Letters to the Editor

Readers respond with challenges to the need for Maintenance of Certification, debate on the value of accountable care organizations and electronic health records, and a self-reflection on why one reader became a physician.

Debating Maintenance of Certification

Regarding the recent profile on Richard J. Baron, MD, MACP, the new CEO of the American Board of Internal Medicine (“New ABIM leader looks forward to changes, challenges,” ACP Internist, June 2013), perhaps Dr. Baron could answer if he believes it is reasonable to force Maintenance of Certification (MOC) on those who can find other ways to keep current with medical literature. Does he believe it is right to impose this costly procedure on a large number of unwilling internists who have no representation on the American Board of Internal Medicine (ABIM) or the American Board of Medical Specialties? Please ask if he thinks this is a form of taxation on the career of an internist without representation. Since shared decision making between patient and physician is currently considered optimal practice, does it follow that recipients of the MOC mandate have some say in the process?

Does Dr. Baron believe in mandating MOC, for which there is no high-quality evidence of efficacy improving patient and physician outcomes or patient safety? Does Dr. Baron subscribe to the ABIM Foundation prescription for being skeptical of studies funded and performed by the pharmaceutical industry? Then please ask if it follows if an internist should be skeptical of studies attempting to show MOC efficacy funded by ABIM and performed by ABIM employees.

How would Dr. Baron respond to the increasing evidence that MOC is detested by those forced to participate? That evidence includes a 2:1 response against MOC participation in a nonscientific New England Journal of Medicine poll; the recent lawsuit by the Association of American Physicians and Surgeons against the American Board of Medical Specialties alleging restraint of trade; and resolutions against MOC recently passed by the American Medical Association (AMA) and the state medical societies of New Jersey, Michigan, Ohio, Oklahoma, New York and North Carolina. A cursory reading of social media medical websites will demonstrate strong physician sentiment against MOC.

Dr. Baron's predecessor at ABIM, Christine K. Cassel, MD, MACP, stated in a 2012 letter to the editor in the Journal of the American Medical Association that MOC is necessary since “on average, clinical skills tend to decline over time and the amount of clinical experience does not necessarily lead to better outcomes or improvement of skills. Also a physician's ability to independently and accurately self-assess and self-evaluate without guidance is limited.”

Does Dr. Baron have any evidence that MOC stops the alleged decline over time in clinical skills? Does Dr. Baron have any evidence that MOC is any better than any other form of physician self-assessment, such as MKSAP, for example?

I believe most internists resent the onerous, costly MOC process forced upon them with no high-quality evidence for achieving positive outcomes of any worthwhile parameter. In my opinion, this MOC farce needs to be made voluntary as expeditiously as possible. I hope Dr. Baron uses his new position to accelerate this needed change.

Marc S. Frager, MD, FACP
Boca Raton, Fla.

Richard J. Baron, MD, MACP, responds: I thank Dr. Frager for his questions about MOC. I've been through the process twice (the first time before I was involved with ABIM) when I was in full-time community-based practice. I know how difficult it can be to balance MOC with seeing patients, completing paperwork and mastering an electronic health record. But I also felt the responsibility to assure my patients and myself that I was keeping up enough to provide the care they needed and deserved. I found that MOC helped me do that, providing a framework for self-assessment and improvement, even as there were a lot of other things competing for my time.

At the end of the process, both times, I shared the pride felt by many internists and specialists who choose to meet standards set by peers, a level of pride I didn't get from sending my $550 to the Drug Enforcement Administration or my $360 to the Commonwealth of Pennsylvania for my medical license.

Since 2008, ABIM has surveyed all of the internists who go through MOC. Sixty percent of those who responded said MOC made them a better physician, and 63% said it was a valuable learning experience. Both numbers can and should be improved. In addition, there is considerable evidence in peer-reviewed journals, some but not all of it generated by ABIM researchers, that the process adds value. We welcome rigorous research by others, and we're supportive of the recent AMA resolution for an independent third party to evaluate MOC. MOC needs to be a meaningful credential that results in better patient care, and we appreciate any data that can help us better meet that objective.

There's no question the process could be better. ABIM's core business is to define specialties and deploy assessments that assure colleagues and the public that someone calling himself or herself a gastroenterologist, for example, actually has “the knowledge, skills and attitudes essential for excellent patient care.” Not surprisingly, that is very challenging to do, particularly in a world where so many things are changing about what is “essential” to excellent patient care.

We are proud that other stakeholders in health care—hospitals, insurance plans and other payers—see increased value from certified physicians and embed the credential into their various processes. Despite what some may have heard, we don't believe MOC should be the only option for reporting to these organizations. Many of the resolutions Dr. Frager cited in opposition to MOC are based on the misconception that MOC would be made a requirement for licensure. This is not what ABIM and the Federation of State Medical Boards have advocated. Rather, we want physicians who choose to participate in MOC to automatically meet maintenance of licensure requirements. We also believe that other avenues outside of MOC should be available for physicians to meet those requirements.

Certification and MOC have always been voluntary. As ABIM's new CEO, I commit to Dr. Frager and our colleagues that I will uphold a more than 75-year tradition of setting meaningful standards by continuously evaluating and improving our MOC program. All feedback is valuable as we work to improve the relevance and efficacy of MOC.

ACOs and EHRs

I take issue with two stories in the July/August 2013 ACP Internist.

The article “Success in ACOs depends on collaboration” states that “patients are more empowered in ACOs [accountable care organizations] because they are not restricted to a network of clinicians the way they were in [managed care organizations].” The failure to clarify, emphasize and describe the consequences of this aspect of ACOs reflects an incomplete understanding of the model's economic (real-world) operating principles.

For an ACO to survive financially, it must keep its patients' care contained within its clinician network. The term for patients' obtaining care outside the network is “leakage,” and it costs the ACO a lot of money. ACOs contract with insurers in a capitated system. An institution (ACO) receives its contracted prepayment, then disperses it to its clinicians. A patient obtaining care outside the ACO generates a charge that is not contracted; the institution providing care is free to charge whatever it chooses and sends a bill to the ACO, which literally cuts a check to that clinician; and premium dollars “leak” out of the ACO.

Patients have expressed their intense dislike for these restrictive-access (capitated HMO) plans in the past, directing their wrath toward insurers but also toward physicians who were viewed as collaborators. In the new ACO model, insurers shrewdly “dumped the restricting” of physician choice back on the ACO and its physicians, telling patients that they, the insurers (by contract), are not restricting them; rather, their physicians are making that unpleasant decision. This structure pits the economic health of the ACO against the patient's choice of clinician. The article gives the insurers a pass on this contentious issue.

The second story that concerned me was the President's Message (“The bad, the ugly and the good of electronic health records”), by Molly Cooke, MD, FACP. Dr. Cooke devotes three-quarters of her message to describing “great things” about electronic health records (EHRs) and the remaining space to her “capitulation” to them. If EHRs are so great, why do good physicians have to “capitulate”? Because institutional medicine's leadership did not demand strategic involvement in EHR design, other “interests,” namely insurers, payers, vendors, Medicare, and large provider institutions, built EHRs with functionality to primarily serve their needs.

As an internist in practice for over 30 years, I've witnessed the “rise of the machine,” EHRs, to the extent that they now exercise absolute primacy in my practice. We serve EHRs; EHRs don't serve us. Documenting my patient visits in traditional pen-and-paper “SOAP” format helped me formulate and integrate my clinical thought process and treatment plan. My EHR significantly distorts that process; I don't organize my thoughts about my patients as well as I used to.

Maybe I'm just old, overworked and cranky, but this “concession/capitulation” of my clinical process to the EHR's directives is clearly not a good thing. Also, of importance, the time required to “feed” the EHR takes away from the time I spend directly with my patients. Despite impending payment system changes, my productivity is still measured by my relative value units and the demand for more patient visits of shortened duration. Dr. Cooke should be aware, as she notes “declining physician satisfaction with EHRs,” that capitulation and wishful thinking that vendors hear our complaints are not an effective strategy to advance our interests.

Michael E. Miller, MD, ACP Member
Waban, Mass.

Neil Kirschner, PhD, ACP's senior associate, health policy and insurer affairs, responds: Dr. Miller's comment about ACOs refers to a section of the article differentiating ACOs from the failed managed care organization (MCO) models of the 1990s. The addition of risk adjustment and quality measures within the ACO model is a clear differentiation. Dr. Miller questions the improved patient empowerment under ACOs suggested in the article, specifically the ability of patients within the ACO model to choose clinicians outside the ACO network. I agree that ACOs, through various forms of patient engagement, will encourage patients to receive treatment from their participating clinicians for the reasons Dr. Miller outlined. Nonetheless, under the Medicare Shared Savings ACO program, beneficiaries still retain the ability to see any Medicare participating provider of their choice, and ACOs that inform beneficiaries otherwise are in violation of their contract with CMS and should be reported. The College has been actively addressing this issue, and the related issue of ACO provider exclusivity, with CMS, and these efforts are described in a recent article in the ACP Advocate. It is also quite likely, both in commercial and public ACOs, that the substantial role patient “experience of care” measures have in determining payment serves to empower patients to expect that their needs and preferences are considered and may provide a pathway for some increased clinician choice, if permissible by the underlying insurance contract.

Molly Cooke, MD, FACP, ACP president, responds: Regarding EHRs, I think Dr. Miller and I fundamentally agree. My goals in writing this column were 1) to register that despite the pain of learning to use an entirely new system and, in my case, a system that while being “new” has a paradoxically 1990s feel, there are a number of ways in which the EHR is unequivocally better than the paper systems it is replacing; 2) to encourage a discussion among physicians about misuse and abuse facilitated by the digital platform and perpetrated by us, such as unattributed cut-and-paste; and 3) to see if a community might emerge, within internal medicine and beyond, of clinicians who would like to see the next steps in the development of EHRs take the tool in a more user-friendly direction.

When I tried to emulate my old patterns of working in the EHR, I drove myself crazy. Stepping back and asking what the strengths of the system are and how I could exploit them to my patients' benefit made my notes better. Once I learned to put the S and O that were critical to my thinking in the “Assessment and Plan,” it unlocked the power of the “view all previous notes” function, allowing me and my colleagues to see my thinking unfold over time.

Can today's EHRs be improved? Absolutely. Let's work on it together.

Column strikes chord

The column by Drs. Hartzband and Groopman on the physician who was diagnosed with cancer (“Reflections from a physician who faced his mortality,” ACP Internist, May 2013) touched me for a couple of reasons.

I myself was diagnosed with lymphoma (Hodgkin's) over 20 years ago, and it inspired me to become a physician and a hematologic malignancy specialist. I'd like to think I have a good bedside manner because I myself was once told that I had lymphoma. I try to be as patient as possible, answer all of my patients' questions, and explain the plan of therapy in detail because that is what I would have wanted. I don't routinely share my own diagnosis, but I will if doing so seems helpful and appropriate.

For example, if I am doing a bone marrow biopsy on a patient who appears uncomfortable, I can tell him I really do know how he feels, having been through such a procedure myself. The other day, when a patient who'd had radiation to her jaw region wondered how long she would have to brush her teeth with fluoride, I shared my own experience with such paste. Having had lymphoma in the past gives me more awareness into what my patients are thinking and dictates the way I act with them. My cancer diagnosis reminds me that I am always a patient and should act the way I would want my doctors to act in key moments.

The other reason this article touched me is that my 76-year-old father was just diagnosed with the same lymphoma as Dr. Robert Brown (the focus of the article). My dad presented somewhat similarly and also with stage 3 diffuse large B-cell lymphoma. He is undergoing RCHOP chemotherapy as well right now. Like Dr. Brown, my father was having nonspecific symptoms that were initially attributed to flecainide for newly diagnosed atrial fibrillation. However, he soon began having abdominal discomfort, more so at night, and he saw a gastroenterologist who performed an endoscopy that did not reveal anything significant (perhaps a mild ulceration). He soon began having very bothersome back pain. His daughter-in-law, my brother's wife, was able to arrange for him to have an ultrasound that showed a 10-cm mass in his abdomen (the lymphoma), which pretty much explained all his new symptoms.

When my dad kept telling his army of doctor kids (myself, the lymphoma doctor; my brother, a cardiologist; my sister, a gynecologist; and his daughter-in-law, a gastroenterologist) that he was having symptoms, we all felt that he was such a difficult patient. We just wanted him to take his heart medication, and all along something more sinister was explaining his symptoms. However, his belief that this medication was causing some of his symptoms (particularly the GI/abdominal symptoms) also threw off, in our opinion, his “official” doctors. Suffice it to say, it was a relief to finally have an explanation and to know that it was not a GI malignancy or sarcoma. Like Dr. Brown, my dad has a 50-50 chance of beating this disease.

Amir Steinberg, MD, FACP
Larchmont, N.Y.