ABEM is over-reaching their role

The American Board of Emergency Medicine (ABEM) describes itself as:

Welcome to the American Board of Emergency Medicine (ABEM) public website.  ABEM certifies qualifying physicians who specialize in Emergency Medicine and is a member board of the American Board of Medical Specialties (ABMS).  ABMS certification is sought and earned by physicians on a voluntary basis. ABEM and other ABMS member boards certify only those physicians who meet high educational, professional standing, and examination standards.  ABEM and other ABMS member boards are not membership associations.

The thing I’d like to bring your attention to is that it’s a Voluntary organization.  For a voluntary organization they’re adding lots of requirements without asking members…

Since most of you don’t know about Board Certification, it’s a way for doctors to demonstrate (mostly to their peers and employers/hospitals but also to patients) that they not only finished their residency, but paid attention and learned enough to pass the Board Certifying exam.  Yes, it’s possible to be a doctor, finish a residency, but not pass the board exam and have a nice lifelong practice anyway.

I’m Board Certified by ABEM, which required completing an accredited residency, passing first a written then an oral examination.  Okay, I’m done, right?
Emmm, no. I’m BC for 10 years.  In order to re-test to be BC for another 10 years, I have to take (and pass) yearly tests over medical literature, tests payable to the ABEM.  Which ABEM didn’t bother to figure out how to give us CME credit for.  Genius.

Imagine my surprise at ABEMs’ latest addition to hoops to jump through to maintain my Board Certification: the Assessment of Practice Performance.  In a nutshell: show ABEM that 10 patients didn’t hate my medical performance, prove that on 10 hand-picked charts I’m keeping up with published treatment benchmarks (like aspirin for ACS, antibiotics in 6 hours for pneumonia, etc), and self-certify the same to ABEM.

While that’s easily doable for me at Giant Community Hospital where I work (we already keep track of this, and a lot more), it’ll no doubt be harder for very small ED’s.  I agree this sort of performance thing needs to be tracked, and practice outliers nudged back toward the middle, but what on earth does this have to do with being Board Certified?  Where in ABEMs’ mission statement does it say they’re going to certify we’re practicing on par?  Nowhere.

This would be an entirely different argument if Board Certification were required for employment in EM (it’s not), at my hospital (it’s not), in my group (not), exempted me from any state CME requirements (doesn’t), increased my pay (doesn’t), you get the idea.  That’s a lot of work to keep a voluntary certification that gives me back… nothing tangible.  Oh, I’m a Diplomate of the American Board of Emergency Medicine, and with that and $6 I can get coffee almost anywhere.

I find it interesting there’s not much push-back on this new requirement.  ACEP’s President-Elect ‘interviewed’ ABEM President Debra Perina about this latest addition, uncritically and without any challenge: EM Leaders Discuss ABEM’s Maintenance of Certification Program.

To paraphrase the question, why? The answer:

SS: Is it correct to say that the public is asking for more accountability regarding continuing medical education, even between board examinations?

DP: That’s correct. I know that ACEP and the emergency medicine community have been following testimony in House and Senate hearings from consumer advocates requesting assurances that physicians remain competent throughout the course of their practice. The public is questioning boards that test sporadically or in some cases offer lifetime certification.

Hmm.  I genuinely understand the desire of the public to make sure docs are keeping up, and practicing inside norms (and this is not asking for a flaming: I’m aware there are docs who give amoxicillin for everything imaginable, who don’t keep up, etc) but this is a) window dressing on that front and b) if meant to serve as some reassurance to the public, it’s inadequate, at best.

But that’s really beside my point, which is that it’s not ABEM’s role to make certain my practice is up to par, that’s the role of, ultimately, my State (which licenses me) and my peers, who have a lot more impact on my practice than the ABEM.  ABEM should document that the provable (I’m keeping up with my certification, meaning the every 10 year tests, grudgingly the yearly tests*), and that’s it.

In an upcoming rant: competition is good, is it way past time ABEM had some legitimate competition from another Board Certifying organization?

*In either the first or second year of these yearly tests, the article being tested was about Neseritide, which in the article was the best thing for CHF since phlebotomy.  Of course, by the time we were being taught/tested on it, Neseritide was out of vogue as it hadn’t worked out in practice as it had in studies.  But, you had to give the currently wrong answer to the test.  Pitfalls of keeping up through testing.

Dying man robbed in ER waiting room – More health news- msnbc.com

Dying man robbed in ER waiting room – More health news- msnbc.com
PHILADELPHIA – Police say three people who noticed a man unconscious and dying in an emergency waiting room robbed him instead of going for help.

The City of Brotherly Love.  I don’t think it means what they think it means…

Holman Jenkins: Why Obama Bombed on Health Care – WSJ.com

Holman Jenkins: Why Obama Bombed on Health Care – WSJ.com
Someday this country will have a health-care debate that’s not abject in its idiocy.

It will involve a term used by Congressional Budge Office chief Doug Elmendorf, who has become a notoriety for harping on the word “incentives.” The same word was used the other day by Warren Buffett, about what’s missing from the health-care plan on Capitol Hill.

We actually prefer the formulation of Duke University’s Clark Havighurst, who speaks of restoring the “price tags” to health care.

Now that’s a concept that the public could actually make sense of

Amen.  The lack of pricetags, and ‘skin in the game’ is directly responsible for a lot of the healthcare spending explosion.  Market, please.

It’s All Excessive Medical Care In Hindsight « The Central Line

It’s All Excessive Medical Care In Hindsight « The Central Line

Wow.  Very nice rant from Graham.  Another ED basher gets is head handed to him.

Then there’re things you can do that you shouldn’t…

AMNews: Sept. 21, 2009. Should you keep patients from commenting online? … American Medical News
What do physicians have in common with restaurants, dry cleaners and plumbers? All are being critiqued online by the public.

Is there anything you can do about it? Yes. Have your patients sign a contract promising not to talk about you online.

First, this sort of thing just feeds the idea that docs are out of touch at best.  (The people who would sign this are the kind who wouldn’t even think about it anyway, or are willing to lie to get the medical care they came for).  Really, this is as stupid as a Loyalty Oath.

Second, if I’m a patient and my doc handed me one of these, I’d laugh and walk out. I hope you will, too.

This blog has not been abandoned.

Please don’t tow it.  (What follows is just stream of consciousness crud to see if I remember how to type. It’s not interesting.  Go read Kevin, or Rob, or Kim).

Yes, I’m in quite the slump.  I’ve had several terrifically interesting, challenging cases recently, but they’re “So interesting” I cannot blog about them.  I cannot figure out a way to anonymize them to my satisfaction.

(I know my blogs’ in a slump, as today I only had one comment-spam attempt.  When even the spammers give up, you know it’s bad).

The irony is that I’m going to BlogWorld (where bloggers will congregate) and I’m in the worst blog-slump I’ve had.  And blogging about blogging is fully as interesting as this post.  You see my predicament.

As an aside, by youngest child, just left for college, texted me last night she was disappointed that I hadn’t done a blog post about her birthday, which was earlier this month.  It was a conscious decision, as just because I have a blog I try not to use my family for filler (unless they agree in advance).  So, nice to know she wouldn’t have minded much.

I’m having an interesting adjustment to the Empty Nest.  It’s only been a few weeks, but with just the two of us we’ve discovered how quiet the house really is (and that the cat squeaks when she walks.   Seriously).  So, I’m in an adjustment period, and this too shall pass.

Pardon me, but this makes nearly no sense

Alert on Doctors’ Abuse of Propofol, Drug Suspected in Michael Jackson’s Death – WSJ.com
Abuse of the sedative suspected in Michael Jackson’s death is a growing problem among medical professionals, increasing pressure on the government to restrict it as a controlled substance.

So, doctors (a very very few) abuse this drug, so the answer is to…restrict its prescribing to doctors.

Brilliant!

DB cannot help himself. He hates ER docs, and won’t stop talking about it

One way universal coverage can save costs | DB’s Medical Rants
An ER physician justifies an admission for expediency. This patient needed an outpatient evaluation, but our dysfunctional health care “system” make him consider inpatient evaluation the best option.

So this patient spent 3 days in the hospital, at an outrageous cost, to obtain the evaluation. Of course the ER physician justifies the admission.

This isn’t the first, or second, time he’s gone out of his way to cast aspersions on EM docs (see here and here), but this might be the dumbest.

I know nothing of this particular case, but I’ve been in the same situation: a patient who needs an eval by a good internist, or a specialist, but it’s the patient has no insurance/it’s a long holiday and the patient cannot wait/the patient is unlikely to follow up as an outpatient/ it takes little imagination to understand why this is occasionally done.  So, we get the patient admitted, usually to an overworked hospitalist who nonetheless understands the patients’ plight and admits them.

That’s right: it’s not the ER doc who admits patients.  It takes two to tango, and to admit.  The admission Dr. Centor is raving about here was done NOT by an EM physician, but an internist.  All any ER doc can do is plead their patients’ case, but it’s the internist who makes the decision.  Sounds like some displacement…

“Expediency”.  One persons’ expedience is anothers’ outstanding, expedited care.  Just because it’s inconvenient for Internal Medicne doesn’t make an admission wrong.  That the system is screwed up and costs several fortunes isn’t the fault of ER docs.

As there is a shortage of primary care docs in this country, his last paragraph (go read the rest) fails to impress.  We could go Single Payor/Universal care tomorrow and there would still be a primary care shortage for a decade, and that’s assuming primary care gets paid like they should.

DB is a very good blogger, and a terrible Emergency Medicine bigot.  Too bad, he’s missing out on the most interesting group of docs, personal and professional, ever.

Michael Jackson, King of Pop dies

My first thought: I’m willing to bet drugs (legal, clean, prescribed by a doctor) were involved, and that a review of the records will show some questionable prescribing.  First Do No Harm, unless it’s a celebrity?  Why are docs willing to engage in this kind of horrible, destructive prescribing?  It’s reprehensible.

If it is doc-assisted, please relieve society of this doc’s license.

Anna Nicole Smith, anyone?  Elvis?  A string in between?  This doc-assisted destruction has to stop.

(All of this presumes the most likely, a doc involved; if not, Mea Culpa).  Oh, and Matt wants me to say: no actual individual doc, living or dead, is implied in this post.

Second: somewhere in Beverly Hills there’s a Plastic Surgery group applying for TARP funds.

Better Health » Some of My Best Friends Are Doctors

Better Health » Some of My Best Friends Are Doctors

Dr. Val does a nice Fisk!  Yes, docs make a decently good living.  No, it’s not why the health care system is in trouble.

Dr. Wes: An Open Letter To Patients Regarding Health Reform

Dr. Wes: An Open Letter To Patients Regarding Health Reform
Dear Mr. and Ms. Patient,

It has come to my attention that in order for your to enjoy success as patients in the new era of health care reform, you must start working now to prevent illnesses that might befall you. Do not, under any circumstances, eat or drink too much.

Nice…

Radical Moderation | Removing politics from healthcare

Radical Moderation | Removing politics from healthcare

A nice rant in favor of all of us doing something. The Devil remains the Details….

ERNursey – An ER Nurse’s Blog: This is why we are failing

ERNursey – An ER Nurse’s Blog: This is why we are failing

Nice rant. This talk of socializing healthcare really is bringing us all together, isn’t it?

Pandemics and Politeness

I have learned the Western Way of politeness: when meeting a stranger look them in the eye and give a firm handshake.  I do this quite a lot in this ‘patient satisfaction’ world, shaking the hands of not just the patients but also their families.  (And sometimes you’d think I’d learn).

I’m wondering if we need some sort of socially acceptable way to say ‘I’d shake your hand but given that this is a hospital where illness concentrates, let’s not’.   Seems like a good tradeoff from a risk-benefit standpoint.

Yes, I use the alcohol-based foam gels between patients, and when I pass a dispenser, and when I think about it.  I’m pretty obsessive about it.  I’m not advocating not touching patients appropriately, just seems like something we should be able to change.

Lobsters of Medicine

I’ve never cooked lobsters but was reminded of the trick to the recipe today: if you try to put lobsters into boiling water you’ll have a big fight and it won’t go well, but put them in cool water and slowly turn up the heat, by the time they realize there’s a problem they’re cooked.

I thought about this while turning sideways between gurneys in the hall to get through to the next patient of many.

The temperature in my ED continues to climb, but I’ve been here so long it just seems like it’s getting a little warm.

ED’s everywhere have rising census, increasing demands, physical plants that aren’t keeping up with the crush.

Coal mines have canaries.  Medicine has lobsters.

It’s getting warm, but there’s plenty of time.

Right?