Leaving corporate medicine
I was somewhat saddened by the column in which College President Sandra Adamson Fryhofer, FACP, described her decision to start over in a solo practice. ("How some internists are surviving the corporatization of medicine," November ACP-ASIM Observer.) I am glad, though, that she has found peace of mind.
I too sold a thriving practice to an academic network, only to have it destroyed. I don't blame managed care or corporate medicine for my experience, however. Untrained physician managers did us in.
Rather than starting over solo, I pursued management training through the American College of Physician Executives. I have a gratifying new career leading an academic practice into a better future rather than retreating into the past.
Despite the allure of the "good old days," the truth is that unmanaged care seriously hurt the U.S. economy and contributed to a decline in our standard of living. For all its warts, managed care has forced us to look hard at ourselves. Unexplained clinical variance, lack of evidence-based medicine and an absence of an organized quality movement are glaring reminders of our past.
I believe the future is bright. With the emergence of physician executives, physicians will regain control of health care. Once we recognize that we are part of both the problem and the solution, we can help create organizations that balance fiscal discipline, accountability and value while preserving the sanctity of our calling.
Michael A. Patmas, FACP, CPE
I was encouraged that the ACP-ASIM Board of Regents approved a new position paper opposing physician-assisted suicide concluding that the practice should remain illegal. ("Regents discuss recertification, assisted suicide, independence of pharmacists and access," December ACP-ASIM Observer.)
It is appropriate for our organization to take this strong position. The experience in the Netherlands has made the consequences of assisted suicide clear. Despite safeguards, assisted suicide inevitably leads to euthanasia. If death is declared a medical treatment, there will be no way to control it in America-especially in the setting of managed care and cost containment.
We now have the finest palliative treatment and technology in the history of medicine. Ironically, however, the quality of doctor-patient relationships may be at an all-time low. Suffering and loneliness at the end of life are great challenges that have no easy solutions. But helping patients end their lives is not the answer.
In the Hippocratic tradition, we must not abandon dying patients, but reach out to them with true compassion and help them find meaning and comfort at the end of their lives.
Kenneth J. Simcic, FACP
Responding to the ABIM
While I am delighted to read an open exchange of ideas concerning recertification, the ABIM's response to legitimate criticism of its recertification process is troubling. ("ABIM responds to concerns about recertification," January ACP-ASIM Observer.)
Widespread dissatisfaction is evident in the continued stream of letters to the editor in this publication. I know many internists who have contacted the ABIM to complain about the overly burdensome process. I find the assertion by David R. Dantzker, FACP, that physician discontent is merely anecdotal to be dismissive and an insult to those who have taken the trouble to voice concerns.
The data presented by Dr. Dantzker in the article are misleading because they were acquired between 1996 and 1999, when recertification was voluntary. The resondents were, therefore, a self-selected population unlikely to reflect the opinions of those now required to submit to recertification.
The data did indicate that a sizable minority (20% to 30%) did not find the questions relevant or the process "important." In my experience, hunting down arcane medical information to answer self-evaluation process (SEP) module questions was frustrating. If the Board wanted to create an educational experience, it should have supplied test-takers with explanations of the answers and references for further reading, not a sterile answer sheet with the correct letter response to each question.
I do not hear internists decrying the need for time-limited certification. The Board seems to be overly defensive in its response. Obviously, valid criticism has been voiced, or the Board would not be revamping the process. How about an acknowledgement from the ABIM to this effect, and a pledge to make the process more open, inclusive and responsive to internists' concerns?
Glenn S. Ross, FACP
Newport News, Va
Dr. Dantzker noted that "the best solution to concerns about inconvenience [of recertification examinations] would be to administer computer-based testing in smaller centers," adding that "today's testing centers can not yet handle the Board's sophisticated examinations … "
There may be good reasons why the ABIM recertifying examinations are not administered by computer. As president of the National Board of Medical Examiners, however, I cannot agree that today's testing centers are inadequate to administer highly sophisticated examinations for health professionals.
The United States Medical Licensing Examination and certifying or recertifying examinations for orthopedic surgery, anesthesiology, physical therapy, pathology, nursing and veterinary medicine have all been administered at hundreds of secure computer-based test delivery sites for some time. I am sure that Dr. Dantzker would agree that these established computer-based examination programs are both sophisticated and rigorous.
Donald E. Melnick, FACP Philadelphia
I find it interesting that the ABIM states that "the era of unexamined practice and self-asserted excellence is over." Are we not examined every day by our patients and peers? Every time we make a diagnosis, do we not question ourselves, as do our patients? Medicare looks at our every move: admitting, coding, diagnosing, testing and treatment. We are required to complete CME credits to maintain licensure.
How does a paper test prove anything except how we did on that test? This test is supposed to "provide regular, direct evidence of quality improvement." How does it do this? We could answer all questions correctly and still miss a diagnosis because we are harried for any number of reasons: the insurance company will not allow a test, the patient gives an incorrect history, we're in a rush to attend a child's recital, or we have to spend so much time plodding through CPD modules.
I see the test as a way for the ABIM to make money, and for hospitals and insurance companies to accept or reject our privileges and claims. However, I will follow the crowd and proceed with the test because the Board feels that a pen and paper test outweighs the results seen in our daily practice.
Mark Janes, FACP
While it is irritating to be in the first group of mandatory recertifiers, I do support the concept and agree with Dr. Dantzker's view that a recertification process should not be merely "fast, easy and have negligible consequences for poor performance." However, I don't support the Board's implementation this past year.
I found the vast majority of the 300 questions in the SEP modules to be a waste of time, covering clinical areas of little relevance to me. To add insult to injury, some of the "correct answers" were debatable. When I could not find the answer to obscure questions in texts or online, I consulted subspecialty colleagues. More than half the time, the answers they gave were judged wrong. Either I travel in subpar physician circles, or some of the questions covered areas of evolving agreement on "best practices."
I'm also not sure how Dr. Dantzker does his math. He estimates 15 hours for each of the five SEP modules, plus 40 hours to prepare for the exam, which comes to 115 hours, not the 100 he cites. Dr. Dantzker then spread these 100 hours over 10 years, which future applicants under the refined process will face. Those of us who recertified under the current system, however, weren't able to spread those hours over 10 years.
I also have a major problem with the Board's steadfast refusal to provide " a syllabus, references or rationales for answers to SEP questions." Dr. Dantzker says this is because "CME is the responsibility of specialty societies and other institutions."
I don't believe most specialty societies would want to waste time teaching the trivial content covered in the SEP modules, nor would I want to pay for CME courses on such topics. I could do it on my own. But after poring over books, journals and Web resources, I still couldn't find some answers. I assumed that, like MSKAP, the Board would return my results with an explanation of each correct answer, including references. Merely knowing that an answer was "c," not "b," is of little value.
I called the Board to request the references, something that would help me "continuously develop professionally," which is allegedly the overarching purpose of this process. My request was dismissed out of hand. This policy makes no sense to me. Presumably all of these answers were carefully researched and the author can provide references. Why should SEP modules be different than MKSAP?
The revamped recertification process sounds a lot more appealing and relevant than what I endured the last nine months. I would have appreciated a clear recognition of this reality from Dr. Dantzker rather than a defensive stance. The 2000 recertifiers were guinea pigs in a flawed process-one that I hope will improve for future test-takers.
Sean O. Stitham, ACP-ASIM Member
As I read about physicians leaving hospital-owned practices, I was reminded once again that pure numbers too often override all other concerns. ("As doctors leave hospital practices, some are finding a 'soft landing'," January ACP-ASIM Observer.)
Hospitals need to expand their outlook if they are going to succeed in a practice environment that has a growing elderly population and an increased prevalence of chronic diseases. This healthcare climate requires hospitals to pay attention to more than just physician practices' hospital admission rates, clinic income and revenue from ancillary service referrals.
While hospitals have many successes treating acute illness, they generally have a poor track record managing chronic disease in the outpatient setting. Financial success involves more than preoccupation with patient volume, revenues and referrals. It requires an appreciation of the human condition in context, one that takes into account the physical and psychosocial variables that affect the course and outcome of chronic medical disorders. It also requires administrators to listen to experienced clinicians about the value of outpatient programs that change patients' lifestyles and improve care quality.
Active interventions to prevent hospitalization have become an important trend in outpatient practices. Perhaps this threatens hospital managers concerned only about census figures and practice volumes, and not the true health of the communities they serve.
While chronic disease programs do not produce immediate profits, they are necessary to broaden and enhance patient care and, in time, an institution's reputation. This factor, in addition to good business management, eventually leads to long-term financial success.
Stephen G. Gelfand, FACP
Myrtle Beach, S.C.
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