Board Certification: Be Careful of the Grandfathers
One routine piece of advice that many of us patient advocates give about scouting a new doctor is to make sure the doctor is certified by one of the boards under the umbrella of the American Board of Medical Specialties. But there's a "grandfather" issue that patients need to know about even with these boards. Doctors who were certified before 1990 have a lifetime certificate, and it's strictly voluntary whether they stay up-to-date by taking the re-certification exam every ten years.
Here is a guest column on this topic by John James, a patient safety advocate from Houston. I'm reprinting this with John's permission. John James is a NASA Ph.D. scientist who lost his son Alex to medical malpractice. Dr. James wrote a book: "A Sea of Broken Hearts -- Patient Rights in a Dangerous, Profit-Driven Health Care System." His description of the book:
This is the story of a father's journey through the healthcare that resulted in the death of his 19-year old son, and the incredible coverups of mistakes that were made. The reader is taught a little basic cardiology, and then invited to use those skills to solve "medical mysteries" that were missed by the boy's cardiologists. Chapters are devoted to understanding how physicians are educated and why current medical care is infested with errors - many of them lethal. The last chapter is a patient bill of rights that would enable patients to protect themselves from healthcare that is centered on making money and not patient safety.
The book is available from several on-line sources. Please go to http://PatientSafetyAmerica.com to read short reviews and learn about the sources.
And here is John James' column:
Does your Doctor Know?
Keeping up with new medical discoveries and applying them effectively to patients is a daunting task. One might suppose that physicians have developed an efficient and comprehensive way to capture new medical discoveries and disseminate these into the clinician community.
You would be wrong, perhaps dead wrong.
In a series of opinions from physicians published in the New England Journal of Medicine the woefully inadequate way physicians continue to learn is inadvertently revealed. That is not the intention of the opinions, but a little inspection discloses the problems. Besides their ongoing experience base, there are two major ways doctors can acquire new knowledge. The first of these is state-mandated continuing medical education (CME). Among the states, the mandated number of hours per year ranges from zero to fifty, but none is specifically required in the physician’s declared specialty. Is it any wonder that one of the articles, citing three studies, observes that CME does not improve physician performance or knowledge.5
The second way that physicians acquire new knowledge outside their practice experience is through board certification and periodic recertification. Surprisingly, a physician does not have to be board certified to represent himself as a specialist to the public. In addition, there are many second-rate board certifications appearing that are generally regarded as unable to give any assurance of competency.
What about the traditional and well-respected boards, such as those under the purview of the American Board of Medical Specialties. Can certification by these boards assure physician competency? There are two cases. One applies to physicians given limited certificates after 1990. They must periodically recertify. For example, internists must recertify every decade. Unfortunately, medical knowledge grows so quickly that information more than 5 years old may be well out of date. This approach is better than nothing, but it is clearly inadequate to ensure that your internist is up to speed on the latest findings.
Physicians that were board certified before 1990 trouble me most as a patient. These physicians were given lifetime certificates. This means that they do not have to recertify to continue to represent themselves to the public as board certified. However, these specialists can choose to voluntarily participate in maintenance of certification (MOC). This choice prompted the series I am reviewing here.
Two MDs make the case that internists with lifetime certificates should voluntarily recertify.5 They view MOC as a superior process to CME and cite several studies linking MOC to better physician performance. They note that physicians’ ability to self assess their learning needs is poor. Barriers to voluntary participation include costs and time. Of course, the fear of failure is another barrier. They note that there are flaws in the testing, but that these can be reduced by feedback from participants.
Three other MDs argue that a physician with lifetime certification should not voluntarily recertify.6 They note that very few physicians choose to recertify, which they interpret to mean that the specialists think the process is irrelevant to their practice. I would argue that it is more likely the cost, time, and fear-of-failure that limit voluntary MOC. They argue that there is not “definitive evidence” that recertification benefits patient care. They further argue that the recall of facts on the closed examination does not make an improvement in patient care.
As a patient I feel that physicians should demonstrate some level of competency through recertification or be required to disclose to all their patients when the last time was that they were subjected to a competency assessment. You might like to know that almost ¾ of cardiologists in a national survey admitted that they had not been evaluated for competency in the past 3 years.7
5) Levinson, W and TE King, Jr. Enroll in the MOC program as currently configured. N Engl J Med 362:949-950, 2010
6) Goldman, L, AH Goroll, and B Kessler. Do not enroll in the current MOC program. N Engl J Med 362:950-952, 2010
7) Campbell, EG, S Regan, RL Gruen, et al. Professionalism in medicine: Results of a national survey of physicians. Ann Intern Med 147:795-802, 2007
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