Is Maintenance of Physician Board Certification a Sham?

Over the last few years, medical specialty boards have begun to compel physicians to maintain board certification by a number of means. This is an extension of recertification requirements which have been in existence since the mid-1970s.

Here is what the American Board of Surgery (ABS) mandates for Maintenance of Certification (MOC) every three years except where noted:

1. You must have an unrestricted medical license, hospital privileges in surgery, and references from the chief of surgery and the chair of the credentials committee of your hospital. It’s hard to argue with the need to have a license and practice in a hospital. However, if a surgeon had real quality issues, shouldn’t they have come to light before the end of a three-year cycle of MOC?

2. You must document 90 hours of CME credit, 60 of which must include some sort of Q & A testing which must be passed with an average score of at least 75%. I have previously blogged about the inadequacy of most CME programs. Even CMEs that require testing are often laughably simple. The American Board of Internal Medicine offers (for a price) open-book and Internet-based courses. Regarding self-assessed CMEs, the ABS website states, “[t]here is no required minimum number of questions and repeated attempts are permitted.”

3. You must successfully complete a written recertification examination every 10 years. Surely that must be an effective measure? Maybe not. For the last five years, the pass rate for recertification in general surgery is 94% or greater. The American Board of Internal Medicine (ABIM) recert exams must be a little tougher or those who take it may not be as smart as surgeons. The pass rates for the ABIM recert exams have been 88% to 92% for the last four years with similar rates for all of the medical subspecialties.

4. You must participate in a national, regional or local outcomes registry or quality assessment program. Participation in a national outcomes registry sounds great, but none of the available registries have policing powers and many rely on individual surgeon input to track outcomes. As mentioned in the critique of the first requirement, quality issues are far more likely to be discovered at the local level than by a registry that collects data submitted by the surgeon herself.

As if all of the above issues are not enough, how about this for a hot potato from the ABS? “Periodic communication skills assessment based on patient feedback may also be required in the future.” I can’t wait to see how that information is going to be collected. By what criteria will communication skills be judged? And what will happen to someone deemed a poor communicator?

I suppose the boards are doing all of this to forestall government or other regulatory bodies stepping in. Meanwhile, let’s everyone play along.

None of the MOC requirements address another issue, which is fitness for practice. A December 10^th article in the Washington Post on aging physicians notes that some hospitals are setting age limits at which doctors are required to have physical and mental evaluations in order to maintain staff privileges. That’s great but not for just the elderly; every doctor needs to have period fitness testing.

Right now, all you have to do to stay on the staff of most hospitals is have a colleague attest to the fact that you are in good health, hardly a rigorous standard.

I’ve known a few physicians well under the age of 65 who could have used a checkup from the neck up.

To answer my own question, maintenance of certification is a sham.

Are they serious? School board approves carrying of handguns by custodial staff

Is there a worse idea in the world than arming janitors in public schools?

I don’t think so, but a school board in Ohio had other ideas and voted unanimously to give guns to their custodians.

The Toledo Blade carried the story.

"Sitting back and doing nothing and hoping it doesn't happen to you is just not good policy anymore. There is a need for schools to beef up their security measures," Superintendent Jamie Grime told The Blade today. "Having guns in the hands of the right people are [sic] not a hindrance. They are a means to protect."

OK, so the right people are the schools’ janitors?

"Our main goal is to offer safety for our students while they are in the classrooms and in the building," Mr. [School board President Larry] Martin said. "We have to do something and this seems like the most logical, reasonable course to go with."

Do they have to “do something” and is this logical and reasonable?

I say “No.”

Other than being physically present in schools, what qualifications for carry guns do janitors have? The article says they will be sent to a two-day training course on handgun use given by the renowned Tactical Defense Institute of West Union, Ohio.

This strikes me as a typical “system error” type of response. I have written about this in the past. You can search my blog using the term “system errors” to see the other posts. An unusual event occurs and rather than chalking it up to bad luck or human factors, organizations attempt to correct a “one-off” occurrence with a system change.

Here’s why won’t arming janitors work.

1. Armed guards in schools don’t have a good track record (see: Columbine).

2. The janitor would have to be mighty alert at all times because the crazy guy hell-bent on killing someone has the element of surprise in his favor.

3. Even if an armed janitor serves as a deterrent, which I doubt, what is to stop a shooter from taking out the third grade while they’re outside at recess or getting off the school bus?

4. I assume the janitors will be packing pistols of some kind. Are they going to stand up to a shooter in full body armor carrying an AR-15 Bushmaster semi-automatic rifle?

Where does this end?

What if the next mass shooting is at on a field trip, at a basketball game in a high school gym or at football stadium? How can those very public areas be protected?

The answer is, they can’t.

Just as putting metal detectors in movie theaters won’t stop a determined psychopath, arming a janitor will not stop one from attacking a school. It’s much more likely that the janitor will shoot himself or an innocent person than a crazed attacker.

In addition, there will always be a place that does not have an armed guard. Use your imagination.

Pap smears, guidelines and churning

A friend called me the other day to say that his wife had just received a rather concerning message after a visit to her gynecologist. They had been away over the holidays and returned to find this registered letter.

Dear Patient,

We have previously contacted you or attempted to contact you regarding follow-up of your abnormal test results. As we have not heard from you, we are writing to urge you to seek medical attention if you have not already done so.

It is very important that you contact us at your earliest convenience. If you have any questions or would like an appointment, please call between the hours of 8:00 AM through 5:00 PM.

Very truly yours,

They were not too upset because many years ago she had a false positive Pap smear (a test done to detect cancer of the cervix) and received a similar letter. On that occasion, the repeat test was normal.

They made the appointment. During a three-minute visit with the gynecologist, they were informed that the Pap smear was normal.

My friend asked the doctor why the letter was worded in such an ominous way. He was told that was their standard letter and that the doctor “would look into it.”

My friend wondered why the normal result couldn't have been been simply told to them by phone. I replied that the purpose of the registered letter was to generate an office visit.

During the phone call, my friend told me that his wife was having Pap smears every 6 months. He asked if that was routine. I said I had never heard of anyone doing it that often, especially with no history of abnormal Pap smears in the past.

Did I mention that his wife was 71 years old?

All guidelines say that women over 65 without risk factors don’t need a Pap smear at all, so every 6 months seems a bit excessive.

Regarding the office visit and the too frequent Pap smears, the stockbrokers have a word for this sort of thing. It’s called “churning.” To boost his income from commissions, a broker will churn by unnecessarily buying and selling a lot of stocks for his clients.

It’s not unique to this gynecologist. According to an article about a CDC report, 60% of women who have undergone a total hysterectomy, a procedure which involves removal of the cervix, continue to have Pap smears done. In case you aren’t familiar with this topic, cervical cancer is not going to occur when the cervix is in a jar in the pathology department.

And even more amazing is that the article says in 2010, “About two-thirds of women 65 and older who hadn't had a hysterectomy reported having a recent Pap test. That's down from nearly three-quarters in 2000, but it's not a huge improvement.”

“It’s not a huge improvement”? That’s quite an understatement.

It's Medicare, so we're all paying for it.

Things like this make me really worry about the future healthcare of my children and grandchildren.

Two new posts are up.

Law school applications and enrollments are down. Could this happen at medical schools too? On Physician’s Weekly. http://is.gd/rDTAwj

News flash. Operations take longer when residents are involved. My blog on General Surgery News. Registration is required, but it’s free.  http://is.gd/Tgh9Kq

Patients can be clueless about their insurance coverage

Not long ago, I blogged about a plastic surgeon who aggressively pursues patients who refuse to pay her bills. The state is suing her to make her stop and also considering lifting her medical license. You may want to take a look at that post to get the details, but the central theme is that she makes patients who she sees in the ED to sign a form stating that they will pay her. It is unlikely that the patients are aware of the amount of the fee up front. Then she won’t accept what insurance considers a reasonable reimbursement and goes after the patients with lawsuits and liens on their houses, ignoring the fact that balance billing of emergency department patients is illegal in her state.

A number of doctors have defended the surgeon. Many have said that the patient should have asked her what the fee would be. In my experience, that is a rare occurrence. I’ve been a surgeon for four decades and I can’t recall a single patient asking me what the fee for an elective operation would be. I hardly think a patient would ask at the time of an emergency.

Most patients either don’t think about it or don’t consider it an issue. In many cases, they don’t understand how the system works at all. Here's an example.

A new patient arrived for an appointment with the doctor. At the time he called to schedule it, he was told that the doctor did not accept his insurance. At check in, the secretary reminded him of this, and having amnesia for the previous conversation, he was taken aback and said, “I thought everyone had to accept WeDontCare.”

Further questioning revealed he had a $5000 deductible policy and he had not used any of it yet this year. Even if the MD had participated in WeDontCare, the patient was shocked to learn that he would have had to pay for the office visit.

He was then told that the fee for the comprehensive new patient examination would be $250.00. When he balked at this, the nurse asked him why he chose such a high deductible policy if he didn’t want to pay for visits out of pocket. He said it was because the premium was so much lower.

The nurse explained that the point of a high deductible policy was that in exchange for the lower premium, he accepted the risk that some or all of the money saved might have to go toward paying for medical care, probably a reasonable risk for someone in good health. He didn’t seem to understand that unless he paid out of pocket for more than $5000 (less what the lower premium cost was) worth of medical care in a year, he was ahead of the game.

The patient then began to see the light. If this man, who was a retired financier, had never thought this through, how would anyone expect the average patient to do so?

New screening test for diabetes unveiled

Game-changing new screening test for Type I diabetes. Read all about it on Surgery Watch.  http://is.gd/pVueNk

My seven most-read blogs of 2012

I want to again thank everyone who has taken the time to read my blog and follow me on Twitter. I appreciate all the comments agreeing or disagreeing with what I have written.

Interest in the blog has grown over the last year. It’s averaging about 800 page views per day, up from 400 per day at the end of last year. And I now have over 4200 followers on Twitter, a gain of about 2700 over the year.

Here is a list of my top seven most-read blogs of 2012:

A medical student asks, “Is surgery the right career for me?”

Robotic surgery financials explained.

Stuff I see on charts that drives me crazy.

What happens when a doctor is paged? 

What do interns do when they are on call?  

Antibiotics instead of surgery for appendicitis. I don’t think so.

Patient satisfaction and reality.

I hope you have a healthy and prosperous new year.