Maintaining My Surgical Certification

After graduating from medical school, the would be practitioner is still required to complete a residency in one of the medical specialties before going into practice. These residencies range from 3 to 5 years or more. After completing the residency, there is then the requirement to take, and pass, a certification exam administered by the Board responsible for the residency program. In my case, I became certified in Surgery, and then, after completing another residency in Thoracic Surgery, became certified in that specialty, also.

Currently, there are at least 24 approved medical specialty boards of the American Board of Medical Specialties (ABMS) and 18 approved medical specialty boards of the American Osteopathic Association (AOA). Most practitioners have to undergo a recertifying exam by their specialty boards every 10 years. These exams are not easy. They require focused study, a detailed application process, and then, a proctored exam. I have maintained both of my certifications. I orginally certified in Surgery in 1984 which means I have recertified in 1994, 2004, and 2014. My orginal certification in Thoracic Surgery was 1992; the recertifications were in 2002 and 2012.

The concept of maintenance of certification (MOC) was to ensure that physicians would work to keep up with advances in their fields, improve their delivery of care, and commit to the necessary lifelong learning needed to practice competently. Studies show that board certified physicians provide better quality of care than those who are not certified. Other studies show that the quality of care of a practitioner decreases as time elapses from the time of their initial certification. This is probably related to new knowledge and new clinical skills needed to keep up with modern practice. An argument has been made that there are ways other than that provided by MOC exam requirements which can help the practitioner keep up and there is no data that the MOC exam fulfills this goal, but it is currently the way the boards want to do it.

As for the legal field, in my State, lawyers are required to do 15 hours of continuing legal education every year in order to maintain their licensure. This is far easier than the requirements for MOC for Surgery or Thoracic Surgery. In fact, once you pass the Bar Exam for your State, no further exams are required. However, if a lawyer wants to practice in another State which may not have a reciprocity arrangement with the original State, another Bar exam may have to be taken and passed. No Bar recertification exam is required for lawyers.

For years, many hospitals, insurance carriers, and medical licensing boards, have used board certification as a necessary requirement for licensing and privileging. Historically, it was up to the Boards to decide the standards needed for assessing clinical competence of their members. It seemed that society was comfortable in letting the medical profession regulate itself; this was probably based on the assumption that the profession had the knowledge, expertise, and training to best understand what their members needed to know in order maintain a lifetime of professional competence.

Through the years, it has become more difficult to maintain certification. The costs are high and the knowledge requirements may not be indicative of an individual’s practice. For example, a thoracic surgeon like myself who mainly does heart surgery, may not keep up on the latest developments of laparoscopic colon resections (which I am unlikely to ever do), yet, the recertifying exam may have questions related to this topic. As for costs, I am required to write a check every year to one of my Boards and this money will go to defraying the costs of the looming recertification exam. These costs come to several thousands of dollars over the 10 year period.

Because of the issues of cost and relevance, many Boards are looking for new ways to evaluate a clinician’s on-going continuation of medical education. For example, the new Director of the American Board of Surgery, Dr. Jo Buyske, is making a reassessment of MOC her top priority after she takes office. She is putting together a task force to look at new ways to assess high value and practice relevant continuing education for surgeons and hopes to have a new MOC process in place by 2018.

Continuing medical education from self-study, taking courses, participating in research, and quality improvement programs are being looked at for relevance and rigor so as to keep the maintenance of certification meaningful. So far, self assessment has not been shown to assure quality of care and more clinical experience in and of itself does not result in improved outcomes. Some form of independent examination is probably needed. Perhaps some of the anguish associated with taking the exams can be alleviated by decreasing the costs and letting the practitioner generate income from his employing hospital or clinic for doing the necessary work to maintain the certification.

The rising costs and questions of relevance relating to the recertification exams has resulted in some pushback and many physicians have lobbied their state legislatures to take a stand against using certification as a necessary credential for hospital or health plan privileging and licensing. For example, Texas recently passed a Bill (SB 1148) which was intended to prevent managed care plans from “differentiating between physicians based solely on a physician’s maintenance of certification in regard to: (1) paying the physician; (2) reimbursing the physician; or (3) directly or indirectly contracting with the physician to provide services to enrollees.”

In Tennesse, my home state, Senate Bill No. 298 states that medical board re-certification will not be required to practice in this state. Similar laws have been passed or proposed in Alaska, California, Florida, Georgia, Maine, Maryland, Massachusetts, Michigan, Missouri, New York, North Carolina, Ohio, Oklahoma, and Rhode Island.

Obviously, there is a significant number of physicians who just do not want to keep taking the exams required for MOC. However, looking for relief from politicians can be problematic.

Letting the state legislatures get involved in questions previously the purview of the Boards is setting a dangerous precedent. Self-regulation in the medical profession has been working well for a long time; standards were set for medical school admissions, medical school curriculum, requirements for granting a medial degree, standards for residency training programs, and guidelines pertaining to competent medical practice i.e., maintaining a medical license. The patients want their physicians to be board-certified and it seems like they prefer some form of periodic recertification; most physicians willingly do this; even though we would like to see the costs decrease, we understand that the Boards need to get income in some way.

State legislatures are ill-equipped to oversee our re-certification programs. By doing away with the significance of what “maintenance of certification” means, the public may perceive this as a nefarious way for the medical profession to lower its standards. This is not a good public relations action and in light of the difficulties the medical profession is facing with new legal requirements, requirements of third party payers (including the government), this not a battle we need to be facing at this time.

It is time for the state legislatures to stay out of the recertification process for physicians. Physicians are still reeling from the effects of the Affordable Care Act with its increases in administrative requirements, decreases in patient contact, and decreases in compensation. Doing away with the recertification process might cause the public to think that their physicians are more interested in maintaining their privileges than in maintaining their standards. This could result in further diminution of the physicians’ stature in our society. This would not be good. Let the certifying boards to their jobs.

by Darryl S. Weiman, M.D., J.D.

Professor, Cardiothoracic Surgery, University of Tennessee Health Science Center and Chief of Surgery, VAMC Memphis, TN

MORE ABOUT THE AUTHOR: Darryl Weiman is a featured expert in on February 17, 2016. 

Morbidity and Mortality Conference

Being a surgeon is more than just operating on patients. Life-long learning is a requirement of the profession. One of my favorite ways to learn is participation in the Morbidity and Mortality (M&M) conference which most departments of surgery conduct on at least a monthly basis. Although it is important to learn from your own mistakes, it is even better to learn from someone else’s mistakes.

The purpose of the conference is to discuss surgical complications (morbidity) and deaths (mortality) so that any mistakes, technical, judgmental, or systems based, can be learned from. Hopefully, mistakes made will not be repeated and the advancement of surgical knowledge can occur. The discussions are the hallmark of the conference and need to be open and critical. Truthful discussions are unlikely to occur if there is fear that the minutes could be used by plaintiff’s counsel in a malpractice action. Most states recognize a “peer-review” privilege which is equivalent to the attorney-client privilege; in most states, this privilege will protect the work-product generated from the conference.

In 2005, the United States Congress passed the Patient Safety and Quality Improvement Act. The main goal of this law was to encourage health care providers to present their errors without fear of reprisal. The idea was to improve the quality of care for all patients; this is an important public policy interest. The errors reported would eventually be listed in a database created by the Department of Health and Human Services. This database could be accessed and medical errors could be analyzed, to hopefully develop best practices that would result in a decrease in similar types of errors in the future. There are currently some databases available for review, but the product envisioned by the law has not yet been realized.

Discussions at M&M are often heated, personal, and critical. The presenter often gets very defensive and sometimes angry when questioned about their judgment and actions on the case being discussed. Only physicians are supposed to attend so as to keep the “peer review” privilege; even medical students are not supposed to be in the conference as the law does not yet recognize them as peers of the surgeons.

At programs which have a surgical residency, it is the resident who usually presents the case. As the story unfolds, various surgical attendings in the room will start to grill the resident as to his thought process or technical skills. The questions and innuendos are often nasty. Where I did my training, the attendings would advise us to fight back if we felt the attacks were unjustified. “Fighting back” often became “overly defensive” as it was not easy to disagree with an attending, many of whom were known as being among the best in the world.

I have advised my residents to maintain their composure no matter how angry or fearful they become. They must know the facts of the case and they must project confidence. This is also something they teach you in law school but there are no classes for how to present a case in medical school. I also advise them to own their mistakes, learn from them, and be resilient.

Presenting at M&M requires good communication skills. The case being presented had a bad result, a death or a significant complication. Under questioning, the presenter may become angry, frustrated, or indignant. These emotions are normal and expected, but they must not show it. They must maintain their professionalism and they must be truthful. No matter how stressed out they feel, they must remain calm, speak clearly, and be respectful to the inquisitors. After all, the attendings asking the questions have spent years acquiring the skills, knowledge, and experience to be in their positions.

I have noticed that several of the younger surgeons in the audience have their lap tops open and they have “googled” the entity being presented. Some have asked questions meant to put the presenter on the spot and, in my opinion, make the questioner appear to have more knowledge than they may have had a few minutes prior. This behavior is obnoxious, but that’s the way some surgeons are.

Some of the residents in the audience will try to get a quick course on the problem from their computers, but they are unlikely to put one of their colleagues on the spot; they are probably trying to prepare in case one of the attendings hits them with a question to see if they have been listening.

The “straw-man” argument is often used to try and discredit the presenter at this conference. This happens when a questioner changes the facts of the case in such a way as to make the presenter’s argument seem unreasonable. When presented with a “straw-man,” I advise the resident to point out the differences in the fact scenario in the hypothetical and then do their best to answer the question. This is another thing that they teach in law school that is lacking in surgical education.

Another thing they teach in law school is to stop talking when you are interrupted by a judge who wants to ask you a question. I have found this stategy to be very effective at M&M. If I am talking and someone interrupts, I immediately stop talking and I listen to the interrupter closely. This usually results in a period of silence where the whole room is waiting to hear what I was going to say. Being interrupted by a judge is accepted policy in court; it is rude if you are speaking at M&M.

Knowing the facts of the case is required but is not sufficient for a good presentation. The resident also needs to be up to date with the literature pertaining to the patient they are discussing. It is especially beneficial if they cite literature that has been written by one of the attendings who is sitting in the audience; this is actually not too difficult to do if it is a residency at a major university. The endgame is to keep cool, maintain professionalism, and be correct.

Presenting a complication or a death at the M&M conference can be a stressful experience. It is meant to be that way so that the resident can learn to think on his feet and be able to articulate an answer or a plan that is reasonable. If they cannot present well at M&M, it is unlikely that they will perform well when all hell breaks loose in the operating room with a real patient. Being grilled at M&M and learning how to handle this stress is an important part of becoming a surgeon.

by Darryl S. Weiman, M.D., J.D.

Professor, Cardiothoracic Surgery, University of Tennessee Health Science Center and Chief of Surgery, VAMC Memphis, TN

MORE ABOUT THE AUTHOR: Darryl Weiman is a featured expert in on February 17, 2016.