Computers & Software Medicine

Is Medical Board Certification Testing Outdated?

vintage-elevator-operatorTimes change, and, as with Darwinian natural selection, those who adjust survive and those who don’t perish. Henry Ford’s assembly line greatly ramped up the production of automobiles but put many people out of work. The elevator operators of my childhood are long gone. Those who have embraced new technology have usually thrived; those who have fought it or failed to understand it have suffered. Witness the success of Amazon versus the demise of Borders.

Medicine is a conservative business. Who else still uses beepers and fax machines? Doctors have been slow to adapt to new technology, such as Electronic Health Record systems. Nevertheless, despite challenges, I don’t see doctors going the way of elevator operators, at least for the foreseeable future. But there is a medical industry that does need to go the way of the dinosaurs: the medical testing industry.

To briefly recap, doctors used to take a board certification exam after residency that provided lifelong certification.  In the case of internal medicine doctors the examination agency is the American Board of Internal Medicine (ABIM) which is one of the specialty boards that make up the American Board of Medical Specialties. Arguing that the rapid changes in medicine warranted periodic recertification, but probably also noting that once per lifetime certification is not as lucrative as repeated certification, the ABIM subsequently imposed a requirement that certification testing had to be renewed every 10 years. Still not satisfied, the ABIM came up with Maintenance of Certification (MOC), consisting of a lot of busy-work for the already busy physician that includes a mandate to carry out non-IRB approved research on physicians’ patients.

Judging by social media, MOC has really hit a nerve among physicians. I and many others (e.g. see Dr. Wes’s website, containing many good articles on MOC and exposés of the ABIM) have written about MOC, and the whole board recertification fiasco has finally reached the mainstream media in a recent New York Times article.  Despite the aversion to MOC, many physicians don’t seem to be as upset by the every 10 year retesting. Yet the whole concept of sitting down to take a test as a means to assure that a doctor knows what he is doing is as outmoded as using a dial-up modem to assess the internet.

When I was in academics, my colleagues played a game that consisted of arguing a point by quoting some obscure statistic from some obscure study. Something like: “Well, in the MADEUP-VII trial, subgroup analysis of incidence of restenosis based on horoscope sign showed that Scorpios had a 32% risk reduction compared with Virgos, with p less than 10 to the minus 20th.” I was never too good at that game, which is one reason I went into private practice, only to learn that private practice docs played the same game. I’ve considered doing a study comparing these off-the-cuff literature quotes with the actual published data. I don’t think the correlation coefficient and p values would be very good.

There’s really no need to play that game anymore. Just as with the invention of writing poets no longer needed to memorize the poems of Homer, and with the invention of the printing press monks no longer needed to copy books by hands, with modern technology I don’t have to memorize detailed results of medical studies for later regurgitation at Grand Rounds. Today I carry around in my pocket a computer with always-on internet access — a computer much more powerful than the computers that were used to send men to the moon. I have apps that can check drug doses and watch out for drug interactions. I can look up anything in a few seconds. With this capability it is not only unnecessary, but would be reckless for me to rely purely on my memory, especially when dealing with the potentially catastrophic results of making a mistake.

I’m not saying that doctors don’t need to know any facts or memorize anything. I’m not saying that doctors shouldn’t attend lectures, go to medical meetings, or carry out Continuing Medical Education. But the fact is that, as with any craft, the best teacher is the work itself.  Being asked to regurgitate memorized facts on a test is not a test of anything other than the ability to memorize facts. It is not a reflection of how doctors do their jobs today, and is not a indicator of competence in the field of medicine.

The medical testing industry needs to go the way of the elevator operator.


Can Writing About Medicine Change Medicine?

I’m getting to the point where I think it might be time to stop or at least decelerate the pace of my writing on medicine. When I retired from medical practice almost a year ago there were a lot of pent up experiences that I felt a need write about. But now I have already written about almost everything that I wanted to and, as I am no longer a practicing physician, I lack the ongoing experiences and frustrations of day-to-day medical practice to replenish the store. Moreover I am having a growing sense of futility when writing about medicine.  Can writing about medicine change medicine for the better?  Is anyone listening to physicians’ voices?  Or are we all just grumbling to each other?

How many posts bashing electronic health record (EHR) systems does one need to read (or write)? I’m certainly not the only one writing on this topic.  Criticism of EHR systems is very popular amongst physician bloggers nowadays.  I hope someday the shear quantity (and quality) of these posts reaches a critical mass that results in the EHR companies paying attention and making some changes to their products — but I’m not holding my breath. Similarly a large number of physicians rail against the current Maintenance of Certification (MOC) process, yet I see no indications that anyone who can change MOC is listening. The negative effect of the Great Hospital Buy-Out of Physicians of the last decade is also a favorite topic, as are increasing regulations, the hegemony of insurance companies, and countless other annoyances, but what is the use of grousing about all this if no one is listening but our fellow physicians?

Despite voicing our concerns online, we physicians don’t seem to have a voice where it counts — politically.  We don’t have effective representation. Societies that are supposed to represent physicians such as the Heart Rhythm Society, the American Heart Association or the American Medical Association are beholden to groups other than physicians, i.e. drug and device companies — the same drugs and devices that they publish supposedly objective guidelines about. These medical societies also are in bed with the American Board of Internal Medicine, the progenitors of endless board recertification and MOC, and indeed have a nice side-business going on providing expensive board-review courses to prepare for these tests.  Corporate funding of these societies ranges from 20 to 50% of their total revenue (see here, here and here). Go to any big national meeting of these societies and wander through the acres of exhibits. Some of the exhibit booths are bigger than the home in Philadelphia that I spent my first years in. These glittery exhibit halls reek of money. Every time the pharmaceutical companies complain that they have to charge so much for their drugs because of the cost of R & D, I  recall these lavish exhibits as well as the constant TV commercials for erectile dysfunction products and drugs for quasi-diseases like short eyelashes.  It makes me sick! (Ah! New syndrome: TV drug commercialosis!) Money is power in politics, and physicians, despite being perceived as rich and even overpaid by the general public, are low down on the money totem pole compared to other facets of the health care system.

I’m not trying to be pessimistic, just realistic.  Yet if writing is the only weapon we have, what choice do we have but to continue to use it, blunt instrument though it may be?  The growing multitude of physician-bloggers and physician-commenters will continue to write, will continue to fight for changes in EHR systems, recertification requirements, and health care policies. Maybe we’ll get lucky and someone holding the purse strings will be swayed and do something to make the lives of physicians better. Possibly the decision-makers will come to realize that if our lives are better, our patients’ lives will be too. That’s important because everyone, whether politician, hospital administrator or EHR corporation CEO, will sooner or later be a patient in need of a good doctor.