Thursday, January 29, 2015

Making a MOC-kery of Medical Professionalism

A recent war has erupted between physicians and speciality certification organizations, particularly the American Board of Internal Medicine. This revolt has been lead by in particular several impassioned cardiologists in response to the so-called maintenance of certification (MOC) requirements now being levied upon physicians in order to return their status as ‘board certified’ physicians. Board certification is increasingly a necessary requirement for any physician who desires to practice in areas that are considered financially or geographically advantageous. As such, ‘passing the boards’ is the obsession of most house officers and subspecialty fellows I have ever trained. Ironically, most physicians I have known who ‘failed the boards’ are generally poor test takers, or more accurately anxious test takers, rather than those who lack the knowledge to pass the boards. That is not too say that the initial examinations are not in themselves a useful exercise early in ones career. 

However, most board certification organizations now limit their certifications to a somewhat arbitrary term limit of 10 years. Once past that time frame, recertification examination is the norm and increasingly in addition to the certification test, additional work is required to qualify yourself to sit for the board examination. These additional requirements are referred to as Maintenance of Certification activities, which generally require outside study and additional test taking prior to the board examinations. 

A fire storm has erupted in the rank and file of the physician work force particularly the cardiology work force concerning MOC requirements in general and even the requirement for board recertification in particular. Physician complaints are centered around the costs of the process, both in dollars and time commitments, the perceived irrelevance of in particular the MOC activities, disputes over the credentialing bodies assertion that these activities or examinations verify clinical expertise or ensure that the physician is keeping ‘up’ with developments in their respective fields. 

A principle driver for the controversy seems to be in particular the diminishing time horizons for non-academic practicing physicians, by this I mean that wide scale use of EMR technologies have resulted in several hours per day being added to that day in order to document care activities. Additionally, increasing regulatory and statutory requirements also eat away at the practice day adding what is usually considered non-value added tasks to the clinicians work day. Furthermore, as many have argued, the recertification processes are considered extremely expensive and the output of the process considered by many to be irrelevant. Furthermore, bitterness about one more set of agents who demand gold for their services when the value of those services are contentious and debatable. 

Personally, I believe it is naive and virtually delusional to believe that an examination occurring every 10 years makes any contribution in a practical way to ‘keeping up’ with current practice and technical innovations.   

I will use my own professional experiences as an example to illustrate the dimensions of the debate. I completed cardiology fellowship training in 1991, and was a product of a three year fellowship interval, which in the year of my graduation from fellowship was made mandatory from 2 years to three years of training. Current fellowship training is now four years in duration, with an additional 1-2 years added on if you wish to sub specialize in interventional, Electrophysiology, diagnostic imaging (MRI/CT Angiography/Nuclear Cardiology/Echocardidiography), or Advanced Heart Failure and Transplantation). 

At the time of my fellowship training, EP and Interventional Fellowships were just being established. As a fellow, I was trained in non-dynamic SPECT thallium imaging for ischemia scanning and Tc-99m labeled MUGA scanning for LV function assessment as nuclear cardiology techniques. Echo techniques included m-Mode, 2D, pulse wave and continuous wave Doppler, and the hot new thing, color flow Doppler imaging. I was the 2nd Cardiologist in the USAF to be specifically trained in transesophageal echocardiography. IV thrombolysis had just evolved into the standard of practice for acute MI therapy. Diagnostic catheterization was done by brachial artery cutdown or femoral artery access using 7 or 8-French sheaths with manual hold procedures. Dual chamber percutaneous programmable pacemakers were widely implanted but ICD implantation required thoracotomy placement of epicardial patches, and implantation of the defibrillator generator in the subcutaneous tissues of the abdomen with tunneling to the previously placed epicardial leads.The defibrillator had no pacing functionality and if pacing was required a separate pacemaker had to be implanted at the time of that implantation. I was not trained in pacemaker implantation as a fellow. Peripheral angiography and the rudimentary interventions of the time were done exclusively by interventional radiologists. Coronary interventions were limited to proximal lesions of single vessels treated with on the wire balloon systems or over the wire balloon systems that were not rapidly exchangeable and which required two physician operators to effectively utilize the balloon dilatation systems. Complications of angioplasty balloon only procedures were reasonably frequent and ‘bailout’ for complications usually lead to emergency coronary bypass surgical procedures. Post PTCA anticoagulation strategies were limited to heparin and coumadin. Coronary artery non-invasive imaging was limited to dedicated cardiac only high energy tomographic x-ray systems utilizing mono-energetic focused beam x-ray tomographic imaging techniques. Mechanical assist devices were limited to the intra-aprtoc balloon pump. 

I recently sat for and passed my third cardiology board examination. Over the course of my 20(+) career as a cardiologist technical progress has been mind blowing.

I now use Nuclear imaging techniques that include dynamic assessment of LV systolic function, enhanced tracers that greatly improve image quality over the older Thallium image techniques, advanced computer work stations that facilitate on the fly analysis of the images, and I have passed and re-passed a dedicated certification board in Nuclear Cardiology which is now required by many private payers in order for me to bill for these interpretations. I have recertification of this board examination above and beyond the cardiology board examination looming in front of me in 2018. 

I implant pacers, bi-ventricular lead pacing and defibrillator systems as well as subcutaneous defibrillators. In order to do so, I underwent rigorous self study, tutorial and proctored clinical experiences in implantation techniques as well as dedicated CME training in ICD implantation and follow up as well as becoming formally tested for expertise in device implantation and follow up by a certification board that will mandate a re-certification evaluation in 10 years from initial certification. 

I was not doing interventional cardiology for several years after fellowship training, so that when I once again practiced in a community in which interventional procedures were done, I underwent proctored training by my partner in modern stenting procedures as well as intense self study and CME based education in interventional cardiology and peripheral interventional cardiology. As of now, neither my partner nor myself do valve replacement by catheter or catheter based mitral valve repair, but we still need to understand these techniques in order to appropriately select patients for referral for these procedures. Within the cath laboratory, I now do radial artery angiography as well as trans-femoral angiography and routinely utilize femoral closure devices that have dramatically reduced the incidence of femoral arterial complications and results in mobilization and discharge of the patient post procedure within 4 hours of that procedure. 

Instead of spending 5-10 days in the hospital after their MI, my patient’s now meet me in the ED are taken urgently to the cath lab, routinely have the ST elevation MI aborted by direct percutaneous interventions within the 90 minute time frame felt essential to good outcomes and routinely leave the hospital the day after their aborted infarction. Peripheral angiography procedures include intra-arterial and venous interventions designed for severe claudication and limb salvage procedures as well as advanced catheter based therapies for treatment of severe occlusive DVT and acute catheter based pulmonary embolism therapies.   

Echocardiography techniques have expanded explosively since my fellowship training, and I now interpret echocardiograms utilizing strain analysis, real time 3-D techniques, and my TEE systems have evolved from monoplane imaging to real time 3D systems. And yes, in order to certify our practices echocardiography laboratory I had to become boarded in echocardiography by yet a different certification board. 

Additionally, what used to take a $250.000 echocardiography system in order to generate 2D/ color Doppler images can now be done with a hand held ultrasound system costing < $10,000, without involvement of another technical resource (U/S technician). In addition to superb cardiovascular imaging, this system does chest/abdominal), Ob-GYN imaging as well as 2D/Color Flow vascular imaging. This revolution in providing immediate U/S imaging at the point of care, means that as a cardiologist, critical care physician, and Emergency Medicine physician I can answer clinical questions with the initial evaluation of the patient that previously took valuable minutes or hours to answer. And if those questions have life threatening dimensions, such as an acute pulmonary embolism, I can save valuable minutes and hours in diagnosis and institute effective therapy literally at the point of initial evaluation of the patient.  So important is this capability that I have also trained and subsequently certified as both a general and cardiac specific ultrasonography technician. 

Over a 3 year time frame, I intensively trained myself again through self-study, CME based education, and very expensive and intensive focused work shops in CT cardiac computed tomography, so that I can offer my patient’s non-invasive high resolution coronary, carotid, and peripheral angiography when this is a reasonable alternative to invasive angiography. Once again, demonstration of this expertise requires yet another certification board testifying to my expertise in this area. 

My partner and I have embarked on a program to provide advanced heart failure technologies for our patient’s above and beyond Bi-V pacing therapies and are starting to manage LV assist devices as destination and bridge to transplant therapies in our metropolitan area. This also entails specialized self directed and proctored learning and ultimately another board certification process. 

The point of this tedious discussion is that these advances have been made, and as a matter of professional growth and expertise, I have had to continuously expand and refine my own cardiology diagnostic and therapeutic tool kit. All this has been done in spite of rather than as a requirements for cardiology board recertification not because of them. It is in the context of this overwhelming personal commitment in time, energy, and cash outlay that the debate about board recertification turns. 

From the context of taking the cardiology boards three times, I can’t say that study for them were helpful in coming to grips with the specialized knowledge required to support my current clinical practice of cardiology. Never mind the fact that as someone also board certified in critical care medicine, that this field also has demonstrated an explosive growth in techniques and knowledge that also requires intense time commitment.  

A much more important factor for helping me keep up with the brisk rate of change of biomedical knowledge and techniques is real time access to the internet and the plethora of medical resources found their. Prior to wide scale access to internet resources, I used to always have multiple reference CD’s, now obsolete since I can access literally any relevant medical information resource with a laptop, tablet, or smart phone. 

So, in summary, I agree with my colleagues who feel that MOC activities demonstrate no value with respect to staying abreast of new techniques and therapies, and in fact detract from this knowledge acquisition, as time is a zero sum game, and no one other than yourself understands what contributes to your practice. The most important lesson, spoken by someone who stopped going to classes after my first 6 wk test in medical school, is learning how to learn, i.e., how to learn on your own in response to your own goals and learning needs and the needs of your local medical practice and needs most importantly of your patient population.     

Tuesday, January 13, 2015

The 5 Stages of EMR Acceptance (With Apologies to Kubler-Ross)


                 I can’t believe they are making me use this system!




‘Look if I agree too willingly and cheerfully use this system, can you ask for and fund these change orders, add these features, re-engineer this screen…..blah! blah!  Blah!, etc. '


I can’t beeeelieeeeeeve (sob, sob, sob, sob) theeeey (sob, sob, sob) are making meeeee (pouring tears from both eye tear wells) use this system!’ 


           I believe they are making me use this system.  (Resigned Sigh) 

And just as in the original Kubler-Ross model, our only release from EMR agony is death……. an eventuality that I used to accept stoically as inevitable, but now positively look  forward to its release (as do my carpal-ly tunneled wrists!). 

Over the last months and the last several years as the deployment of EMR systems have proliferated even the most enthusiastic advocates of electronic documentation have difficulty pointing to any compelling advantages of the EMR systems other than enhanced legibility of charting and improved justification for higher billing. 

The costs are enormous for the front line clinician and his patient struggling to connect across the increasing gulf of random bytes and bits that contain the essence of the second oldest 1:1 relationship on the planet. 

It is perhaps the time of life to romanticize the old in preference for the new. But I don't think I really suffer from that illness. However, the thing that attracted many of my colleagues, and certainly myself to medicine was the unparalleled opportunity to be autonomous in a respected profession. 

However, the profession has been under systematic assault from outside and within. Furthermore, for my own part, having spent the vast majority of my time as a physician within the US military I have become totally disenchanted (if I ever was enchanted with ) with medicine for profit.  

As an undergraduate mathematics major with a heavy interest in and emphasis in computation theory during my undergraduate days, I was attracted to the field of medical informatics as a resident, just as I was attracted by the physics and mathematics that underlie most of cardiology.

However, when I learned in my informatics training that 80(+) % of medical costs were driven by physicians decisions, it became axiomatic to me that control of those decisions was a major hidden agenda item in the field. Furthermore, my non-physician informatics mentors, most prominently Reed Gardner failed to ever understand why I would want to look at my own radiological studies since I am not a radiologist, he considered this a waste of energy and effort, and never accepted my own assertion that since I brought the patient to the film, I could (and do) find things in the study either missed or overlooked by my fine radiological colleagues.

For me the allure of this field medical informatics was how to help myself and others make better decisions, not necessarily make standardized decisions. 

I am really un-humble, I am an exceptionally good clinician, but then that is all I have done for an average of 12-16 hours a day, every day for about 32 years (wow has it been that long) if I can't figure out this dance after 80,000 (+) partners I am a slow study.  

To my eye the current quality initiatives are laughable in their simple mindedness. But the reality of statistical control theory, the soft and unpleasant underbelly of the theory is that the highs, i.e., the exceptional as well as the under performer are both squeezed/regressed to the mean. As some one never content to be within the mean, it makes me mean, and unpleasant at times to be forced towards the just barely acceptable. 

And that is how every good doctor is feeling right about now with the drive towards poorly designed encounter capture systems (I won't dignify these monstrous pieces of software by calling them Electronic Medical Records), we are being driven to a pabulum state of consciousness just as our teachers have been driven to teaching the test, we are driven to documentation for billing, not for caring for the patient or for doing an exceptional job clinically. 
If I compare my professional dictations of yesterday, they were elegant, articulate, crafted with the care a good writer exerts over his/her craft;  But using the charge maximization systems now so prevalent, I can examine the chart with a magnifying glass and not find a recognizable part of my patient within the 'sameness' that characterize these infernal charting schemes.

Designed by engineers with the advisement of financial trolls who believe that a complete record is preferable over a patient's story. For those of us who learned to enjoy the patient's story and who are replenished and nourished and enchanted by these tales, there is are no real stories anymore. And the price of this de-emphasis on the unique patient in front of you, is higher medical costs, for the other 80% rule in medicine is 80% of the diagnoses are made by history and careful, intelligent, and active listening. The practice of narrative medicine is in my view, the best way to practice no matter what you practice, but the infernal button pushing, needed to be done to get paid, prevents the elucidation of the story at the center of the symptom and as such, results in good billing, but often times the wrong or incomplete answer.

Especially in my Emergency Department work, much less so in my cardiology practice, the time pressures result in conformity to a standardized and scripted response for the problem at hand since you don't have the time to produce a hand-crafted thoughtful response to the problem at hand. This becomes disheartening to those of us in the profession who were raised to adhere to a standard in which you did your best for everyone, no matter what the odds or inconveniences or personal sacrifices. But this atmosphere/culture of expected exceptionality has been replaced by 'is it enough to guarantee maximum return of billing.'

But at least for me it is the uniformity of the appearance of the products of medical work that is the output of electronic documentation systems that makes it seem like such a soul robbing endeavor. And I believe passionately that true clinical expertise is shown by what you choose to leave out, not put in the story or presentation of the patients case to colleagues.

Again, my goal here is not to be nostalgic for the old but rather to mirror for the fresh and unprejudiced minds in our mists, that the backlash at EMR technologies being seen among my colleagues does not necessarily represent push back from techno-Luddites but rather can be interpreted as a meaningful critique of the inadequacy of the current systems to support the healer and shaman that is the core personality component of every good doctor I have ever met, trained, or practiced with.

Existence of preventable medical errors is a feature of all types of practice, and as we well know, as detailed many times by Scott Silverstein ( (also a negative nelly — but than I think in the field of medical informatics you have the choice of two diametrically opposed roles the negative nelly or the cheerleader)  that those who chant the mantra of patient safety seem perfectly content to minimize, ignore, or down play the new and more difficult to detect and prevent errors attendant to use of medical software systems. Classic example of EMR safety failings was the recent EPIC disaster (pun intended) related to the failure of diagnosis of the 1st case of Ebola virus infection in the US. ( ( "Travel Information Wasn't Communicated In Dallas Ebola Case Due To Electronic Health Record Flaw" (Huffington Post),

As many do not  know, the most costly software on the planet is Space Shuttle code which costs about $100,000 per line of code, and for which the code has meet the most rigorous software engineering tests, i.e., each line is proven by mathematical techniques to be complete, consistent, and free of unexpected/unpredicted program errors. Compare that level of software engineering excellence to software I have personally used where not only are there bug upon bug in the software, but the damn labels on buttons representing symptoms are misspelled. I consider it axiomatic, if the buttons are misspelled the code is flawed, but than you can't judge a book by its cover, or can you?