Monday, January 26, 2015

The conversation on maintenance of certification (MOC) continues

Recently a medical journalist jumped into the discussion on MOC, criticizing the detractors who have expressed recent outrage about the process. I criticized the piece here, calling out what I thought was a series of straw man arguments. Now the journalist, Larry Husten, has opined again.

He states emphatically in his posts that he is not defending the current MOC process. In fact, in one of his comment threads he says he doesn't even know enough about it to do so. He's not defending the process. Practicing doctors merely want to reform it. It would appear we are in agreement. So why all the fuss? Mr. Husten explains it this way, from the same comment thread:

Remember, I am NOT defending the current MOC system. I don’t know enough about it. I am responding to some of the arguments that have been made against MOC. These ideas strike me as wrong and dangerous and should not go uncorrected simply because everyone else is angry– and perhaps justifiably so– at the current MOC system. In other words, just because the current system may need reform does not justify the use of poor arguments.

The problem is, as I pointed out in my earlier post, Mr. Husten has mischaracterized those arguments. His posts read like attack pieces on the character of practicing doctors. The title of his first post implies that the MOC detractors (who represent the rank-and-file of the profession) are a bunch of crybabies: Three Reasons Why You Don’t Need To Feel Sorry For Doctors. The second title implies that the MOC detractors are wanting immunity from accountability: Why Doctors, Like Airline Pilots, Should Not Be Completely Trusted. Straw man again.

The airline industry analogy, popularized in the early days of the patient safety movement, has since been overstretched. It falls apart on many levels. In using it to build his straw man for the medical profession Mr. Husten does have one valid point in that he seems to be saying that since airline pilots have to be accountable so should doctors:

I would never get on an airplane if I didn’t feel highly confident that the pilot was fully competent. In order to fly a commercial airplane a pilot has to undergo rigorous and continuous training and testing. I’d walk before flying with a pilot whose only credential was his assurance that he’d been diligently “keeping up with his field” and that he was extremely confident in his abilities. I’m glad to know that the FAA and the airlines have extremely demanding programs to ensure the competency of pilots.

Nobody in this discussion disagrees with that.

But a little further down he references my earlier post in this manner:

One of my critics proposed that “it is the individual physicians who should be mainly responsible for their own learning needs, not some group of outsiders.” I wouldn’t get on a plane flown by a pilot who was “mainly responsible” for his or her own learning needs. The same logic is even more true for doctors.

Here the airline pilot comparison falls apart. Airline pilots have a domain of knowledge they have to master. If that's true in medicine it's true in a very different way. Medical knowledge is an ever moving, rapidly expanding target.  Over 2000 citations are added to Medline every day. That's why an essential component of the practice of evidence based medicine (EBM) is looking up answers to focused clinical questions at the point of care. This process is widely recognized as a major part of life long learning. And to my earlier point, it has to be done by the individual clinician rather than some outsider because it is centered around a unique patient.

But to say that individual doctors are responsible for their own learning is not to say they are immune from accountability. None of us are asking to make up the questions to our own certifying exams! Accountability must be objective and it must be external. We would all agree with Mr. Husten on that point.

Finally, the conversation up to now has ignored the fact that doctors have accountability structures in place that go way beyond MOC and licensure. In my work in credentialing I deal with other types of certification as well as clinical process and outcome monitoring of physicians which takes place continuously and on many levels.

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