Reasons to MOC®: Board certification revisited

Detail of The Apotheosis of George Washington by  Brumidi. Capital Dome, Washongton, DC. (Photo credit Ron Cogswell via Flickr).
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Bob Wachter has written a lengthy defense of the American Board of Internal Medicine (ABIM) and its Maintenance of Certification (MOC®) program, addressing contentions that the ABIM may have engaged in questionable financial practices, and that MOC® is irrelevant, time consuming, and onerous.

These allegations, however, are not the only questions board organizations may need to confront.  Along with several recent articles devoted to the topic of professionalism, Wachter’s piece provides us with an opportunity to examine three foundational arguments that board leaders invariably bring forth to justify the commerce of certification.

Skills, Knowledge, and Prediction

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The following letter to the editor was published in the American Journal of Cardiology in response to an excellent article by George Diamond and Sanjay Kaul who highlighted the limitations of quantitative methods for achieving relevant “risk-stratification” at the individual level.  Comments made by these authors prompted me to reflect on the tension between the appeal of quantitative methods and the value of unquantifiable clinical skills.  I hope you will find these remarks stimulating.

In the March 15, 2012, issue of The American Journal of Cardiology, Diamond and Kaul1 provided an insightful analysis of the complex relation between risk stratification schemes and therapeutic decision making. The investigators clearly identified some of the reasons why predicting response to treatment at the individual level is difficult. However, they conclude their report with a caution against “wholesale abandonment of evidence-based guidelines in favor of idiosyncratic clinical judgment,” which, in their opinion, runs the risk of “intellectual gerrymandering” and “wasteful utilization of high-cost technology.”

Proponents of quantitative methods of clinical assessment frequently portray critics as Luddites ready to “jettison” objective evaluation in favor of personal opinion rooted solely in clinical experience.2 This is an unfair characterization.

Blood pressure and the conundrum of medical numerology

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As part of a series on heart disease, Gina Kolata of the New York Times is calling attention to Blood Pressure, The Mystery Number.

And what a mystery it is!  Reading Kolata’s piece, one gets a sense that hypertension researchers are chasing after the optimal blood pressure the way Pythagoreans of old sought numeric answers for the riddles of the universe.

Kolata relates:

What about a patient like Glenn Lorenzen, 67, whose systolic pressure was a frightening 220 in October? On a chilly day in December…he had received the good news that drugs and weight loss had lowered his reading to 124. Should he be happy? Should he aim to be below 120? Or should he ease up on the medications a bit and let his pressure drift toward 140 or even 150?

Unfortunately, with Lorenzen’s happiness hanging in the balance, doctors must make decisions “in a fog of uncertainty.”

Will a single payer system cure the administrative bloat? A Hayekian perspective

Friedrich Hayek, 1959.  Source: Austrian Public Library, via Wikimedia Commons (public domain)
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In contrast to the expected shortage of tens of thousands of physicians, there appears to be an abundance of health care administrators, at least judging by the following graph:


The originators of the graph—economists and physician-activists at Physicians for a National Health Program (PNHP)—invoke the administrative bloat as reason to promote a single payer system.  With a single payer, they argue, complexity will be greatly reduced, the administrative burden wiped out, and costs brought under control.

For those who contend that administrative positions consist chiefly of make-work jobs soaking up a glut of workers otherwise destined to swell the ranks of the unemployed, this outcome could indeed be welcome.  Unfortunately, if PNHP gets its wish, we may all discover that gluts and shortages are enhanced, not avoided, by the central planning process that would necessarily accompany the establishment of this program.

How Western medicine lost its soul

William Blake, The soul hovering over the body, illustration to Robert Blair's The Grave.  Public Domain, via Wikimedia Commons.
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A few decades ago, the idea of medicine presented no difficulty.  A patient who fell ill would go to the doctor to get treated.  He might get better or he might not, but there was no need for him to consider at the outset what type of medical care he should choose for his ailment.

Today, someone who needs attention for a health matter can seek conventional “Western” medicine or opt to receive a “holistic” treatment from the realm of so-called alternative medicine.  For most people, there is a clear distinction between the two.  Sure, some licensed physicians claim to provide holistic care, but this usually means that they might add an alternative form of therapy to standard treatment, or perhaps that they strive to be exceptionally considerate.  The holistic character of the care rarely, if ever, comes from Western medicine per se.

The Institute of Medicine and the doctrine of perpetual conflict.

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The Institute of Medicine’s 2009 report on Conflict of Interest in Medical Research, Education, and Practice aims to encourage institutions to develop conflict of interest (COI) policies to safeguard against circumstances in which individual members of the institution, or the institution itself, could risk neglecting primary professional interests (e.g., the welfare of patients or the integrity of medical research) in favor of secondary interests, such as financial gain.

As the IOM correctly notes, the means by which COI leads to a failure of professional responsibility is through bias, conscious or unconscious.  Conflict of interest policies, then, are codes of conducts erected to prevent bias from unduly influencing one’s professional actions.

I have no objection to the aim of the report or to the way in which the IOM defines COI (p. 46).  But given that the overwhelming bulk of the document’s analysis and recommendations serve to specifically guard against conflicts of interest arising from financial relationships and, furthermore, from financial relationships with commercial rather than non-commercial entities, it is worth examining whether this emphasis does not itself reveal a bias or prejudice against private enterprise.

Austin Frakt’s conflict of interest disclosure

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Austin Frakt is a health care economist, creator of The Incidental Economist website, and a regular contributor at the New York Times’ Upshot.  A few days ago, he published a great piece about the best evidence for the treatment of insomnia.  I enjoyed reading it, learned from it, and passed it on to personal connections who suffer from insomnia.  As of now, this article is still at the top of the “most emailed” list for the NYT, and I will keep it as a reference for my patients.

In that piece, Frakt presented to the reader the objective information comparing different treatments for insomnia.  To do so, he reviewed the medical literature about clinical trials where drug treatment was tested against a form of psychotherapy (cognitive behavioral therapy).  The results Frakt reported seem to clearly favor behavioral therapy over drugs.

Yet, for all his claim to simply present objective data, Frakt disclosed a number of personal biases that could very well have influenced his interpretation of the medical literature and put him in conflict with his stated goal.

Is medicine a scientific enterprise?

Abraham Flexner, By Hollinger [Public domain], via Wikimedia Commons
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I was recently involved in a Twitter tiff triggered by the following Mayo clinic announcement:

Readers were promptly outraged:

The murky call for transparency

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Yesterday, Bill Gardner weighed in on the conflict of interest firestorm set-off by Lisa Rosenbaum.  On the surface, his New Republic article seemed to offer a middle-of-the-road and nuanced counterpoint to the vigorous—and at times spiteful—counterattacks to Rosenbaum’s NEJM series.  But despite his efforts to achieve a balanced perspective, Gardner failed to resolve the question with clarity.

While he conceded that Rosenbaum made valid points, Gardner advanced the standard and seemingly indisputable 3-part argument in favor of COI disclosure

Three questions for the Missionaries of Quality

"Crossing the River Styx" by Joachim Patinir (circa 1480-1524) - Museo Nacional del Prado. Licensed under Public Domain via Wikimedia Commons -
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Two thoughtful healthcare analysts (a physician and an economist) wonder about health care quality:

They are not alone.  Even though the Institute of Medicine’s 2001 epic poem mobilized legions of missionaries of quality, it is far from obvious that we have clarity about the overall aim of the crusade.

Our eyes may have been opened to the sins of medical errors, the shame of healthcare disparities, the wastefulness of therapeutic inefficiencies, and the guilt of runaway costs, but if quality care is in fact the goal, and not a pretext for bureaucratic do-goodism, agreement on its meaning seems to be of the essence lest the campaign to “cross the chasm” turn instead into a crossing of the Styx.