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Editorials |

“Practice Makes Perfect” … Or Does It?

Steven E. Weinberger, MD; F. Daniel Duffy, MD; and Christine K. Cassel, MD
[+] Article and Author Information

From American College of Physicians and American Board of Internal Medicine, Philadelphia, PA 19106.


Acknowledgments: The authors thank John Tooker, MD, MBA, and Eric B. Larson, MD, MPH, for their helpful suggestions.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Customer Service, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106-1572.

Current Author Addresses: Dr. Weinberger: American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106-1572.

Drs. Duffy and Cassel: American Board of Internal Medicine, 510 Walnut Street, Suite 1700, Philadelphia, PA 19106-3699.


Ann Intern Med. 2005;142(4):302-303. doi:10.7326/0003-4819-142-4-200502150-00014
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The current public focus on health care quality is mobilizing payers and regulatory bodies alike to measure quality of care and to link quality with physician reimbursement through “pay for performance” (1). For the medical profession to address the public's concern and improve its care of patients, it must understand the determinants of quality so that physicians can model and emulate predictors of good quality and recognize and remedy predictors of poor quality.

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Does promoting recertification give the ABIM and ACP a Financial Conflict of Interest??
Posted on February 15, 2005
Ira D. Breite
NYU
Conflict of Interest: None Declared

February 15, 2005

TO THE EDITOR:

I read with great interest the editorial "˜"Practice Makes Perfect" "¦ Or Does It?' in the February 15th edition of Annals. I do not necessarily disagree with the findings; I recently recertified my boards and found the experience useful. I am also a proud dues paying member of the American College of Physicians. What I do object to is that Drs. Weinberger, Duffy and Cassel claim that there is no potential for financial conflicts of interest. While they themselves may not personally financially benefit from recertification, the organizations they represent do. As an example, the ABIM "self assessment" modules link directly to the ACP website, which requires ACP membership. In fact, membership can save a tremendous amount of time as it gives the test-taker direct links to the answers in the self assessment modules. This is despite the fact that many physicians use other programs, such as "Up to Date" to stay current in their clinical practice and may have no other need to join the ACP. There is more than a hint of financial conflict of interest in the ACP and the ABIM in promoting tests that they produce and charge for, and review programs that, because of the relationship between the two organizations, are more "tailored" to the test than those of competitors. There is a financial conflict of interest in having a relationship between a professional organization and a testing organization.

Ira Daniel Breite, MD Westside Medical Associates LLP 228 West 82nd Street New York NY 10024

(212) 362 6468 ibreite@westsidedoctors.com

Conflict of Interest:

None declared

Experience plus Study do make Perfect.
Posted on February 22, 2005
Byravan Viswanathan
None. Retired from practice.
Conflict of Interest: None Declared

The Editoral and the related study in the Feb. 15th. issue of the Annals do make a lot of sense. Mere experience of seeing patients cannot substitute for keeping up actively with the constant changes in diagnostic and treatment modalities. That can only be achieved by diligent and continuos study but to retain the new knowledge one must subject oneself to tests. I know the value of self assessment courses provided by the College while I was in practice.This exercise every two years greatly increased my self- confidence and made medicine more interesting. During my last years in practice I continued to obtain my required CME credits through self assessment courses and despite being not as thorough as recertifying examinations, they were much more effective than mere attendance at couses at exotic locations. There is no substitute for years of close interaction with patients in acquiring that special clinical skill,but knowledge through compulsry and dedicated study will make complete physicians. The old saying what the mind does not know, the eyes will not see, does hold true in diagnostic medicine at least. Byravan Viswanathan.

Conflict of Interest:

None declared

Who needs to be treated to prevent decline in physician performance?
Posted on March 4, 2005
Jack G. Beaird
Woodlake Clinic, Richfield MN
Conflict of Interest: None Declared

As a 61-year-old geriatrician, I find myself wondering if Dr. Choudhry's disturbing findings are associated with age itself or instead are due to the toxic effects of the processes and institutions of medical practice and who needs to be treated for the problem.

I wonder if there are not toxic elements in the daily practice of medicine that, over time, damage physicians. I would like very much to know if some practice environments are "safer" and are associated with long-term high performance by physicians. Think about a practice structure that encourages and provides abundant support and opportunities for learning every day of one's career. It is hard not to believe that this would produce a better outcome than the strictly production driven environment in which so many of us find ourselves. If "safer" practice environments do exist, we should study them carefully and learn identify the protective and nutritive elements.

I would urge that we look to the lessons of geriatrics in trying to decide who to treat for this problem. Look at the example of bone health. It is increasingly clear that it is better to build strong bones in children and maintain healthy bones throughout adulthood than it is to begin with a 65 year old with a hip fracture and a T score of "“ 3.5 and try to repair the damage.

The same is likely true of who needs to be treated to assure physicians long in practice perform well. We need to learn why the performance of physicians falls off with time. We need to remove the toxic elements of practice and provide the needed supports to keep the decline from happening. We need to do this starting year one of practice and keep at it throughout a doctor's practice lifetime. Us old guys won't be around too much longer: keep an eye on us and help us if you can. But, if we really want to solve this problem, we must focus not on treatment of the late disease, but rather on "preventive" care and support for physicians in their early and middle years. If we don't do this, they will turn out just like us.

Jack Beaird, MD Woodlake Clinic Richfield MN jackbeaird@earthlink.net

Conflict of Interest:

None declared

No Title
Posted on March 7, 2005
Richard L Neubauer
No Affiliation
Conflict of Interest: None Declared

To the Editor:

I read with great interest the editorial "Practice Makes Perfect: Or Does It?" I am heartened by the collaborative spirit expressed by Dr. Weinberger representing the American College of Physicians (ACP) and Drs. Duffy and Cassel representing the American Board of Internal Medicine (ABIM). I agree with the shared visions expressed and the goal of identifying ways to "maintain the highest quality of care throughout a career that spans several decades." I further agree that Maintenance of Certification (MOC) is a tool that has great potential toward furthering the stated goal.

I also have a nagging and uncomfortable feeling that there are aspects of the MOC process that, as well intentioned as I know they are, may be counterproductive in the long run and in some ways miss the mark in achieving the ultimate goals: effective transfer of current knowledge to physicians as they mature in their careers and maintenance of the highest standards of care in the practice of medicine.

Specifically, I am concerned:

1) That the process remains needlessly complex and difficult to navigate for busy practitioners, especially those who are furthest along in their careers

2) That sub-specialists in internal medicine will increasingly choose not to re-certify in general medicine as the process is currently structured

3) That some, perhaps many, generalists will evaluate the current process, especially the high stakes secure multiple choice examination that concludes each re-certification cycle, as having a low value and thereby may choose not to re-certify (especially late in their careers)

4) That by adhering to the notion of a high stakes secure examination as a key component of re-certification, ABIM is missing an opportunity to make re-certification a much better accepted and widely used tool to achieve the lofty goals that underlay the endeavor

As our focus sharpens on how physicians must participate in improving the quality of health care in our nation, we also need to make sure that our efforts do not have unintended adverse consequences. Our professional societies and certifying organizations need to work together to create tools that treat physicians as mature adult learners who embrace the professional obligation to grow and learn throughout their careers in medicine. There needs to be recognition that, at a time when interest in general internal medicine as a career choice is seriously declining, MOC needs to be carefully structured as a benefit, not an impediment, to viewing such a career positively. I hope to see the MOC process evolve further as the collaborative efforts between ABIM and ACP that are mentioned in the editorial continue.

Richard L. Neubauer MD

Anchorage, Alaska

Conflict of Interest:

None declared

A Better Answer
Posted on March 28, 2005
Caroline M. Poplin
National Naval Medical Center
Conflict of Interest: None Declared

Earlier responders have expertly critiqued the analysis by Dr. Choudhry and others (1) of studies comparing physicians with varying levels of experience.

I object to the authors' solution: recertification.(2) There is little empirical evidence that recertification improves medical practice (surgery may be different). I am a full-time clinical internist. I recently recertified in Internal Medicine. Despite the expenditure of significant time (mine and others') and money, I found the exercises largely irrelevant to my patients, even though I practice at a tertiary care center. My principal diagnoses are hypertension, hyperlipidemia, diabetes, heart disease, community acquired pneumonia, depression. I remember virtually no questions about these. The emphasis, particularly in the secure exam, was on speed, memory, and obscure or tricky problems. And the stakes could not have been higher--my job requires continuous certification.

It is no surprise, then, that among the physician-authors, two list their principal occupation as "administration" and one as "research"-- apparently not a single full-time clinician among them. Indeed, Drs. Cassell and Duffy are President and Vice President of the ABIM, which oversees and derives its income from the certification process, not exactly a neutral vantage point.

The disagreement between academic and community physician over what is important is, unhappily, not new in American medicine (3), nor is the effort to maintain standards by threatening to exclude those who fall behind. Now, insurers demanding "quality" are also trying to manipulate physician performance by carrots ("pay-for-performance") and sticks.

But we are not rats in a maze. No physician wants to be a bad doctor: every physician wants to meet the standard of care, even state of the art, with every patient, as Dr. Berwick himself has noted (4). Instead of judging us, why not help us? Tell us what we need to know. Academic physicians have time to assess studies, to monitor the literature for new diagnostic and treatment paradigms, that the relentless drive for "productivity" denies to us. Recommending important changes in practice based on new evidence is hard, controversial work: the federal Agency for Healthcare Research and Quality gave up after publishing a few useful but quickly outdated pamphlets, because of objections from physicians. Yet this is what we need more than tests, audits, and criticism. Make such material available, accessible and persuasive to all of us, on and off the Internet, especially to those practicing alone in remote locations. If you build it, we will come.

1. Choudhry NK, Fletcher RH, Soumerai SB. Systemic review: the relationship between clinical experience and quality of care. Ann Intern Med. 2005;142:260-273.

2. Weinberger SE, Duffy FD, Cassel CK. Practice makes perfect...or does it? Ann Intern Med. 2005;142:302-303

3. Starr P. The Social Transformation of American Medicine. New York: Basic Books,Inc.1982.

4. Galvin R. A deficiency of will and ambition: a conversation with Donald Berwick (1/12/05) content.healthaffairs.org/cgi/content/abstract/hlthaff.w5.1.

Conflict of Interest:

The opinions in my letter are my own and in no way represent positions of the U.S. Navy or the Department of Defense.

Response from the authors
Posted on April 8, 2005
Steven E. Weinberger
American College of Physicians
Conflict of Interest: None Declared

To the Editor:

Dr. Neubauer raises important concerns emphasizing fundamental principles that the American Board of Internal Medicine (ABIM) is working to accomplish with maintenance of certification, and that the American College of Physicians (ACP) believes are important for all internists. Reducing complexity of the process and making maintenance of certification in the core discipline of internal medicine attractive to subspecialists are goals that both organizations strongly support. The secure examination component of maintenance of certification can cause anxiety, particularly if there is a perception that physicians will be tested on obscure factual knowledge or on information that is not relevant to their practice. The ABIM and the ACP are now working together through a joint committee to reduce the anxiety about the examination, to improve its composition and content, and to provide more accurate information about the examination and how it is developed. Specifically, among the goals of the joint working committee are the following: 1) clarifying important differences between the content of the certification examination and the content of the maintenance of certification examination; 2) stressing that the maintenance of certification examination is testing physician judgment rather than factual recall; and 3) developing and refining questions to focus on core content that is clinically relevant to both general internists and subspecialists. There is detailed information available at www.abim.org.

While none of the authors of the editorial has a personal financial conflict of interest relating to the content of the editorial, Dr. Breite is correct that there are potential institutional conflicts of interest for the ABIM and the ACP when discussing physician education and maintenance of certification. These conflicts were indeed noted by the authors from both organizations on the disclosure forms that we completed and submitted. We would, nonetheless, disagree that there is a conflict of interest in having the two organizations work together to improve the maintenance of certification process. Development of questions by the ABIM and creation of educational materials by the ACP are entirely independent processes, with strict guidelines prohibiting a physician's participation in both processes. Most strongly, we believe each organization has a responsibility to contribute in its own way to enabling physicians to maintain and improve their knowledge and skills.

Steven E. Weinberger, MD American College of Physicians

F. Daniel Duffy, MD Christine K. Cassel, MD American Board of Internal Medicine

Conflict of Interest:

Dr. Weinberger is an employee of the American College of Physicians. Drs. Duffy and Cassel are employees of the American Board of Internal Medicine.

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