of her own.

But as I watched the OR team prepare her for surgery, I started to feel like an odd combination of a mama lioness and a secret shopper. To the staff members who came in and out of the hospital’s preoperative area, it was clear that I was simply the family member in the corner, and they probably figured I had little clue about what was transpiring. Meanwhile, I was taking in every detail. Some tasks were performed excellently — others, not so much.

The hospital where her surgery took place is a small community hospital on Long Island. It enjoys a location where Jerry Seinfeld, Christie Brinkley, and other wealthy New Yorkers maintain lavish homes for weekend and summer holidays.

My daughter was instructed to arrive at 6:30 a.m. Her procedure involved an initial stop in radiology, to be followed by the actual surgery. As a veteran of hospital life, I questioned whether radiology even opened that early, but we had no way of checking. So we left her house at 5:25, driving carefully on dark, icy roads with fresh snow, and lining up for a 5:40 a.m. ferry ride from her home town so that we could arrive at the hospital by 6:30.

The good news — a valet met us at the hospital door and whisked away the car, so we had only a moment to savor the 20-degree weather and the harsh wind that made it feel colder. My daughter was promptly escorted to a private room to change clothes.

Hurry up and wait

A nurse gave her an insulated paper gown with two openings to connect it to a wall-mounted forced air warming unit. This, I thought, was a wonderful thing. Where I’ve worked, we had forced air warming blankets in the ORs but the hospital wouldn’t spend the money to put them in the preoperative areas. I thought of Tina Fey, playing an immigrant from Albania in a Saturday Night Live spoof of the HBO series “Girls”, and imagined her saying, “In my country, we do not have such things.” Within minutes, my daughter’s gown was hooked up to the warmer and she was feeling much cozier.

Then we waited.

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Is it always wrong for a surgeon to book cases that will be done in two operating rooms during the same timeframe?

If you’ve paid much attention to the overheated commentary on social media since the Boston Globe published its investigative report, “Clash in the name of care“, you might easily conclude that the surgeon who runs two rooms ought to be drawn and quartered, or at least stripped of his or her medical license.

John Mandrola, MD, a Kentucky cardiologist who I’ll bet doesn’t spend a lot of time in operating rooms, weighed in on Medscape with a post called “The Wrongness of a Doctor Being in Two Places at Once“, accusing surgeons of hubris and greed.

Respectfully, I disagree.

The Globe’s story tells the dramatic tale of how a prominent surgeon at Massachusetts General Hospital often scheduled two difficult spine operations at the same time. According to the Globe’s reporters, the surgeon typically moved back and forth between two operating rooms, performing key parts of each procedure but delegating some of the work to residents or fellows in training.

On one particular day, a complex case ended with a tragic outcome. The patient, a 41-year-old man, sustained spinal cord injury at the level of his neck, leaving him permanently unable to move his arms or legs. Another prominent MGH surgeon leaked details of the case to the press, and was summarily fired.

Of course, I have no special access to information about what goes on at the MGH, and can’t comment on the specific cases highlighted in the Globe’s report. But I’ve been giving anesthesia for a long time in first-class hospitals. On countless occasions, I’ve seen surgeons run two rooms, and have administered anesthesia to a patient in one of them.

Have I ever seen a patient come to harm because the surgeon scheduled concurrent cases?  No.

Have I ever been annoyed because a surgeon delayed the start of my patient’s case because of the demands of the case in the other room? Yes, but I always agreed with the decision to delay, and the wisdom behind it. If the surgeon is at a critical portion of the first case, we have no business starting the second case until the surgeon gives the go-ahead.

Have I ever been thankful that the surgeon had two rooms? Yes indeed. Here’s why.

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