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.     


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