A strong argument can be made that the biggest story from the American College of Cardiology 2014 Scientific Sessions was the contentious debate concerning the quasi mandate to enroll in the American Board of Internal Medicine (ABIM) Maintenance of Certification (MOC) process. Managing editor of heartwire , Shelley Wood, covered this issue in a report aptly titled: "Today Is the Day: Cardiologists, Did You Register for MOC?"
I've been trying to put together my thoughts on this one for a while. My good friend and colleague, Dr Wes Fisher (Chicago, IL), has led the opposition to mandating MOC testing. Wes's blog and Twitter feed hold a trove of reasons for his opposition. As for me, I needed a nudge to start writing on this contentious topic.
My inertia ended when reading the hubris evident in the words of two doctors Wood interviewed for her piece. What follows is both a response to the words of Dr Richard Becker (University of Cincinnati College of Medicine, OH) and Dr Kim Williams (Wayne State University School of Medicine, Detroit, MI) and an attempt to synthesize my thoughts on MOC testing. Here goes (it's brief):
The matter of ensuring physician quality is a very difficult problem. I'm for having informed doctors. You are too, surely.
Becker and Williams make important points about the pace with which the practice of medicine moves. They emphasize the importance of keeping up. There can be no argument about continuing education.
The matter for debate is whether the ABIM method—and, to be frank, its arm-twisting tactics—is the best means to achieve physician quality.
Doctors are taught to be skeptical of evidence. Here, there is simply no evidence to judge. We can't know whether this brand of medical education achieves improved patient outcomes. Maybe it will. Maybe it will not. Or, perhaps it could even make it worse. How could aggressive education and measuring of quality make things worse? Think heart-failure metrics and an 89-year-old, who, a week later, presents with a broken hip from all those evidence-based pills. I have many more examples, but I promised brevity.
One of the factors used in judging clinical evidence is conflict of interest. It's normal to question studies from companies and groups that stand to benefit. So, even if the ABIM and its medical specialties, like ACC, for instance, had studied the MOC question, which they haven't, the conflicts of interest would be enormous. When medical specialties benefit financially and top physician-executives at the ABIM make more than $700K per year in non–call-taking roles, a skeptic is left troubled.
Then there is the paternalistic tone Becker takes toward his working colleagues. I'm not sure he got the message: paternalism in medicine is out. Maybe he is not keeping up to date?
Becker and Williams laud the utility of doctors knowing new information. Indeed, the stay-up-to-date mind-set is an easy heuristic, but valuing new over old information has flaws. Consider that renal denervation is new. Wink. Squishing valves in the infirmed and elderly is new. (And you don't find it surprising that there's a new awareness campaign for valvular heart disease.)
Here's an observation: One of the biggest quality problems I see from my front-row seat in the real world of medical practice is that the new stuff doctors learn sometimes pushes out the important old stuff. You know, old stuff like asking patients what bothers them most (eg, taking a history); or noticing frailty from the door (eg, doing an exam); or seeing a person rather than a list of diseases for which boxes need to be checked; or this, which is most relevant for cardiologists: recognizing death as inevitable rather than optional.
Will MOC modules accomplish all that? Call me a doubter.
I know what you may be thinking. If not the ABIM MOC brand, how else could medical education be accomplished and confirmed?
You know I don't have those answers. But it's useful to note a few things about the time we live in.
First, there is this thing called the digital revolution. I can look up impossible-to-remember QT syndromes on a smartphone in five seconds at the bedside of a patient. Grapefruit juice and drug interactions? No problem either. Just two taps on the white screen.
Then there is the fact that a Twitter feed can provide links that lead to educational material that's not behind pay walls. Shh. You can learn from blogs. (Darn it, I'm not sure I should have typed that.)
Then there is the fact that I can send an ECG image around the globe in seconds for consultation.
Finally, there is the fact that many educational institutions have stopped using SAT/ACT testing in evaluating students. Why? Because when studied systematically, the mandatory tests did not predict student performance. Imagine that.
Perchance we need a time-out for MOC testing?
JMM
Cite this: Call Time-out for the ABIM MOC Mandate - Medscape - Apr 01, 2014.
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