Pediatrician Flea posted about feeling like the jerk he was on the telephone with an ED physician.  (I was going to type colleague, but one doesn’t behave boorishly to a colleague).  He says they ‘have a history’ which explains why the ED physician was near tears during their phone call. 

Flea’s been subject to nearly enough derision in the comments of his own post, and those on Kevin, MD (which is where I found the Flea post) and I have nothing more to add on that individual interaction.  I do have something to say about the telephone and its use with the ED Consultant.

 The vast majority of the consultant physicians I call are collegial, knowledgeable, and helpful.  I personally don’t care if they’re “friendly” on the phone, but it’s a plus of they are.  Typically I only have about 33 other things I need to get done while placing calls, so it’s a to-the-point quick presentation, respectful of the consultants’ time, and trying to use mine productively.  I usually have a plan, lay it out, and we come to a conclusion that benefits the patient.

And then there are the four consultants in my practice history whom I utterly detest calling, as they’re condescending jerks of the first order (four in the entire history, and just two active now).  After my usual presentation, which is the same as I give to everyone else (and, I do my utmost to keep my prior irritation hidden from them on the phone; no sense letting them know their awful behavior gets to me), it starts.  Usually it’s the ‘why are you calling me?’ in a decidedly whiny tone, and when it’s explained (problem clearly in your specialty, you’re on call, etc) then comes the attempt to get me to change the diagnosis so it’s not their problem.  Playing 100 questions, we go back over all the history, the physical (pertinent and not), labs, etc.  Many ‘gotcha’ moments are tried with stated holes in the above, all in attempt to put me on the defensive, to defend the entire interaction and workup, not to help the patient but to get themselves off the hook.   This doesn’t work with me, and I stand my ground.  They get to do their consulting bit, and the patient gets appropriate care.  And I hate calling them.  To me they are physicians in title only; oh, they’re fully trained and qualified, but don’t embody what I’d call a physician.

 There was one occasion with a consultant on the phone wherein the belittling of my ED and ultimately my personal professionalism and judgement wouldn’t stop.  Finally I asked the consultant to come in and do their own eval, and before we hung up I asked him to feel free to repeat his diatribe to me in person.  I was avoided when they came to the ED, and no direct confrontation occurred.  I don’t think anyone had stood up to this jerk before, and we now have a civil working relationship.  We’re not Christmas card pals, but we work together effectively.

Finally, the consultant who generates an acrimonious relationship with the ED is not doing himself or his patients any favors.  We need each other to take effective care of our patients.  And boorish behavior is for boors, not Physician Colleagues.

Here’s a nice, brief editorial by Dr. Michael M.E. Johns, CEO of the Woodruff Health Sciences Center at Emory  University.  He’s got a point about the current state of CME and relicensure being somewhat anachronistic.

Here’s where he and I can completely agree:

CME credits are now the measures by which most states certify physician competence, and the vast majority of CME offerings have little impact on how physicians practice medicine.[1] Knowing that this is a flawed system, organized medicine continues to endorse it.

So here are 3 proposals to modernize:

…
3. CME should not be used for certification or relicensure. The American Board of Medical Specialties’ stepped process of certification[2] should be applied to relicensing. Submit a step every 2 years and earn relicensure.

Well, details, details.  My specialty society is doing yearly exams, which qualify me to take only one test at the end of ten years, instead of two.  I don’t know about the 2 year steps he’s talking about, and hope a reader can educate me.  But, we agree on the basics, that CME isn’t useful in practice, and that we already have systems in place to certify and recertify docs and their abilities.

As a practicing doc I’m required by the states I’m licensed in to have 25 hours of CME a year (minimum, one of which has to be in the “Ethics” category, and there’s a series of rants in that one idiotic hour requirement).  So, I go to conferences in nice places, listen to CME that usually covers things I already know, or that add a tidbit or two.  Is that a waste of time?  Probably.  A waste of money?  Decidedly.  Does it ‘change my practice’?  Not yet.  (It has spawned an entire industry of medical CME, though).

I think our CME requirement could be waived if our Board Certifying Societies attest that we pass a meaningful test every year, as we’re doing in EM now.  (To clarify: we take a test but still have to have the hours of CME as it stands).  We could have our test result sent directly to the state medical boards in lieu of CME.  I see a role for CME for those who aren’t board certified / certifiable, but that’s another detail.

Enough with the agreement. 

Whenever the answer to a complex problem is “Federalize it”, I’m not going to be a proponent.  Joke about the DMV all you want (and I will), but there’s a local / state answer to my problem.  Try that with the IRS, which I’ve been doing for about two years now.  Federalizing medical licensure won’t make the system any better or safer, but it will add a level of government (read:bureaucracy) that won’t be simple or straightforward.  For example, I give you every interaction (outside the Passport system, which I’ve found to work very well) you’ve had with the Feds.  I’m not some anti-government nut, but I don’t think an abject State failure has been laid out here.  Do individual states screw up individual licensure decisions?  Yes.  The answer is better information clearinghouses, not the IRS for Doctors federalizing the licensure of Physicians.