"All that is necessary for the triumph of evil is for good men to do nothing" Edmund Burke, 18th century Philospher.

"A long habit of not thinking a thing wrong gives it a superficial appearance of it being right." Thomas Paine

"The welfare of humanity is always the alibi of tyrants." Albert Camus

"Choice is the essence of ethics: if there were no choice there would be no ethics, no good, no evil; good and evil have meaning only insofar as man is free to choose." Margaret Thatcher, March 14, 1977

“It is difficult to get a man to understand something, when his salary depends on his not understanding it.” ― Upton Sinclair

Explaining the Cause

I am a practicing obstetrician who is a strong supporter of patients rights to informed consent and refusal. I believe a patient has the right to choose her own path given true and not skewed informed consent. Following that tenet, just as a woman should be able to choose to have an elective c/section she should be able to choose not to have one, as well. The American system of hospital based obstetric practice has been eroding those choices for women for quite some time. Due to concerns of economics, expediency and fears of litigation women are being coerced to make choices that may not be in their best interest.

I have had a long relationship collaborating with midwives and find the midwifery model of care to be evidenced based and successful. I was well trained at Cedars-Sinai Medical Center in the mid 80's to perform breech deliveries, twin deliveries, operative vaginal deliveries and VBACs, and despite evidence supporting their continued value, hospitals are "banning" these options. Organized medicine is also doing its best to restrict the availability of access to midwives.

Home birthing is not for everyone but informed choice is. Medical ethics dictates that doctors have a responsibility and a fiduciary duty to their patients to provide true, not skewed, informed consent and to respect patient autonomy in decision making. Countries with the best outcomes in birthing have collaboration between doctors and midwives. This is not what has been happening in the hospitals of America. Its time for a change and the return of common sense.

The midwifery model of care supports pregnancy as a normal function of the female body and gives a legitimate and reasonable alternative to the over-medicalized model of birth that dominates our culture. Through this blog I hope to do my part to illuminate what is wrong with our maternity care system and what is right with it. I do not expect all to agree and that is OK. We must all understand that given honest data it is not always reasonable to expect two people to come to the same conclusion. Our differences should be respected.

Sunday, May 29, 2011

Board Recertification Abuse

When the chains of bureaucracy obstruct the physician’s ability

to care for patients appropriately, the physician has an ethical duty to

discard the chains and escape, to be free to practice according to the

physician’s best clinical judgment, as opposed to the substituted

judgment and whims of arrogant bureaucrats

Lawrence R. Huntoon, M.D., Ph.D.

The American Association of Physicians & Surgeons has taken a stand on the ridiculous burden of annual Board recertification. The onerous and tedious requirement of annual board certification is without evidence to support its efficacy. It has long gone past the goal of quality maintenance and taken on the life of a self sustaining monster with the apparent self-interest of monetary gain and power. Here are some comments by my longtime associate and friend, Howard Mandel, MD FACOG as well as Dr. L.R. Huntoon that expose another view of annual MOC (Maintenance of Certification).

Dear Dr. Huntoon:

I thank the editors of the Journal of American Physicians and Surgeons for their publication of Dr. Dubravic's insightful article regarding board certification and recertification. As an obstetrician/gynecologist who finished my residency in 1985, I was required to take my boards and earned a 10 year certificate. If I would have graduated in 1984, I would have been boarded for life. The ABOG, requires a two part exam, the first written and the second a three hour oral examination, part of which is based on the first entire list of all the physician's hospitalized patients plus a significant number of representative outpatient visits. I passed both examinations the first time and was reboarded 10 years later. Since that time, my speciality board has changed the requirements to six years and now a yearly exam as well as the MOC. In Los Angeles where I practice, we have observed the erosion of younger physicians partaking in our local speciality meetings. The LA OB/Gyn Society is a skeleton of what it once was. The LA OB/GYN Annual Assembly, which was once world renown, with upwards of 700 participants attending, barely has 150 attendees, many of which are retirees. I hypothesize that the numerous hours and costs required to maintain our certification have added to the demise of these once impressive meetings and organizations. Another unfortunate outcome is the destruction of the collegial relationships developed by OB/GYNs in our region. I would scientifically study my theory, yet I am too busy preparing for yet another annual examination. Perhaps, the ABMS or any of the individual sub specialities can spend some of their resources on why comradery, collegiality and membership in local organized medicine has plummeted since the introduction of reboarding.

Howard C. Mandel M.D., FACOG
10309 Santa Monica Boulevard
Los Angeles, California 90025

And another message from Dr Huntoon, The Editor-in chief of the Journal of American Physicians & Surgeons:

Subject: Re: MOC article from the Journal of American Physicians and Surgeons

This is not unlike what happened with the AMA.

When the AMA made the "secret" agreement with the
government for exclusive use of the CPT coding system (in 1983),
the AMA made a huge leap in the direction of no longer being
financially dependent on membership dues for survival.

Once an organization gets in a position of no longer depending
on membership dues for survival, they are no longer accountable
to the membership and the needs of the membership.

In the current MOC environment, our specialty organizations see the
potential for huge windfall profits as the specialty organizations will be providing
the CME and practice evaluation tools needed to comply with MOC.
Once the specialty organizations start down this road, there will be no turning back.
The specialty organizations, like the AMA, will no longer be dependent on membership
dues for survival and accountability to the membership will be severely eroded or lost.

The leadership of specialty organizations, many of whom are in academic medicine and
who may see a significant financial benefit by providing compliant CME/evaluation tools,
are not likely going to lobby to stop this trend.

It is likely that the grassroots membership is the only hope for stopping it.
Alas, physician apathy and reluctance to "get involved" or "speak out against"
the trend are significant barriers to overcome.

Those who believe in exerting ever increasing control over medicine (like implementing
onerous MOC and MOL requirements), fail to appreciate the adverse consequences
of their actions.

A significant percentage of physicians in this country are over the age of 55.
As physicians get closer to retirement, many will simply refuse to jump through
all of the nonsensical, non-evidence-based bureaucratic hoops, just to remain in
practice in an environment where they can be expected to be paid less and less
which each passing year. They will retire or do something else.
The shortage of physicians, which will occur, cannot be replaced over night.
Many patients will suffer with increased waiting times and decreased access to care.
The MOC/MOL bureaucrats who engineered this debacle cannot provide the care.

Ultimately, we need to educate patients about these predictable adverse consequences

As a start, feel free to copy the articles our journal has published on MOC and
place them in your waiting rooms for patients and distribute them to your colleagues.
AAPS has published a White Paper on our recertification survey. You can find all of the
articles we have published by searching the Cumulative Index on our website under the terms
"maintenance of certification" and "maintenance of licensure."
Our journal website is www.jpands.org
And, as I have said before, we would be happy to accept more commentaries
on this topic.

L.R. Huntoon, M.D., Ph.D., F.A.A.N.
Journal of American Physicians and Surgeons

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