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Tailoring to the Needs of One's Practice: It's about Time

Edward J. Volpintesta, MD
[+] Article, Author, and Disclosure Information

From Bethel, CT 06801.

Potential Financial Conflicts of Interest: None disclosed.

Ann Intern Med. 2007;147(8):592. doi:10.7326/0003-4819-147-8-200710160-00019
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Tailoring to the Needs of One's Practice: A Response
Posted on October 26, 2007
Seyed H Aleali
No Affiliation
Conflict of Interest: None Declared

It is important for generalists, even in non-academic setting, whether office based or not, to stay up to date. The focus of generalists practice is the broad field of internal and family practice. There is no timing as to when they would see a case of uncommon disease that has common signs and symptoms, as all of us have seen missed and near-missed cases; uncommon diseases do not have a flashing neon sign to alert practicing physician, and declare themselves.

The whole objective of re-certification is therefore to keep us informed about all of new and ever evolving field of medicine.

ABIM with help of MKSAP, and Practice Improvement Modules, which are computer based, open book and chart oriented, give us opportunity to stay currant, and improve ourselves, and helping us to practice better medicine.

Not doing this, will turn generalists to dinosaurrs. This is not good medicine, and equally not good for our patients.

(1) Volpentesta. EJ. Tailoring to the Needs of Our Practice. It's About Time 2007; 147:592

Seyed H. Aleali, MD, FACP 4699 Main Street Bridgeport, CT 06606

Conflict of Interest:

None declared

Boards Out of Sync With Reality of Primary Care
Posted on November 2, 2007
Edward J. Volpintesta
Conflict of Interest: None Declared

In response to Dr. Seyed H. Aleali's rapid response of October 30, 2007 to my letter in the Annals printed on October 16, 2007, titled "Tailoring to the Needs of One's Practice: It's About Time".

Needless to say, Dr. Seyed Aleali is correct to point out that it is important to say current or as he warns, run the risk of becoming, "dinosaurs".

But I wasn't implying that doctors don't need to stay current and informed. What I suggested was that the current methods of recertification for generalists, particularly family doctors are burdensome and out of sync with the real world of medicine. This is particularly acute for family physicians, but really applies to all physicians who consider themselves providers of primary care.

Most primary care doctors over time customize their practices according to the types of patients they see, the procedures they do, and the types of diseases that they feel comfortable in treating. This customization even includes the number of patients they see per day and whether or not they use physician extenders, and the number of specialists in the area.

The point is that after, say ten or fifteen years, or even less some of the skills and knowledge a physician had at the end of residency are no longer relevant.

Doctors are way too busy dealing with regulations, the ever- increasing demands of patients, and administrative red tape have the time to take off for board review course; and many of them cannot afford the time off and the costs involved.

Yes, as Dr. Aleali says, there are many unusual diseases that may present and it is important to be aware of them. But these are matters of judgment more than rote memory. If a doctor's judgment is good he or she will recognize when an unusual set of symptoms or signs present and seek consultation. Most errors in medicine are not because of lack of knowledge but of poor judgment or poor timing in getting consultations.

It sees ironic, that trying to conform to the boards' vision of what a generalist is has caused many generalists to actually come close to the "dinosaur" status that doctor Aleali mentioned. How? Because by trying to do it all and know it all, in the hospital, the intensive care unit, the office, and the nursing home, many generalists have deployed themselves so thin that they have created a vacuum that has been filled by physician assistants and advanced practical nurses. In this context, maybe generalists are already on the way to becoming the dinosaurs that Dr. Aleali worries about. As the saying goes, the road to hell is paved with good intentions. In fact the "generalist" of the future just well may be one of these mid-level providers and current generalists may end up being medical managers.

For generalists in particular, the boards need to change their focus. They should uncover areas of weakness in a physician's practice and offer remedial study and they need to move away from a pass/fail approach. If a physician has passed initial certification or is board-eligible, that should be sufficient to take the tests and qualify for remedial education.

The very name "board certification" implies a degree of excellence that is not necessary to deliver good medical care. Its significance is more academic than practical and is more appropriate for teachers in medical schools or residency programs and any one who simply strives to acquire certification as a personal accolade.

Finally, although the boards are said to be voluntary, they are not because of the threat that many doctors feel of being dropped from HMO panels if not board-certified. In this sense, the boards are anything but voluntary. In fact, they are coercive.

Many primary care physicians believe that the boards need to change.

Conflict of Interest:

None declared

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