Maintenance of board certification

Who is thriving and who is struggling?

An examination in the Paris faculty of medicine.  1901. H. de Toulouse-Lautrec.  Public Domain via Wikimedia
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Nov-Dec-15-Web 1This article first appeared in the November/December issue of San Francisco Medicine, the magazine of the San Francisco Medical Society. That issue was dedicated to the theme of ‘Thriving in Medicine.’ For other blog posts on the topic of MOC, see here.

Up until recently, obtaining and maintaining a specialty board certificate seemed essential for a physician intent on having a thriving medical career.  Doctors and the public alike widely viewed board certification as a proof of proficiency that distinguished those with advanced training and expertise.

To maintain board-certified status, certificate holders were quite willing to be subjected to a decennial examination, and some doctors even looked forward to preparing for the test and to an opportunity to systematically review their field of expertise.

In a few short years, however, any positive sentiment regarding maintenance of certification (MOC) exercises seems to have all but evaporated.

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I have added a new page about books and resources I recommend on economics, healthcare, philosophy, medical practice, etc.  The link is also at the top navigation menu.  Check it out!

Taking stock of our existence

Gawande versus Frankl on the meaningful life

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My last post was prompted by a reader’s comment where Victor Frankl’s Man’s Search for Meaning and Atul Gawande’s Being Mortal were juxtaposed.  Since receiving that message, I have had occasion to notice that others also associate these two books.

For example, both are mentioned positively in this moving article by Dr. Clare Luz about a friend’s suicide, and in these tweets from Dr. Paddy Barrett’s podcast program:

Friends and patients of mine have likewise mentioned these two works to me, expressing praise and testifying to the deep impact the books have had on them.

I suspect that many readers of this blog will at least be familiar with these two books.  If not, summaries are here (Frankl) and here (Gawande).

I read the books in succession and found the difference between the two striking.  Frankl and Gawande seem to be at polar opposites on the question of life and death.  In this post, I will explore this difference, starting with Gawande’s point of departure.

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Medical friendship at the end of life

As hard as it sounds

Photo credit: Reservoir Rothkos by :MrMark: via Flickr.
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Pat, a non-physician reader, writes:

I read your two articles on friendship for more explicit clues on how to deliver very bad news, and wondered if you would consider publishing something on this topic as part 3 of this series. My prompt is a close friend with cancer, and she’s not getting better. At her last visit, the message she took home was: “there’s not much more we can do for you other than more chemotherapy, and we’re not even sure that it will do any good.”   This was a complete and sudden loss of hope.

Two thoughts come to mind.

The first is from Viktor Frankl. In Man’s Search for Meaning he says: “Those who know how close the connection between the state of mind of a man – his courage and hope, or lack of them – and the state of immunity of his body will understand that the sudden loss of hope and courage can have a deadly effect.”

The second is from Atul Gawande’s book, On Being Mortal. He describes two approaches to giving bad news. Dr. Informative supplies hard cognitive information: cold facts, descriptions, outcome possibilities, statistics. A doctor’s other approach might be to look for an opportunity to start the conversation with “I’m worried” and then continue with the patient in an “ask, tell, ask” process. In this approach, the direction of travel becomes clear more gently and perhaps gives the patient a little more time to walk into the possibility than being crashed into it.

…I would be especially interested to read your views from the doctor’s side in the context of your two blogs on the friendship dimension in the doctor-patient relationship.

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On Christmas break

Dear visitor,

Happy Holidays!  May you have a healthy new year, and one that will bring you closer to fulfilling your deepest wishes.

I will take a break from blogging until the middle part of January 2016.  But don’t leave yet!  I have organized some of my articles into themes (e.g., “An Economic History of the American Healthcare System”) and linked each collection to a picture in the right-hand column of this website (or at the bottom of the home page, if you are using a mobile device).

Grouping the posts like this will allow a more in-depth exploration of the topic but will still keep the reading easy to digest.

Happy reading!

Dr. Accad

The physician as entrepreneur

Warning: not a post about "disruptive innovators"

Frank Knight.  Photo via University of Chicago.
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Frank Knight, risk and uncertainty

In this article, I wish to introduce the reader to the theory of entrepreneurship advanced by Frank Knight (1885-1972), and show that the common, everyday work of the physician could be considered a form of entrepreneurial activity in the Knightian sense.

Knight was an influential American economist.  He is best known for his book Risk, Uncertainty, and Profit in which he proposed to distinguish risk and uncertainty as follows:

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Interview on “The Price of Business”

A couple of weeks ago I was interviewed by Kevin Price on his radio show “The Price of Business” which runs on Houston’s 1110 AM KTEK radio station.  Also present was Dr. Geetinder Goyal.  We talked healthcare economics, free markets, and direct patient care.  I hope you enjoy it.

Good medicine starts with friendship

Advice from the ancients

Photo credit: Don't Let Go by Sam Caplat, via Flickr. CC license.
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Whenever I have the opportunity to suggest that good medicine is based on friendship, I usually get a nod of approval mixed with a quizzical look.  What’s that supposed to mean?!

At a recent meeting of an editorial board on which I serve,  the reaction to my suggestion was more forceful and perhaps more honest.  The topic of the day concerned patient education, and how hard it can be to move patients to do things like exercise more or eat better.  I timidly proposed that, as physicians, we might want to start by being our patients’ friends.  The physician sitting next to me immediately objected: “I wouldn’t go that far!”

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How to safeguard your career in a treacherous healthcare environment.

Economics, ethics, and philosophy for medical students

Image credit: Pixabay (Public domain).
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the following post is a slightly edited version of an article kindly commissioned by In-Training,  a website run by and for medical students. The advice I give in the article is based on lessons I learned long after finishing medical school, so I hope you will find this piece of interest, even if you are well established in your healthcare profession.

Dear medical student,

I am honored by the opportunity to offer some advice on how to safeguard your professional career in a treacherous healthcare system.

I will not elaborate on why I think the healthcare system is “treacherous.”  I will assume—and even hope—that you have at least some inkling that things are not so rosy in the world of medicine.

I am also not going to give any actual advice.  I’m a fan of Socrates, so I believe that it is more constructive to challenge you with pointed questions.  The real advice will come to you naturally as you proceed to answer these questions for yourself.  I will, however, direct you to some resources to aid you in your reflections.

I have grouped the questions into three categories of knowledge which I am sure are not covered or barely covered in your curriculum: economics, ethics, and philosophy of medicine.

I have found that reflecting on these questions has been essential to give me a sense of control over my career.  I hope that you, in turn, will find them intriguing and worth investigating.

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Is assisted suicide “medically necessary?”

Canada may soon debate the question

By D. Gordon E. Robertson (Own work) [CC BY-SA 3.0 ( or GFDL (], via Wikimedia Commons.
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André Picard, one of Canada’s foremost healthcare journalists, published an article today in which he analyzes the funding rationale for his country’s healthcare system.

Canada has the most singularly bizarre health-funding model in the world. It is, to use the technical term, bifurcated – meaning there are two distinct categories.

“Medically necessary” care, defined as hospital and physician services, is paid 100 per cent from the public purse. Selling these services privately is, with few exceptions, illegal or subject to punishing penalties…

The rest of health care is, by default, not deemed medically necessary, but still gets varying degrees of public funding. Only about 6 per cent of dental care is paid publicly, as are almost half of prescription drug costs, and about two-thirds of long-term care costs.

Given Canada’s perennial healthcare budget deficits and notorious waiting lines for medical care,  Picard adds:

Getting the mix of public and private care right means ensuring everyone has access to essential care in a cost-effective manner, and still allowing patients a modicum of choice, and the ability to supplement their publicly funded care with other services.

At some point, we have to make some clear, coherent decisions to ensure that happens. Doing so begins with asking, and answering, the question: What is really “medically necessary”?

The final question Picard asks couldn’t come at a more opportune time.

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