I am in receipt of your membership renewal notice. I was formerly a member, but have allowed my membership to lapse, because I, like many physician colleagues, feel that we are not getting much for our money from the ACP. With each passing day, the medical profession is being over-regulated to the point where functioning as a physician in this country is becoming an overwhelming and nearly untenable task. Worse, organizations such as yours purport to speak out for the concerns of physicians, but those of us on the front lines more and more question whether that is really the case. Take, for instance, the issue of MOC and MOL.
I am triple board certified in IM, pulmonary and critical care. I first certified in all three 20 years ago, then recertified in all three 10 years ago, and I just recertified in IM yet again 1 year ago. I have no intention of ever participating in any more MOC. It has become clear to me, as it has to many physicians, that MOC has done nothing to benefit me or my patients, and, in fact ,I believe I can make some cogent arguments that it has been detrimental to both me and my patients, whereas it has been extremely beneficial, financially, to a relatively small group of MOC proponents.
Historically, becoming board certified was the culmination of efforts made to become proficient in a particular branch of medicine and, like the bar for our legal colleagues, once certified, you remained certified for life. By our very nature, and the nature of our work, lifelong education was and is a given, with doctors choosing and pursuing CMEs in those areas most relevant to their interests and the needs of their particular practices. For the purposes of public safety, and to coerce the few medical professionals who might not pursue lifelong learning when left to their own devices, state regulations have for decades mandated a wide variety of requirements for practicing doctors, including, at least in my state of NY, a requirements for 50 hours of CMEs annually (as compared to 12 for our legal colleagues), along with maintaining good standing in other realms (good moral character, with all that that entails).
Ongoing voluntary MOC was offered, but for years, physician involvement was very sparse. Why? Because physicians understood that the process was onerous, did not improve patient care and was costly. Meanwhile, those who stood to benefit financially by expanding MOC understood that unless they found a way to take a process that was always characterized as “voluntary” was in some way make it mandatory, that their cash flow would be a fraction of what it could be. So, in the 1990s, with no credible research justifying the change, we saw the end of life-long certification and the beginning of time limited 10 year certificates. Still, even this did not result in the dramatic upswing in MOC participation that MOC proponents wanted and so now, we see the next phase of turning MOC from a voluntary to a mandatory process, namely, efforts to link MOC to hospital privileges, Medicare, insurance reimbursements and maintenance of licensure (MOL).
The practice of medicine is far different today than even 10 years ago. The sheer amount of medical knowledge, already voluminous, explosively expands every year, well beyond the capacity of all but a few to memorize. Fortunately, memorization of vast amounts of medical knowledge is no longer needed in order to deliver good medical. Modern medicine is open source, open resource and open colleague. I can use smart devices, such as a smart phone, tablet, or PC, at the point of care, to instantly and accurately access vast amounts of medical data exactly when I need it. One can then argue, I suppose, that if a device is providing the information, then why is the doctor even needed? The answer is simple. It is the doctor who is then able to take the raw information and apply it to an individual patient, something a device cannot do.
Let me present some key reasons why I believe I am a good doctor and why my waiting room is packed with patients every day:
1) I know how to do a good physical exam
2) I have excellent communication skills that allow me to establish a rapport with a patient and extract from the patient interview the data I need to understand what the problem is, the first and most crucial step in formulating a treatment plan and to convey back to the patient what I think is wrong and what needs to be done to properly test and treat the problem
3) I communicate well with colleagues, allowing for excellent coordination of care
4) I run a very efficient office and make good use of my EMR, allowing for good patient follow up and follow through
5) I enthusiastically pursue CME in areas that are germane to my daily practice.
Nothing in the MOC program improves any of the above and no device (as least not yet) can really do any of it as well as an actual person, if at all. Now let’s look at the elements of MOC.
1) Home open book modules in which I am asked to answer esoteric questions regarding esoteric medical issues or I am asked to answer questions about medical issues that, while not necessarily esoteric, are constructed in such a way as to be so far removed from real world medicine as to make answering them a near futile and pointless task. Untold hours are spent researching answers to those questions, and, once the question has been answered, the information researched to answer the question is rapidly forgotten as attention is turned to researching the next question, so what is the point?
2) Practice improvement modules (PIM), in which a practitioner chooses from among a list of projects proposed by their board that is meant to “improve one’s practice”. This is nothing more than busy work, involving the pulling and reviewing of many patient medical records, documenting, collating and analyzing data of one sort or another and then proposing and implementing a “plan of improvement”. This is an exceedingly tedious and time consuming activity that takes me and my staff away from our actual work of caring for patients. In my case, I chose the PIM that looked at how well I placed hypertensive patients on aspirin and when all was said and done, it turned out, “shockingly”, that I was already giving such patients aspirin at rates that exceeded what my board felt was the minimum standard. What a waste of time.
3) Patient and colleague questionnaires in which patients and colleagues are supposed to assess me; the effort involved in distributing such questionnaires, ensuring that enough of them get completed and returned and then collating and submitting the results to my board is exceedingly onerous and time consuming
4) The secure exam, very analogous to the take home open book modules, without the open book. A test for which I am practically strip searched, like a common criminal, prior to being allowed entry. A test that contains questions both esoteric and antithetical to real world medical scenarios. I, and all colleagues I’ve spoken to who’ve prepared for this test spend months, sometimes up to a full year, attempting to cram vast amounts of medical trivia into our heads just sufficiently to answer enough questions during a full day test to pass the test, after which all of that crammed knowledge is almost instantly forgotten. Nothing more than the illusion of a educational process that actually fails to educate.
So what has been proven or accomplished by all of my MOC efforts? Am I a better doctor because of this? No! All that has been proven is that I am good, or good enough, at taking and passing a test. I lose time from my practice, time from my family, time for myself and I spend substantial amounts of money on test fees as well as the test preparation courses and study materials without which passing these tests is nearly impossible and for what? So I can hang a piece of paper on my wall that says I am still “certified” and then my hospital, insurance companies, the government and my state licensing board will agree that I can still practice medicine and get paid for my work! Meanwhile, in 2011, publicly available tax documents show that people like Christine Cassel, MD, CEO of the supposedly non-profit American Board of Internal Medicine, made $787,000 and James Stockman, MD, CEO of the supposedly non-profit American Board of Pediatric Medicine made $933,000. These are salaries that I, as a clinician, can only dream about. It is all so outrageous.
This country is facing a variety of medical crises. Physician burn-out is at an all time high. Premature physician retirement is contributing to a substantial physician shortage. MOC, for which there is no compelling research data showing that MOC compliant doctors are better doctors than non-MOC compliant, or for that matter even never certified doctors, is a significant factor is physician burn-out and premature retirement.
More and more doctors feel that organizations like the ACP and the AMA seem to be more and more ineffectual and are not pursuing issues that are important to front line clinicians. Alternative organizations, like Doctors for Patient Care (Docs4PatientCare) and the Association of American Physicians and Surgeons (AAPS), which ask for no dues, minimal dues or voluntary contributions, seem to be the organizations that are now speaking for the practicing physician.
I cannot recall seeing much from the ACP regarding MOC and instead, I feel the ACP should be taking a leading vocal public role in opposing making MOC mandatory in any way. Yet, because the ACP benefits financially from the sale of MKSAP, whose main use is to help doctors pass MOC, many of us feel the ACP is, de facto, in collusion with the FBMS and the ABIM and supports the goal, if not explicitly, than tacitly, of making MOC mandatory.
So tell me, convince me, why I should rejoin the ACP.
Jonathan Weiss, MD