Boards, boards the medical test,
The more you study the more you jest,
The more you jest, the more you scream
Can Boards just be another scheme?
Taken with great artistic license from “Beans, Beans, the Musical Fruit” (http://en.wikipedia.org/wiki/Beans,_Beans,_the_Musical_Fruit)
What does it mean for your doctor to be board certified? Let’s start from the beginning of how your doctor becomes educated in the first place. Believe me, it’s hard enough for your doctor to keep track of the next test to take, much less keep track as a patient. Medical education begins in college as wannabe doctors take prerequisite college courses to prove their mettle in hopes of securing a medical school interview. Successful applications for medical school require a competitive GPA, good scores on standardized tests (MCAT), glowing references, and a first-rate impression during interviews. You would think that would be grueling enough to become a doctor, but there’s more! Once you’re accepted into medical school, you must take a series of exams to demonstrate that you are competent to become “board-certified”. Think of it as a driver’s license exam from hell. If you decide to become a family doctor, cardiologist, or in my case an allergist, there are additional tests you must take to prove that you have the necessary knowledge to become an expert in your field. You know, all those initials after your doctor’s name! Most likely each initial represents another level of test-taking prowess that lets the public know, “I’m truly an expert in my field and here’s the brass to prove it!”
But not everyone agrees on the “business as usual ” approach to medical education. Within the medical community there is an on-going deliberation regarding physician participation in board-developed maintenance of certification (MOC) programs or simply “board-certification”.
I often wonder, “why become board certified at all?” With the last trauma of board certification for allergy all too fresh in my mind, I often contemplate the risk/reward balance of this endeavor. I can’t tell you how many hikes or bike rides I gave up just to study for this test. You know you’re in trouble when you’re daughter says, “oh yea, you have boards to study for”! Needless to say, the task of studying for an exam at this point in my career is not what I’m used to. Not to mention, I live and breathe allergy & asthma, why would I need to study academic minutia?
Come to find out, taking boards of any kind is more than just showing up for the test. I completed two review courses (one involved travel to Chicago), reviewed > 2,000 pages of fun facts, and took many practice exams just to have the opportunity to take the test. (or as we call it in medicine, sitting for the boards)
So if we put this much emphasis on studying for a standardized test, we should be rewarded for a better outcome with our medical care, right? Well, not so fast. Researchers from Henry Ford hospital in Detroit took 2 groups of doctors and compared how well they performed in taking care of asthma patients. One group received training (i.e., similar to board certification) and the other group relied on their usual practice of medicine. As you can see from their results, it didn’t seem to matter if you received specialized training or not!
http://www.ncbi.nlm.nih.gov/pubmed/17998498–improving asthma care Arch Intern Med. 2007 Nov 12;167(20):2240-8.
Improving asthma care through recertification: a cluster randomized trial. Comment in Arch Intern Med. 2008 Sep 8;168(16):1826-7; BACKGROUND: As part of recertification, the American Board of Internal Medicine requires its diplomats to complete at least 1 practice improvement module (PIM). We assessed whether completing an asthma-specific PIM resulted in improved patient outcomes. METHODS: Practices were the unit of randomization in this cluster randomized trial. Physicians in the intervention group were asked to complete the PIM through its planning phase. The primary outcome was the dispensing of an inhaled corticosteroid (ICS) after a postintervention visit for asthma. Secondary outcomes included patient reported processes of care, asthma-related heath care use, and asthma severity. Analyses were adjusted for baseline rates at the cluster-level as well as for individual sociodemographic characteristics. RESULTS: Eight practices (19 internists) were randomized to the intervention group and 8 practices (21 internists) to the control group. For the primary outcome, ICS fill rates, patients seen by intervention group physicians were not more likely to fill an ICS prescription in the postintervention period than patients seen by control group physicians (adjusted odd ratio [AOR], 1.00; 95% confidence interval [CI], 0.64-1.56). Patients seen for asthma by intervention group physicians were less likely to receive a written action plan than patients seen by control group physicians (AOR, 0.67; 95% CI, 0.48-0.93); however, they were more likely to discuss potential asthma triggers (AOR, 1.62; 95% CI, 1.08-2.42) and had lower self-reported asthma severity measures (unadjusted P =.03). Per-protocol analysis supported the latter 2 associations. CONCLUSION: A PIM designed to improve asthma care did not improve filling of ICS prescriptions but may have lessened asthma severity through an increased discussion of asthma triggers.
So not everyone agrees that special certification is beneficial for the practicing physician. But are there any downside risks?
Burnout can happen to doctors just like any other professional but I’ll bet you don’t read about doctor burn-out very often. I’ll summarize a nice article from KevinMD’s blog about a cancer doctor and “burn out”–>http://www.kevinmd.com/blog/2014/11/oncologists-one-lowest-burnout-rates.html–oncology burnout message.
The alarm clock’s blast brings hours of work, running from task to task, always pushing toward the next turn. In moments of failure, the waves of complexity and anxiety batter and you question each stroke. Then you fly downhill, easy breeze in your face, as success urges you on. After the finish, the parking lot empties, the lights go out, and in the quiet you are drained, achy, and left with satisfaction and the thought that perhaps you could have done better. Tomorrow you will run the triathlon again.
How can any person be a cancer doctor, day-after-day, year after year? A rational human being should tire and fade, exhausted by memories, loss, and the tragedy of fighting a disease, which causes such devastation. Nonetheless, oncologists have one of the lowest burnout rates and highest “I would do it again” sentiments in all of medicine.
The people who participate in sole complex endurance sports are often slightly nutty. I think oncologists too, are slightly nutty people who see in an extreme, partially impossible endeavor, an opportunity which appeals to a desire to be challenged, grow and most of all, give. I suspect that their job satisfaction secret is personal preparation, self-competition and thoughtful repair, which they are blessed to combine with the immense gratification of serving their fellow man.
Like an athlete, the key is to prepare. A cancer doctor has a decade of formal post-college education. These years show us not only medical science and about people with disease, but the keys to personal survival. Experience teaches how to work under physical stress, find harmony in our lives, and to protect not only the patient, but ourselves. We learn to support one another.
Oncologists relish the day-to-day, moment-to-moment, chaotic variation that is the practice of medicine. We counsel a young patient with a new cancer, then analyze labs and x-rays, race to treat crushing chest pain and then we are on the phone, always a bad connection, gently trying to coax a hysterical patient to the emergency room. Every day is exhilarating, confusing, exhausting and depressing. Weirdly, this mix fosters satisfaction. Always there is the need to push, fight, and heal. The next patient is just behind that door.
At night, we mend. The events we see remind us always of the beauty and frailty that is life. Few people hug their children or spouse as tight, or so appreciate green pea mush in a baby’s hair. Cancer docs understand the importance of exercise, good food, a loud party and the proverbial roll in the hay. Many express themselves in art, teaching or by serving their community. In addition, where possible, the vital need is simply to rest.
More than any other source of rejuvenation, like the swimmer, the runner, the biker, there is the roar of the crowd. The love of our patients and their families gives nourishment to the soul. For cancer doctors, the honor to serve is returned many fold by the kindness, which is given onto us. We survive the worst moments on the worst day with the worst loss, because someone says, “Hey doc… how are you? Thanks for all that you do.”
Cancer is not a competition. It is a disgusting random curse, which deprives us of our dreams, and the ones we love. For the cancer doctor the struggle takes a triathlete’s preparation, commitment and personal healing. Fortunately, unlike an exhausted runner who climbs a steep hill in a humid, hot, isolated gorge, we are never alone.
Great writing, doc! So it does seem that preparedness is a tool that can be used against burn-out.
The bottom line seems to focus on the questions, “Are board-certified doctors necessary and are they associated with better physician quality, better overall medical care processes, and clinical outcomes?” After all, you don’t care much about doctor certifications; you just want to get better, right? Or do you care? Should you care?
The overall purpose of board-certification is to assure patients and the public that board-certified specialists are current with and can access evolving knowledge, are aware of and use the highest practice standards, are recognized and respected as specialists by their patients and peers, and are continually reviewing their clinical performance and adjusting and improving the processes of care as necessary. The fact is, the public believes physicians already do this on a regular basis. (James JM, Corbett, M. The American Board of Allergy and Immunology maintenance of certification program: “To do or not to do? That is the question.” Annal of Allergy, Asthma & Immunology 2010;105:485-488)
To do nothing certainly does not lead to improved care.
I leave you with a piece from the New York Times written by Dr. Ofri on the whole subject of board-certification. (http://nyti.ms/1zZr8S3)
IT’S hard to believe that another 10 years have passed, but the proof is the 11-volume stack of medical review books at my bedside. It’s time for the decennial rite of cramming a thousand pages of facts for an eight-hour-long multiple choice test.
Doctors are licensed by their states to practice medicine, but they’re also expected to be “board-certified” in their particular field — surgery, obstetrics, pediatrics, etc. This certification comes from the professional organization of each field. In my case, it’s the American Board of Internal Medicine.
It used to be that you tackled those monstrous board exams just once after residency. Then you went into practice and never looked at a No. 2 pencil again. But in 1990, the boards decided that doctors should recertify every 10 years. This seemed reasonable, given how much medicine changes. Over time, though, the recertification process has become its own industry. The exam has been supplemented with a growing number of maintenance-of-certification, or M.O.C., requirements. Some are knowledge-based exercises, but many are “practice assessments” meant to improve care in your own practice that end up being just onerous paperwork. And the recertification process and associated materials cost doctors thousands of dollars.
This year the internal medicine board announced that doctors who didn’t participate would be publicly tagged as “not meeting M.O.C. requirements.” Many jobs require board-certification, so a number of doctors felt that this tactic amounted to extortion. More than 19,000 signed a petition in protest. They complained that the specialty boards are monopolies that control who can practice medicine and use this power to compel compliance and exorbitant fees. Worse, they argued that the recertification process might not even be effective.
It may seem obvious that continuing education would benefit doctors and patients, but in medicine we’ve often learned the hard way that things that seem intuitive (think estrogen replacement therapy) may turn out to have little benefit or to even be harmful.
Two recent studies in The Journal of the American Medical Association are the first to seriously evaluate the role of M.O.C. in physician quality and medical costs. They compared doctors certified just before the 1990 change (who were grandfathered in for life and not required to recertify) and their colleagues who certified just after 1990. The studies differed in methodology but the upshot was that patients’ medical outcomes were no better and overall costs were only marginally lower in the recertifying group (2.5 percent).
All that effort, in other words, didn’t seem to make doctors better. Many doctors are rallying around these findings to call for a wholesale dismantling of the recertification system.
But others are using the data to ask how recertification can be made meaningful. Just because these studies didn’t show an effect doesn’t mean one doesn’t exist. Recertification may benefit certain subsets of patients, such as those with less common illnesses who aren’t numerous enough to influence study results.
Some parts of the recertification process are useful. The practice questions in the review books, for example, exercise muscles we don’t use every day. They re-emphasize important points, remind us about conditions that we see less often and, best of all, are open-book, much like real life. When there is a complex patient in clinical practice, no doctor relies just on memory; we look up the information, check a journal or consult a colleague. To rely solely on memory, especially for rarer illnesses or complicated patients, would be malpractice.
Which is why the huge exam that culminates each decade of recertification should be abolished. Memorizing reams of information to be regurgitated in a “secure testing center” is a waste of time and resources, and does not reflect how medicine is practiced.
Most doctors agree with having some sort of process that updates and refreshes medical knowledge. But the process has become unmanageable. Let’s strip away the archaic exam and the paperwork-heavy practice assessments. A periodic, modest-size, open-book test that incorporates relevant knowledge and updates would be more reasonable.
There is much more to the science, art and practice of medicine than medical knowledge. But it is the one aspect we can easily assess on a profession-wide scale. Open-book, self-paced tests are the best way to keep knowledge current. The act of searching for answers — whether from journals, textbooks, databases or colleagues — is itself the knowledge. All the rest is busy work and red tape.