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Letters to the Editor

From the March ACP Internist, copyright © 2014 by the American College of Physicians

Readers respond on MOC, leadership and the ACA

Two issues in the January 2014 ACP Internist deserve further discussion. First, there’s an ironic juxtaposition of one of the cover stories, “Taking team care from policy to practice,” with the lengthy letter to the editor about Maintenance of Certification (MOC) by Richard J. Baron, MD, MACP.

In the cover story, Stacey Butterfield writes extensively on the ideological schism over team leadership and the reality of the considerably less divisive actual practice environment. Ms. Butterfield quotes a source as saying, “Both the physicians and the nurse practitioners say that they do similar kinds of work during the day.” This is the mantra of the nurse practitioner leadership: functional equality of NPs and physicians in practice that extends to leadership. Not so symbolically, NPs in some states are demanding the title “Doctor,” ostensibly as “Doctor of Nurse Practitionership,” blurring the line as to who is a doctor.

Dr. Baron discusses practical issues with the evolution of MOC for internists (I haven’t obtained MOC because I was “grandfathered” with 34 years of practice experience), a high-stakes exercise involving a very substantial investment of time and effort. For NP leadership to both claim and demand equity with practicing physicians, shouldn’t NPs then be subjected to the same rigorous MOC obligations as physicians?

Second, and more important, the always excellent Washington Perspective by Robert B. Doherty (I always read him first!) on “Health reform’s winners and losers” really gets to the nub, the reality of the impact of the Affordable Care Act, which I strongly support. The opposition to Obamacare from conservatives remains, with token exceptions, ideological and clearly divorced from the reality of the shameful lack of access to quality health care for many millions of Americans. Mr. Doherty’s article is concise, well-written in evidence-based style, and devoid of heated rhetoric (only his concluding sentence is opinion) and should be more widely distributed and, yes, discussed.

ACP leadership clearly supports the Affordable Care Act, although I respect those physician members who do not. In the discussion of the ACA, we as physicians who demand evidence to determine treatment should include the evidence Mr. Doherty presents. Opinions are welcome, but ideology cannot be the primary determinant of a position.

I ask ACP leadership: How much support is it willing to give? ACP is not primarily a political organization, though lobbying for positions beneficial to its members is a valid goal. Is it political for ACP to aggressively present Mr. Doherty’s perspectives, not only to physicians, but to our patients and to our citizens? It’s abundantly clear that very large numbers of Americans are ill-informed of the benefits and harms of the ACA, receiving their information from biased politicians, lobbyists, and entities and individuals with the interests and the deep pockets to denigrate Obamacare.

President Obama surely deserves substantial blame for his failure to explain the workings of Obamacare and the problems with the not-ready-for-prime time healthcare.gov website, as well as for not anticipating an inability to keep his promise about maintaining one’s insurance. None of these faults trumps Mr. Doherty’s conclusion supporting the overwhelming benefits of the ACA.

So, should ACP, which clearly values evidence, invest in educating Americans about the ACA in a visible way? We shouldn’t fear “taking a stand” that is not agreed on by all members if the evidence is clearly supportive on the seminal health care issue of our generation.

Michael E. Miller, MD, ACP Member
Boston

I am responding to the letter by Richard J. Baron, MD, MACP, “Maintenance of Certification is an evolving process,” which was published in the January 2014 ACP Internist. Dr. Baron, president and CEO of the American Board of Internal Medicine (ABIM), argues thoughtfully that Maintenance of Certification (MOC) is an essential and necessary tool to demonstrate our commitment to professionalism and to the public that we serve.

Respectfully, I disagree. Personally, I have not found MOC to have enhanced my clinical skills or sense of professionalism, and I believe the vast majority of my clinical colleagues share this view. Dr. Baron and other MOC supporters need to reconcile their belief in a system with lack of support by most medical practitioners who are mandated to participate in it. The high cost and significant time expended in MOC could be so much better devoted to educational pursuits that have real and direct value to physicians. I am a gastroenterologist in private practice and have always had a strong commitment to staying current in my field and practicing spirited patient advocacy. To whatever extent I am a good physician, the 3 prior board examinations I have passed have not contributed to this.

Some of the changes that Dr. Baron highlights, such as adding a zoom function to photos on the exam or permitting the use of clinical formulas such as the Framingham risk calculator, are purely cosmetic. I am skeptical that ABIM appreciates the level of dissatisfaction among practicing physicians and is truly committed to a thorough reform of the process. Indeed, the very name of the Assessment 2020 Task Force mentioned by Dr. Baron indicates the slow pace of change that is anticipated.

I believe that the MOC system needs to be reconstructed with strong influence from the physician community who make up the majority of MOC participants. This will not be accomplished by simply adding a “non-academic” physician to the board, as Dr. Baron suggested.

We all strive to maintain professionalism and to stay current in our specialties so that our patients will receive the care they deserve. I support the concept of board certification, but I do not believe that MOC in its current form fulfills its promise. Moreover, I do not believe that incremental minor changes or “reform from within” will lead to a system that has majority support of physicians.

Michael Kirsch, MD, FACP
Willoughby, Ohio

Dr. Baron responds: ABIM focuses on the credentials of internists; we don’t offer any credential to other health care professionals.

I genuinely appreciate the constructive tone of Dr. Kirsch’s comments. I’m not sure he appreciates just how dramatic some of the changes at ABIM are. We have community-practicing internists at all levels of our governance. The new subspecialty boards we are creating (and which will meet for the first time next fall) will include public members (members of the interprofessional health care team as well as those with the patient/caregiver perspective) and will take responsibility, at a discipline-specific level, for the full range of MOC programs, not just the exam. The Assessment 2020 Task Force is not tasked with making changes “by 2020”; rather, it is tasked with thinking about what assessment should and will need to look like in the future so that we can evolve our program toward the way in which expectations and needs of internists will change. We have already started a broad public conversation with the community on relevant topics by offering blog entries and inviting comments, and we continuously develop refinements/improvements to our programs based on what we learn.

Whenever ABIM changes requirements and expectations, we face protest from some diplomates who feel we are “breaking commitments,” and yet we need to change those requirements to assure relevance and meaning to those who participate and for those who use the credential. ABIM will always be balancing the need for change with an acceptable pace of change, so many of the changes will indeed take some time to “hit the ground.” That said, I believe our changes will lead to an improved experience for our diplomates and a more meaningful credential.

Richard J. Baron, MD, MACP
Philadelphia

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