Wednesday, January 14, 2015

A non-physician weighs in on maintenance of certification

Larry Husten is a medical journalist who writes for Cardiobrief, a blog I often link to. Recently he wrote this piece on the maintenance of certification (MOC) debate. The title is a dead giveaway: Three Reasons Why You Don’t Need To Feel Sorry For Doctors. Apparently Husten thinks doctors have little more than whiny arguments to contribute to the discussion. In fact at the end of the article he suggests that the debate has deteriorated to “the ill-tempered ventings of a highly privileged elite.” (Doctors represent a highly privileged elite? On what planet?).

He opens by saying he has no strong opinions on how doctors should be certified but then goes on to express some very strong opinions against the prevailing objections. I'll give him credit for one thing. He correctly points out that there has been very little argument (and, I might add, zero argument of substance) put forth in favor of the recent MOC changes. Instead the specialty boards have just put it out there and said, in effect, “here it is, take it or leave it.”

He goes on to attack three of the objections he says rank-and-file doctors have put forth.

First, that doctors think they are extremely diligent in staying current and therefore don't need MOC. He used as his example a cardiologist interviewed in this Medscape article who in the casual format of the interview wasn't vigilant enough in choosing his words, to make the case that doctors are generally self motivated to stay current. I hope even Mr. Husten would agree with that general premise. But for purposes of his argument he takes the words of the cardiologist literally and carries them to their extreme, thus building a straw man which he can easily ridicule:

Really, Dr. Tierstein? You’ve never met a single physician who had relaxed his standards over time? You’ve never encountered physicians who fail to keep up with important developments? I guess, in your view, all doctors are, like the children of Lake Woebegon, above average.

That is not the argument doctors are making. Husten was stretching the point for purposes of ridicule but I believe I understand what Tierstein was trying to say. The point is that it is the individual physicians who should be mainly responsible for their own learning needs, not some group of outsiders. That's what is known as self assessment and is the original concept, by the way, of MKSAP (which stands for Medical Knowledge Self Assessment Program).

Husten then goes on to build another straw man:

Another argument I’ve heard repeated is that the current continuing medical education (CME) system already provides a perfectly adequate system for MOC.

Again, no one is making the argument that CME is perfectly adequate. Not even Dr. Tierstein in the Medscape interview. In fact, Tierstein's statement about accredited CME is that it is only “pretty good,” not perfect. But Husten rejects even that:

The problem, of course, is that in reality the current CME system is largely funded and controlled by industry...
As I said, CME can play a key role in MOC, but only when the doctors pay for it themselves.

In other words if industry funding is involved there can be no educational value. That's a conveniently simple litmus test but it's empty because there's no evidence of substance to back it up.

The third objection Husten cites is that MOC has not been tested, an argument he dismisses in this manner:

There are many things in life that we all agree are necessary that have not undergone rigorous testing. I’m sure there’s never been a randomized trial demonstrating that 4 years of medical school is better than no medical school, for instance.
No one is asking for a randomized trial. But if you want to add significantly to the already onerous baggage doctors carry you ought to sustain a burden of proof at some level. Medical schools have not been subject to randomized trials but their education offerings have been studied extensively. In fact, entire journals are singularly devoted to studying medical school curricula and holding the educational process accountable. MOC likewise needs to be held accountable.

I usually enjoy Husten's articles and find them informative. Unfortunately, and much to my surprise and disappointment, in this particular post he seems to view doctors involved in the discussion as a bunch of whiners.


Anonymous said...

There is a robust literature on the ability of doctors to "self-assess" and what we know about the subject is not encouraging (see: Davis DA, et al. JAMA 2006;296:1094-102). For those who argued that MOC has not been adequately assessed, what is their position on CME? Indeed, the data on CME indicate its utility is “questionable” (see: Sibley JC, et al. N Engl J Med 1982;306:511-5; Choudhry NK, et al. Ann Intern Med 2005;142:260-73). While MOC may not have been “studied extensively” it has been studied and is being studied on an ongoing basis (see: To suggest otherwise is uninformed or misleading. MOC is not perfect and needs revisions ... but to dismiss it outright because of its flaws is a mistake. Finally, Dr. Teirstein evidently has changed his mind about CME and must now believe it is "perfectly adequate" since his new Certification Board uses CME as the main basis for granting "certification" (see:

R. W. Donnell said...

I don't know what other participants in the discussion think but I agree that the data on CME are very low level and evidence of benefit is scant, just as is the case with MOC. A doctor's career learning needs to go way beyond anything that can be certified or measured, in my view.

I have seen no one in this discussion who wants to dismiss MOC outright.

I think Dr. Teirstein's decision to use accredited CME for his certification alternative only means he feels it is better than the current MOC process. I gather from what he has written, and from his recent interview, that he does not think it perfectly adequate.

In case you haven't seen, Mr. Husten has responded to my post and I posted a follow up in turn.