Sunday, July 04, 2010

"Independence Day": A Board-Certified Pediatrician's Thoughts On The American Board Of Pediatrics' New "Maintenance of Certification" Requirements

*Note to Housecalls Readers:  This post, one of less than 20 that are not archived off-line, has been edited to eliminate links and dated material/references.  The post remains up because the topic of "Maintenance of Certification" is a much hotter topic than it was when this post initially went up.  It's a foot-print in the ether that I want to keep planted.

*Additional Warning to the Lay-Reader: There will lots of abbreviations in this post. We doctors LOVE our abbreviations. Makes us sound really smart and cool.  Likewise, I pull no punches.


I am one of more than 9600 American Board of Pediatrics Diplomates whose certification is due to expire in December 2010.

The recently re-vamped process of renewal is call "Maintenance of Certification" or MOC. It is a multistage, cycled activity (in Pediatrics, Board Certification is now "good" for ten years) . . . some of which must be completed before Diplomates even enroll for re-certification. I must complete a "Part 2" and one "Part 4" activity prior to early December . . . and prove that I have a medical license.

The ABP also requires a check for $1030.

So far, the North Carolina Medical Board has not pulled a "Rachel Hunter" (free speech is only free if you run with the legal pack) on me (i.e. the license is not an issue), and "Part 2" is actually not a problem . . . because I have been doing the American Academy of Pediatrics' (AAP's) PREP (Pediatrics Review and Education Program) & PIR (Pediatrics In Review) self-assessment curriculum for several years now. It's called CME (Continuing Medical Education).

Since the mechanism-of-earning-a-living I was forced to adopt after getting royally-screwed by my hometown "non-profit" hospital (in Asheboro, North Carolina) eschewed the paid vacations and expensive trips to exotic locations for the privilege of logging a few measly Category 1 credit hours (we physicians in primary care - particularly those of us who do not have CME allowances - have to budget that $1030), PREP & PIR are the cheapest/easiest way (several hundred dollars a year) to get good/solid CME.

And (thank God) PREP is an ABP-approved "Part 2" Activity. So no worries.

[OBTW, for the lay-person's information, The North Carolina Medical Board (NCMB) currently requires 150 hours of continuing medical education over a three-year cycle (60 hours of which must be formal Category 1 credit) in order for physicians to maintain licensure. In other words, we're not all sitting around picking our noses in our "spare time" . . . we have to make a genuine effort to stay up-to-date in our fields. If a Pediatrician simply & steadily completes PREP and PIR every year, that's 76 Category 1 hours a year - more than enough to satisfy the lawyers running the Medical Board.]

The subject of Board re-certification is a topic that, as deadlines near, is beginning to be more contentiously debated in the medical blogosphere. Kevin MD has recently featured a series of posts, and "the veil" has lifted just enough to reveal that many physicians in all specialties . . . doctors already feeling under siege by the healthcare "reform" imposed by lawyers and bureaucrats (and unfortunately drooled-over by the American Medical Association) . . . are decidedly unhappy with recent time-consuming, expensive, intimidating, largely irrelevant-to-their-day-to-day-practice, and wholly-pointless changes to the re-certification process . . . including re-instituting proctored (aka "secure")/timed exams.

The initial Pediatric certification exam (a grueling two-day/all-day, proctored & timed rite of passage), is something that Diplomates have endured at least once (a fair percentage of candidates more than once, as in any given year, very roughly 20-25% of first-time takers do not pass the exam). Once certified, Pediatric Diplomates can be elevated to the status of "Fellow" in the Academy of Pediatrics (provided they pay their yearly dues).

But until now, the re-certification process was something a Pediatrician could do online/at their own pace/in their "spare" time (like PREP and PIR). And it worked quite well for a number of years. I have re-certified once.

In short, the process wasn't "broke". It really didn't need to be "fixed".

It's actually a very sore subject for many of us "younger" folk because the re-certification business (and make NO mistake - it IS a business - 9600 times $1030 equals almost ten million dollars for the ABP courtesy of the 2010 Diplomates alone) always seemed inherently unfair. You see, there is an entire segment of older board-certified physicians (arguably the people who might benefit most from being forced to periodically sit down and open a book) who have been "grandfathered" into certification . . . and who have never had to re-certify their boards.

Even now, the Board is not requiring "permanent" certificate holders to take secure exams - and their "MOC" process is a watered-down version of what their less-fortunate younger colleagues are forced to do. It's totally unfair. And there's really no good reason the ABP can give for that.

On the flip side of this under-cooked burger, there are a lot of doctors out there practicing their "specialties" without having obtained any Board certification at all.

The specialty Boards are now telling their Diplomates that the general public WANTS us to take proctored exams again, and jump through all of these additional ridiculous hoops (a good portion of which a lot of us are doing anyway) in order to re-certify. It's an interesting theory, but based on my experience in the blogosphere, I'm thinking the general public (a good portion of which wanted Obamacare until they didn't) does not have a clue as to what the average physician has to do in order to become certified/licensed/privileged and remain that way. Call me an anarchist (or even worse, a Republican), but I don't think we ought to be basing everything we do on public polls. There's no hard research out there that I know of that proves jumping through all of these certification hoops (dreamed up by academicians) actually makes doctors better or safer or more conscientious - or actually really improves quality of care.

In that sense, it's a lot like the self-perpetuating dog-&-pony show that JCAHO (the Joint Commission for the Accreditation of Hospital Organizations) puts on.

Some physicians are bantering about the idea of refusing to re-certify en-mass, as a way to protest a process into which the huge majority of us had no input (come to think of it, working under a system into which we had little or no input sounds a lot like Obamacare). It's obviously a "dangerous", "Independence Day" kind of idea to the powers-that-be (like dropping Medicare or Medicaid), and they are doing all they can to quash dissent before it becomes a big problem.

The AAP (Academy of Pediatrics) News sent out an e-mail edition to its Fellows this week featuring an article discussing MOC requirements. And I'm thinking the Academy (which also makes a boatload of cash in the process) found this necessary because apparently a large percentage of the Pediatric Diplomates due to expire in December 2010 are balking at the process and have not yet enrolled to re-certify.

That would include me. I'm really struggling with the decision to be or not to be (certified) - more so than I ever thought I would. Or maybe struggling is not the best description. It's more like being resentfully indifferent.

My initial experience certifying (at a time when I was also the senior "partner" in a fledgling/ineptly-managed "non-profit" practice - and covering Pediatric/Neonatal critical-care back-up for anyone who wanted it 24/7) was very demoralizing and traumatic (see below) . . . a very hard win. So board certification actually does MEAN something to me. Moreover, since I work as a Locums (and am currently contracted as a Pediatric Hospitalist), there's no doubt that it would be in my best professional interests (in order to smooth the insurance/hospital credentials and privileging processes) to re-certify at least one more time.

But very honestly, a part of me really wants to tell the American Board of Pediatrics to GO STRAIGHT TO HELL.

My biggest/current problem with the process as it is currently laid out (apart from the notion of a proctored/timed exam . . . BOOOOOOO!!! . . . HISSSSSSS!!!) has to do with the Part 4 "Quality Improvement" activity, which seems contrived and forced . . . and in my case, anticlimactic (we'll get to that in a moment). The options for people of special practice circumstances (i.e. part-timers, semi-retired, travellers, pseudo-specialized generalists, etc.) are actually quite limited to one or two online activities. The eggheads at the ABP apparently think we all work in very structured, "team-oriented" offices with 3.5 like-minded colleagues (i.e. in other words, like the academicians who dreamed up all this crap).

But we don't. Here's an excerpt from the AAP News article:

Confusing, time-consuming and expensive. That is how some Pediatricians are describing the new Maintenance of Certification (MOC) process.

Especially challenging is finding the time to sort out and complete the requirements of the QI (Quality Improvement) project for Part 4.

"It was only after talking to other colleagues that I realized what must be done in 2010", said a hospital-based Pediatrician who plans to complete an obesity QI project. It took several sessions on the American Board of Pediatrics online personalize portfolio before she began to put it all together. 

"I thought it was just me - that I was not navigating it correctly - but it seems my experience reflects that of my peers."

"If you practice in an office, you know you have to do this, you want to do it, but you are not sure how", said another Pediatrician who is "grandfathered" in, but chooses to re-certify because she is a champion of QI in her four-physician practice. Unfortunately, she completed and submitted her project in the wrong cycle and it was rejected.

"It would be nice if they told you exactly what to do", said a part-time Pediatrician who hopes to finish a nutrition project for Part 4. "It's lovely to have choices, but you have to sift through all of this and it takes so much time."

The AAP News article actually made me feel a whole lot better about my very impertinent and uber-unprofessional thoughts regarding the ABP. It was clear I wasn't the only Diplomate who felt that the 250 "distinguished" Pediatricians breathing the rarefied air in the ABP's ivory tower had gone completely daft. I was also relieved to know that the fact that it had taken multiple visits to the Board's convoluted website for this fairly computer-savvy blogger to figure out what specifically she needed to do, did not make me stupid.

As per usual, yours-truly's lot in life is usually to be the tremor before the tidal wave, and I'm not exactly a novice in speaking truth to power. But there's something else going on here. I have a big beef with the ABP - indeed (at this admittedly late date) the entire structure of medical education. You see, I have ADD, which was not diagnosed until after I had completed medical school and done all of of the "inservices" of my Pediatric residency (always struggling with the multiple-choice testing and always being told that my performance on standardized tests did not match my PROVEN knowledge and abilities) . . . and after I started having BIG trouble passing my Boards.

I've never been medicated for any length of time - the trials I did back when the diagnosis was first made had me feeling like a zombie.

Since being diagnosed, it's been a sore point with me that all of the educational gurus (particularly the ones specializing in Pediatrics - supposedly experts in ADD) I encountered during all of those years slaving away in a "world-class" medical/academic environment did not pick up on the fact that something was very wrong and suggest appropriate intervention.

So, I was just a little bit ahead of the sentiments other Pediatricians expressed in the AAP News article (and a tad more "forceful") when I e-mailed Dr. H. James Brown, the ABP's Vice President of Public Relations (right now, I don't envy the man his job) this past May.

[OBTW, I'm baring more of my soul here than most physicians feel comfortable - but hey, what else is new? I figure it'll just be another tender spot that the "children-of-borderline-Mothers-with-sociopathic tendencies" - or the online Roaches - can stomp all over.

In the meantime, I like to think that I stand as an example to children with ADD - and their parents - living proof that you can endure and overcome this disorder and be whatever you want to be. In fact, once free of the academic environment, adults with ADD may actually be at at advantage in many aspects of life. I'm convinced that I would not have been able to survive what Randolph Hospital did to me if I had not been so toughened by prior disappointments . . . more flexible/adaptable . . . and more ideally-suited to cope with adversity.]

Here's my e-mail to the ABP:

I just want to convey to the (American) Board of Pediatrics my frustration with your MOC process and website.

I certified in 1996 - after two unsuccessful attempts. I've re-certified once before. I am due to re-certify this year.

I suffer from Adult ADD and was not diagnosed until after I had problems passing my initial Board exam. I suffered from almost paralyzing test anxiety. The process was EXCRUCIATINGLY painful and embarrassing to me - not to mention tremendously expensive.

It was clear that the ABP did not care about anything but the money.

After a horrific experience in public service (www.drjshousecalls.blogspot.com), I now work as a Locum Tenens/Pediatric Hospitalist in a rural area. I spend a large portion of my time on-the-road. I don't have a lot of free time.

I was tremendously relieved when the re-certification process was modified to at-home/open-book/at-your-own-pace online testing. I had no problem passing the exam.

For the last several years, I have gotten my CME via the AAP's PREP self-assessment program. I now do it religiously and find it satisfactory for my needs.

After getting several ominous e-mails from the ABP this spring (and wanting to re-certify at least one more time), I went to the ABP's website and began to investigate how to initiate the MOC process. Within minutes all of the old/familiar feelings came back and I had to exit the site. Moreover, I could not make heads or tails of what I needed to do.

It seems to me that the ONE medical specialty that deals the most with ADHD and ADD would have more insight into developing a process that accommodates all comers - including and especially practitioners who suffer from these disorders.

The process the Board has devised is ridiculously-complicated, subjective-to-the-point-of-being-absurd, and (once-again) tremendously stress-inducing. Given the daunting difficulties we in the medical field are now facing in terms of just getting by and making ends meet (I've actually considered leaving medicine), it seems to me that the ABP is shamefully out-of-touch with reality. You say the general public wants this - but my own experience in real life indicates that the general public is largely in-the-dark about what really goes on in medicine. I can see no evidence that your certification process guarantees competency (some of the most clinically dangerous physicians I've met were Board-certified).

So I'm wondering what is the point of jumping though all of these hoops again? And are you making any accommodations for those of us with learning disabilities?

Sincerely,

Mary H. Johnson, M.D. FAAP


To his credit, I got a fairly quick response from Dr. Brown:

Dear Dr. Johnson,

Thank you for taking the time to email the ABP with your concerns and questions. As a private practitioner with 34 years of practice experience before retiring I know first hand the value of your time.

The ABP does consider test accommodations for those diplomates with conditions covered under the Americans with Disabilities Act. If you type "test accommodations" in the search feature on the home page there is an explanation of the process of requesting test accommodations relevant to your situation. Alternatively, you can click on "How to apply for and exam" on the home page, then ABP Policies in the left column, and then on Test Accommodations. You can then review the policy and request for special accommodation forms.

If you are having trouble navigating the website you can call the ABP directly, explain the specific problem, and you will be transferred to staff that can assist you. It is helpful if you have opened the ABP website so you and the staff are looking at the screens in real time.

Please remember that the ABP is make up of your colleagues. The 250 members of the ABP basically volunteer their valuable time to make sure that your certification is meaningful to the public. I assure you that the general practicing private pediatrician is well represented at all levels of the ABP including the Board of Directors and the Executive Committee (as well as chairing the BOD) and relevant committees that develop the certification requirements. Those members are more that aware of the vicissitudes of practice that you mention in your email. Self certification by our profession is a privilege afforded us by the public and is one I, at least, feel should not be squandered. I would disagree with your supposition that the public is naive and can supply evidence to support that if you would like.

Again I thank you for your email. Feel free to call me at the ABP if you have further questions.

Sincerely,

H. James Brown, MD
Vice-President, Physician Relations
American Board of Pediatrics


Now, Dr. Brown had the misfortune to catch me on a bad day (extended periods of 24/7 call in isolated areas far-from-home do tend to bring on the blues) . . . AND after I had already been back to the ABP's website unsuccessfully trying to figure out what specifically I needed to do. I felt uber-patronized (never a good thing) by my distinguished-colleague-with-34-years-of-comparatively-benign-practice-experience:

Dr. Brown,

With due respect, if you visit my blog you will see that I . . .

(1) Served Federal & state public service commitments honorably in my hometown.


(2) Within weeks of that obligation being completed, was threatened with termination by "non-profit" hospital executives for reporting concerns about the quality of Pediatric/other care being provided at their rural hospital (a hospital where I, myself, have had surgery seriously BOTCHED not once, but twice - requiring surgical revision/repair both times).

(3) Within days of those threats being issued, was fired for intervening in a case being botched by a Family Practitioner-who-fancied-himself-a-Neonatologist (saving a newborn's life). My hometown practice - a practice the government said I was supposed to be able to transition - was destroyed, and I was forced to sue.

(4) SLAPP-sued (unsuccessfully) for reporting what happened to the government I served - a legal tactic designed to drain my bank account.

(5) Swindled at settlement (in my favor) when the "non-profit" hospital executives who fired me repeatedly lied under Oath about the "confidentiality" of their financial records & salaries.

So. I can assure you that my experience as a private Pediatric practitioner is VERY different from yours. I suffered all of these "vicissitudes" while continuing to work full time as a Locum Tenens (in almost 40 locations in a variety of locations and practice settings - from private practice to Federal clinics to ED's to hospitals), regularly doing PREP and maintaining my licensure and my board certification.

Since 2003, I've tried to get local journalists to report, and the government to act, and NC law enforcement to prosecute (all I've ever asked them to do is enforce their own contracts and the law), but I can get no "traction" because the public is NOT informed and MOREOVER does not care when good doctors are done wrong. They are, in fact, entitled to the privilege of me serving them.


It's okay for the legal system to brutalize good/honest doctors because we're all "rich".

Meanwhile, my so-called "colleagues" in the ABP and AAP and JCAHO and AMA
(American Medical Association) and NCMS (North Carolina Medical Society)/NCMB and everywhere else have sat on the sidelines and watched me endure this in silence without so much as lifting a finger to help.

The healthcare reform bill was a sad/pathetic joke in terms of what really needs to be reformed.

I'm not the only doctor/Pediatrician out there that this sort of thing has happened to. But we languish abandoned in a black hole - because we don't have the money or connections to really take on the businessmen and lawyers who are doing these despicable things under the cover of "charity".

Now, as I contemplate suing some of the oversight organizations that let me fall through EVERY hole of oversight and swing in the wind (for TWELVE YEARS), I've got to wrestle with the decision about paying for and enduring a process that once again does not take what I've overcome, endured and lived through into ANY consideration - and to remain in high-minded "ranks" that seem oblivious to what is actually happening to their own in the real world.

I went to the ABP's website and literally froze. You have NO IDEA how horrific/embarrassing/demoralizing the first experience getting certified was. NONE. I've jumped through the hoops - over and over again.

The re-certification process you had in place was PERFECT for my needs. What is in place now is purely and simply about money. Money for re-certification. Money for "part two" activities. Money for "part four" activities. Like the joke that is JCAHO, it is a cottage industry for cookie-cutter medicine with its foundation in quicksand . . . because you have NO good evidence that this complicated/expensive process actually produces better/safer doctors.

Quite simply, the ABP has gone and "fixed" something that was, in fact, NOT BROKEN.

You'll forgive me if I'm having trouble now trying to decide if I'm gonna buy (again) what you are selling - and put myself through this one more time.

Sincerely,

Mary H. Johnson, M.D., FAAP
Asheboro, N.C.


Alas, Dr. Brown, like so many of his high-minded kind on the medical boards and in the professional societies who freeze themselves when confronted forcefully with the uglier "vicissitudes" of modern medical life that some of we not-so-"distinguished"-Pediatric-life-forms have endured, has gone silent . . . and not responded to that e-mail . . . even though I did send a follow-up e-mail this past weekend.

Of course, going silent is what all the "right people" do when the real world conflicts with their particular vision.

And it's so typical. Like I said earlier this week, my experience, as a not-so-young-anymore professional in public service, does not exactly reflect well on the inherent nobility of medicine (or the legal profession). Talking in such a raw/real fashion about what happened to me in Asheboro . . . and what I've seen/dealt with on-the-road . . . makes the medical establishment (the same establishment that tells the public it cares about patient safety and physician competence, but actually cranes its neck to look in the other direction when those of us actually fighting for it are professionally EVISCERATED) very, Very, VERY uncomfortable.

I'm literally blood on their walls.

But I just don't care any more if what I say makes people like Dr. H. James Brown uncomfortable. Something's got to give.

It really does seem to me that Mary Johnson, M.D., FAAP (Fellow, Academy of Pediatrics), has already bled and Bled and BLED some more for the sake of Pediatric "Quality Improvement" in whatever little part of the world I've happened to work in.

And I'm kind of wondering how different my life would have/could have been if all the time I've poured into the legal battles . . . legal battles that should have/would have NEVER had to been fought (if some of Dr. Brown's compatriots in other distinguished oversight organizations had simply done their jobs) . . . had been poured into getting more CME or even pursuing more medical education (now that I was properly armed - with the simple knowledge behind my diagnosis - to do so).

Of course, in terms of pursuing a fellowship (and "moving on"), the vindictive/greedy/overpaid jerks running Randolph Hospital could not even write me a decent recommendation letter (one of the things we were fighting over) - after throwing me out on the street and stomping on me . . . all because I stood up to them and told them they were WRONG.

And make NO mistake. They were wrong.

Children are alive today because Dr. Mary Johnson, a very good Pediatrician with loads of real-world experience and mad technical skills and boatloads of just plain common sense and (most important of all) a backbone (or as most of the nurses I know laughingly call it, "balls") . . . often times practicing our art in the uber-rural places where other physicians fear to tread (or sniff their ivey-league noses at) . . . stepped up and said, "NO! STOP! Enough! I don't care who you are or how many letters are behind your name, you are NOT going to continue causing harm to this child - or any other!"

It's time this Pediatrician got some credit for it. Maybe instead of some lame/artificial/contrived "QI" activity, the good doctor's blog . . . based on real-world experience . . . a blog that openly talks about what is very wrong with medicine in North Carolina (particularly the "Quality Assurance" part) . . . should be an ABP-approved "Part 4" activity?

The ABP, after all, makes its home in Chapel Hill.

Author's Closing Note: In keeping with the upcoming holiday, the theme of the medical blogosphere's next Grand Rounds is "Celebration". As a small-town healthcare hero whose heroism never got celebrated, and as the victim of twelve years of government-sanctioned-malfeasance-disguised-by-charity who has yet to be rescued by anyone-charged-to-do-so, I don't feel like celebrating much these days. I still plan to submit this post. I feel a lot better having written it.

And now, I am taking that blogging break I keep talking about. Comments are closed.

Happy Independence Day. I pray that God will save this great nation from itself.


2013 UPDATE:  I passed the proctored re-certification exam in 2013.  I get to start all over in 2016 - after I submit another great big phat check to the American Board of Pediatrics.  

In the period since this post was written, things have only gotten worse, on the ground, for Pediatrics in North Carolina - particularly inpatient Pediatrics.