American College of Physicians: Internal Medicine — Doctors for Adults ®

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Protesting recertification

From the March 2001 ACP-ASIM Observer, copyright © 2001 by the American College of Physicians-American Society of Internal Medicine.

As a busy physician in practice for the past nine years who is currently undergoing the recertification process, I agree with the sentiments expressed in the November article as well as most of the subsequent letters. ("As recertification deadline nears, concerns keep growing," November ACP-ASIM Observer; "," January ACP-ASIM Observer.)

I find the process expensive, intrusive, unrealistic and just one more form of stress that will shorten our lives even further. Being on call every other day and every other weekend, it has been impossible to adequately commit time to the process and spend quality time with my wife and three young children, who are my first priority.

I also believe it is unfair that fellow physicians who trained and studied with me do not have to recertify because they took and passed the exam a year before I did. I can't see how this would be upheld in a court of law, because it appears to restrict trade for only a portion of our profession.

We currently have to be recredentialed every two years in the hospitals where I practice. We're under scrutiny from the 101 watch groups of the state medical boards, Medicare and others. Let us not also forget the friendly lawyers who are watching for any little mistake we make—or that they claim we make.

Do we really need any more methods to evaluate our performance than what we all ready have, especially as we get older? Let us not forget that the aging process will make recertification 10 times worse each time we recertify.

I would encourage the ABIM to make recertification voluntary again or make it less expensive, more realistic and mandatory for everyone.

Louis A. Fernandez, FACP
Miami


I agree with the concept of recertification. We need some way to ensure that those who practice medicine are periodically updated on relevant advances within the profession, and that they apply them in their practices.

However, I wholeheartedly concur with my colleagues' assertions that the current recertification format is time-consuming, clinically irrelevant to general internists' everyday practice and an onerous exercise in the pursuit of esoteric knowledge.

The problems that are inherent in the recertification process seem to come from the manifestly different perspectives of those who write the test and those who take it. The test writers are academically oriented physicians who deal with cutting-edge insights into the diagnosis, treatment and pathophysiology of unusual diseases and conditions. The test takers, on the other hand, spend most of their time managing common medical problems seen in office practice.

This inherent disconnection between academics and office-based physicians can be seen in the following example: Some years ago, I listened to a Johns Hopkins grand rounds taped lecture on irritable bowel syndrome. The lecturer noted that over the years, about a dozen of these taped lectures had been given on Wilson's disease, but none on irritable bowel syndrome. In my brief 10-year tenure of practice, I have never seen a single case of Wilson's disease; however, I have seen a plethora of patients with irritable bowel syndrome.

One of the ABIM's stated objectives is to promote improved patient quality. As a clinical coordinator for quality improvement for Medicare beneficiaries, I have worked toward this laudable goal. About four years ago, Medicare began to study its beneficiaries' quality of care. HCFA discovered that it could improve quality and decrease cost if it focused on better management of common illnesses that cause the most morbidity and mortality: acute myocardial infarction, congestive heart failure, community-acquired pneumonia, diabetes mellitus, stroke, atrial fibrillation and breast cancer.

Briefly summarized, the studies indicate that physicians woefully underuse scientifically validated treatments for these illnesses. (For details, see "Quality of Medical Care Delivered to Medicare Beneficiaries" at http://jama.ama-assn.org/issues/v284n13/rfull/joc01200.html.) To enhance the quality of care for the bulk of our patients, we need to focus improving care for these common illnesses, not on the esoteric aspects of rare illnesses like Bartonella Hensalae infections. The current format of the recertification process does not enhance the quality of care for the bulk of our patients.

Ultimately, the controversy that surrounds the recertification process is a good one because it will give the ABIM the necessary feedback it needs to design a better process. In the meantime, I pray that I will be able to pass the test when I take it in May.

Matthew E. Masters Jr., ACP-ASIM Member
Austin, Texas


I am among the first group of physicians that must recertify. I currently serve as a deputy county health officer, conduct epidemiologic research, teach epidemiology, and see patients with infectious diseases at a local county hospital. I am raising three children in San Francisco and must moonlight to make ends meet financially.

Now I must try to find the time to study for recertification and to pay for this dubious endeavor, which is a personal and financial hardship for my family. I work 50-plus hours a week in my regular job; I need my few, precious hours of study time to stay current and excel in my fields of concentration. Now I am supposed to find time away from my family to study for a recertification exam that has little relevance to my career.

Not only is ABIM out of touch, but at a time when bright, motivated students have many exciting and rewarding career options, it has created a process that will discourage students from entering the profession of medicine. Frankly, we all lose.

Tomás Aragón, ACP-ASIM Member
San Francisco


I participated last year as a test subject in the new patient?peer assessment survey. I received a booklet containing 50 patient surveys and 20 physician surveys, which I had to distribute to peers and patients, and ask them to complete a telephone survey about my quality as a doctor and colleague.

I practice in a small Ohio town, and am one of the five internists admitting to a 30-bed local hospital. I distributed survey sheets to about 40 or so patients. I also distributed all of the colleague forms-some to the radiologists, orthopedists, surgeons and emergency physicians with whom I have shared patients. Corralling the physicians was something of a hassle because most of them are in town only at intervals for shifts or scheduled cases, so it actually took several weeks to distribute all of the forms.

Several months later, the study coordinator called to tell me that my results could not be evaluated because only eight physicians and 22 patients had actually phoned in the survey. I still had some time if I wanted to contact more colleagues or give forms to more patients.

Of course, the coordinator couldn't tell me who had returned the survey so that I could remind those colleagues who hadn't phoned to do so. For the same reason, I also had no idea which patients I should ask. I had spent quite a bit of time on the whole process and was angry and upset that my effort was totally for naught.

Perhaps the organizers of this new assessment program should give some thought to those of us who work in rural or semi-rural settings. The returned surveys were probably representative of my peers' and patients' perceptions of my competence and quality, even though the number of participants was low. I predict that many physicians will be stymied by this process through no fault of their own.

The assessment idea might have seemed good at the time, but more work needs to be done before it is mandated.

Georgia L. Newman, FACP
Oberlin, Ohio


When the idea of recertification arose years ago, I thought it would be a good idea to refresh and upgrade my internal medicine knowledge, even though my practice was limited to thyroidology. When I asked the ABIM if the test would be open-book, their answer then was the same as today. Frankly, I have no intention of ever taking a memory test again.

My memory is not as good as when I was younger, but my judgment is better. Indeed it was good enough that when faced with a problem about which I had doubt, I consulted textbooks or colleagues. Does that make me a poor physician?

Given the vast body of information available, it is my opinion that when in doubt, practicing from memory is dangerously arrogant and the mark of a fool.

Will the Board never appreciate the realities of clinical practice? Is recertification designed to be educational or punitive? Does the Board want the widest participation, or participation only by those who need the certificate for administrative purposes?

Joel T. Hamburger, FACP
Naples, Fla.


There is no board exam that will teach doctors to know their limitations. The most important thing to appreciate is when a patient needs to be referred to another doctor. Under managed care, many doctors are limiting their referrals and in turn getting involved in malpractice suits. Thus, a board exam should measure doctors' intelligence in making referrals rather than measuring what they know about treating specific problems.

Each year that a doctor survives in practice, he or she gains more knowledge than is lost for various reasons. With maturity comes immeasurable knowledge that cannot in any way be determined by a recertifying exam.

Instead, the Board could make sure we are keeping up on our reading by sending us articles with questions at the end. We would have to answer a certain percentage of these questions correctly to receive a requisite number of points each year.

Alternately, a psychiatric exam every so many years would seem to be a more viable way to protect both patients and physicians than a recertification exam.

Milan L. Brandon, MD
San Diego

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