Blogged Arteries

Opinion and Commentary from TMA

Immunizations and The Luxury to Choose

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By Travis Bias, DO

The 82-year-old woman lay on her mat, her legs powerless, looking up at the small group that had come to visit her. There were no more treatment options left. The oral liquid morphine we had brought in the small plastic bottle had blunted her pain. Nonetheless, she would be dead in the coming days. The cervical cancer that was slowly taking her life is a notoriously horrible disease if left undetected and untreated, and that is exactly what had happened in this case.

bias_mugWe had traveled hours by van along dirt roads to this village with a team of health workers from Hospice Africa Uganda, the country’s authority on end-of-life care, to visit the woman. She was the second patient of a similar condition I would see that afternoon.

Back home, seeing an 80 year-old woman with advanced cervical cancer, let alone two in the same day, was exceedingly rare. In high-income countries, cervical cancer is a largely treatable disease, especially when caught in the early stages. And it is now preventable thanks to Gardasil, a widely accessible vaccine against Human Papillomavirus (HPV), the infectious agent that causes most cervical cancers. Physicians and other health care experts recommend the vaccine for all pre-teens in the United States.

“If only she had had access to Gardasil,” I thought to myself.

Just months earlier I was busy in my private primary care practice in Austin, Texas. In one of the richest countries on the planet that spends more on health care per person than anywhere in the world, I was putting forth my best effort to explain to a mother why her 14-year-old daughter, who had never before had any sexual contact, needed the series of three shots against HPV. “So this HPV is sexually-transmitted, and she still needs the vaccine even though she is not sexually active? And she does not need this shot to attend school?” Gardasil was a difficult sell in the conservative state that was careful about adopting what government, or anyone for that matter, recommended an individual do for the sake of public health.

It is now February 2018 and news reports are sounding the alarm about the strain of influenza making its way around the U.S., causing remarkably high rates of hospitalization and death. This disease can be easily prevented by one vaccine each flu season, yet patients decline this vaccine due to any number of excuses. “Won’t I be sick or sore for several days after?” “I am very careful about what I put in my body.” And the online “anti-vax” echo chamber encourages this behavior, turning one anecdote of a less-than-desirable reaction into several stories of harm attributed directly to a single shot in the arm.

What a luxury to choose from a menu of technological advances to protect one’s health. What a luxury to have an employer or taxpayer fund these ubiquitous means of preventing disease; whether it is a vaccine, a blood test, or a basic treatment. High-income societies have at times taken for granted life-saving resources. All to the detriment of their communities. What a luxury.

Considering the Centers for Disease Control and Prevention’s list of the top 10 greatest public health feats of the last 100 years, we are on an incredible backslide to the year 1899. Measles was declared eliminated from the United States in 2000 thanks to widespread immunization, yet we now have outbreaks at Disneyland and anticipated future outbreaks due in part to conscientious objectors to the vaccine. Thanks to advancements in water treatment we no longer have major outbreaks of diarrheal disease, yet we now have entrepreneurs selling “raw water.

What a luxury.

It is a cruel reality of inequality and resource mismatch across the globe when those without resources are clamoring for them, while those with resources refuse. Whether based on religious or individuality protests in conservative communities or “natural” ways of life in more liberal communities, the result is the same ignorance of science and reason. What a luxury.

But a heavily and densely populated globe interconnected by the increasing ease of international travel means that one person’s declined influenza vaccine might mean another person’s influenza death. The case of Ebola virus disease transported from Liberia to Dallas, Texas in 2014 highlighted how quickly and easily infectious diseases can spread across borders.

In a world of finite resources (yes, even in America) when does the conversation about personal responsibility turn to demand that individuals implement what is available to him or her to benefit their global community?

In a decade as a family medicine physician in the U.S., I had never before seen a death due to cervical cancer. With our suite of widely used screenings, diagnostic technology, and range of surgical solutions, cervical cancer-related deaths are exceedingly rare. And now that we have deployed the vaccine, Gardasil, cervical cancer rates worldwide have been cut in half.

“If only this woman had had access to Gardasil,” I thought to myself. Instead, the 82-year-old matriarch tried to maintain her dignity in the face of a spreading cervical cancer, urinating on a plastic tarp in her niece’s concrete open-air house and controlling her pain with ibuprofen and oral liquid morphine. If only she had had access to that luxury to prevent her cancer. With a little public will, perhaps her great-granddaughters — and mine — will.

Travis Bias, DO, is a family medicine physician who once practiced in Texas and now practices in California. He also is a medical and public health educator. Dr. Bias was an active member of the Texas Medical Association while in the Lone Star State. Connect with him at his blog, The Global Table, or on twitter @Gaujot.

Dr. Bias’ blog post first appeared in THCB

 

The Secret to Getting Your Patients to Listen

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Many doctors believe the reason most of their patients fail to get better is that they simply don’t do as they are told. They complain that their patient population just won’t listen to reason. The problem may not be your patient population, it may be the way you are talking to them.

Let’s say you have a patient who is at high risk for a multitude of disastrous consequences from their years of not exercising, smoking, and eating fast food. They like cheeseburgers the way that LeBron James likes LeBron. You recommend lifestyle changes and perhaps a medication to help reduce their risk.

Cole_Photo“Yeah, I’ve heard of that drug,” the patient says. “It made Jimmy go crazy and kill himself last year, so there is no way I’m going to take that.” 

You explain to him what the latest research shows us about reducing their risk of heart disease, diabetes, stroke, etc, but your patient wants to focus on the infinitesimal risk of a side effect that a neighbor may or may not have experienced when taking the recommended medication. 

What are the chances that you will convince this patient to look at the data from the literature and that you will be able to convince them to take this drug? I would hazard to guess that my dog has a better chance of winning the gold medal in figure skating in the 2022 Olympics, and she doesn’t even like to wear sequins.

Faulty Reasoning: Media Coverage of New Medications Can Be Risky Business

How many times have we heard a news report about a “breakthrough” medication that promises to save us all by reducing the risk of some terrible disease? The media reports it, and most doctors take it with a grain of salt. However, our patients often take these reports at face value and come into the office demanding a prescription for this new miracle drug.

Because we have all studied statistics at some point in our medical careers, most of us are at least somewhat familiar with the terms relative risk and absolute risk. We may not pay as much attention to it now as we did before we took our Board exams, but it is critical information when we discuss drug studies with our patients. The absolute risk tells us the overall odds of developing a disease, but the relative risk is the amount of risk compared between two groups.

The relative risk is much less helpful in making decisions for most patients, but it is the one that is almost always reported because it tends to be a higher percentage (since the total numbers of people are lower, it is easier to come up with a higher percentage).

Let’s say the news reports on a drug that cuts in half the risk of being stricken with the malady of unicorn flu. Your patient saw the news, looked up the signs and symptoms of unicorn flu online, and decided she doesn’t want to take the risk of getting hit by this bug.

She wants you to write the prescription for her and her entire family so that they won’t have to worry about it.

Before you grab that pen (more likely mouse or electronic tablet) to write that prescription, you should be asking yourself the crucial question, “What is the risk for this patient of actually getting this disease I’ve never heard of?” 

If the risk in the general population is only 1 percent (absolute risk = 1 percent), and the drug decreases that risk by 50 percent (relative risk), then the new risk is 0.5 percent. We’ve effectively decreased the overall risk by a whopping 0.5 percent, not 50 percent. 

Most news outlets are not going to bother reporting a reduction of risk of less than 1 percent, and most people are not going to get too excited by such paltry risk reductions. So what ends up happening is that the news almost always reports the higher numbers, and patients (and many doctors) have a hard time asking the right questions. So your patient is unlikely to get unicorn flu, but very likely to get confused.

Survival Bias — The Reason Patients Make Bad Health Decisions

Let’s talk about diet for the next example of why our patients get confused. Imagine you are at a party with dozens of people. You see a couple that you haven’t seen in years, and they look great. They have lost weight and appear to be in good health. 

You are dying to know their secret, and so you ask them how they did it. They proceed to tell you about this great new diet plan called the Frozen Leprechaun Diet where they eat only Lucky Charms cereal, and they work out daily by playing freeze tag throughout their house. 

Surprisingly, they each have lost about 40 pounds with this diet, and they have kept the weight off for over a year.

After hearing about their success, you may be tempted to try this diet too, but before you stock up on Lucky Charms, you would do well to remember the concept of survival bias. You see, the rest of the people at the party you went to tried the same diet, but instead of losing weight, they actually gained weight. 

The only reason you didn’t talk to them about their failure is because you were too busy talking to the only two people at the party for which the diet actually worked, and you ignored the overweight people who were not so excited about talking to you about green clovers, blue diamonds …

Finally, a Reason to Love Anecdotal Evidence

Most doctors inherently know that making decisions on anecdotal evidence is generally bad medicine, yet we do it more than we would care to admit. 

Let’s say you have been seeing a ton of patients recently with infections that require antibiotics. You are aware that there are potential side effects (like turning their skin blue) associated with prescribing this medication, but the benefits seem to outweigh the risks. 

If you have three patients in a row who develop this supposedly rare side effect, you might think twice about converting a fourth patient into a character from Avatar.

I ran into a similar situation the other day — not the whole Avatar thing, but just a case of faulty reasoning on my part. I was visiting with a pharmaceutical rep about a new asthma medication, and he asked if I had tried their drug on any patients yet. 

I replied no, but I knew that one of my partners had just started two of her patients on the medication and that I was waiting to see how her patients did before I started any of my own. 

Logically, I realize that a study with an n of 2 does not allow for a fair assessment for efficacy one way or the other, but it is a human flaw that is hard to get past even for a physician who should know better.

Anecdotes are a very difficult thing to overcome in medicine. They are terrible predictors of future outcomes, but the reality is that if you are a human, you are susceptible to falling for their undeniable charm. 

Because it is such an inherent human characteristic, why not use it to our advantage? Instead of spending so much time talking to our patients about data and research trials, why not speak to them in a language that they will understand? 

Let’s see if anecdotes can work for us, rather than against us, for a change. Tell them all about how other patients did with the recommendations you are making. Tell them all about how you were successful in getting into shape, sleeping better, or … whatever else you need to tell them about in order to get your message across. 

The point is that patients are much more interested in hearing success stories than they are in hearing about journal articles. That doesn’t mean we shouldn’t read, analyze, and discuss those journal articles. It just means that they may not always translate well at the bedside when you are trying to convince your patient that the planned course is the right one. 

Whether it’s discussing unicorn flu, Lucky Charms, or blue skin, it’s obviously best to make recommendations based on the statistical data, but it may be more effective to talk to our patients using the language they understand — anecdotes.

Steven Cole, DO, is an allergist/immunologist in Dallas who blogs at www.AllergyZoom.com.

Physician Frustrations: Who will be our future?

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I spoke with a young woman recently who is working on her application to medical school. She had the same excitement and nervousness regarding the application process that I had when I began my journey into medicine. Unfortunately, I was disheartened to find out that she had spoken to many physicians who had tried to talk her out of going to medical school and pursuing her dream of becoming a physician. 

I chuckled with her saying I had experienced the same thing. Unfortunately, she was even starting to question her desire to be a physician.

What happened to our field? Why are those of us in practice frequently found telling prospective students not to join our path and seek another one with better pay, better work-life balance, and more appreciation? 

Are there frustrations with the health care system, insurance, and electronic health records? Yes. 

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Do we work long hours with minimal acknowledgment of our dedication? Yes. 

Do our years of study and practice get dismissed for the more vaunted Dr. Google? Yes. 

Do we sometimes forget why we even became a doctor? Yes. 

Do we also have the privilege to help patients through some of the most exciting as well as difficult times in their lives? Yes.

I find it an honor to be a physician. Do I deal with all the above concerns mentioned? Yes. 

However, when a patient says thank you for my support during a difficult diagnosis, or I see the tears of joy on the face of a new mom as I hand her her baby for the first time, I remember why I became a doctor. We as a profession must not forget the reasons we chose to pursue medicine. We all have stories that we so excitedly told during medical school and residency interviews saying why we should be chosen. Maybe we should write those stories down and bring them out every time we feel beaten down by the pressures of practice. Maybe we should think about those stories when a young man or woman approaches us about becoming a physician.

Do I have an answer for all the problems in medicine? No. However, I try to be present and speak up for us as physicians when it is needed. I implore my fellow physicians to join in the advocacy efforts to make change in the field of medicine such that we leave the field better than what we have encountered. Let’s make this a field that we would be happy to have young people join. 

I choose to support and to help bring up the people who come after me. Try to remember the feeling you had the first time you put on a white coat or the first time someone called you doctor. I ask you to remember why you became a physician and try not to quash the dreams of those who want to join you. Otherwise, we may one day be wondering, who will be our future? Let’s not push those eager prospective medical students away. Rather, let’s guide them into the wonderful field of medicine, so that they too will understand the privilege of being called doctor. 

Shanna Combs, MD, is an obstetrician-gynecologist in Fort Worth and a member of the TMA Leadership College Class of 2018.

 

MIPS is Dead, MIPS is Dead; Well, Not Quite

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By Asa Lockhart, MD

On Jan. 11, 2018 the Medicare Payment Advisory Commission (MedPAC) voted 14 to 2 to replace MIPS with the Voluntary Value Program (VVP). So who is MedPAC, why would they make such a recommendation, what could go wrong, what is the impact of their recommendations, and when is MIPS gone? 

Oh, and why we would want the VVP? Important questions to answer before you pull up your MIPS folder on your computer, hit “Delete All,” smile, and think “Good riddance.” 

So what and who is MedPAC? 

lockhart for blogFrom that hallowed resource Wikipedia: “The Medicare Payment Advisory Commission is an independent US federal body. MedPAC was established by the Balanced Budget Act of 1997. The Commission's 17 members bring diverse expertise in the financing and delivery of health care services. Commissioners are appointed to three-year terms by the Comptroller General of the United States and serve part-time. Its primary role is to advise the US Congress on issues affecting the administration of the Medicare program. Specifically, the commission's mandate is to advise the US Congress on payments to private health plans participating in Medicare and health providers serving Medicare beneficiaries. MedPAC is also relied on by Medicare administrators and policy makers to evaluate beneficiary's access to care and the quality of care received. MedPAC's mandate is broad enough that it can also evaluate other issues affecting Medicare.” 

The members include physicians, health care executives, and other policy experts. Alice Coombs, MD (Anesthesia and Critical Care), of South Shore Hospital in Weymouth, Massachusetts, and David Nerenz, PhD, of Henry Ford Health System in Detroit, Michigan were the two no votes. Francis “Jay” Crosson is the chair and recently headed up AMA’s Physician Satisfaction and Sustainability (PS2) efforts after being the lead physician for Kaiser. Drs. Coombs, Crosson, and Rita Redberg, MD, MSc are the only physicians who have a history of direct patient care. The remainder are mainly associated with health plans and think tanks.

Why would they make such a recommendation? MedPAC's analysts believe the fatal flaw with MIPS is that it is not structured to achieve the policy goals that it's designed to achieve. Since the American health care system is at times more different than alike, MIPS required a great deal of flexibility (e.g., reporting options and reasonable exemptions) that introduces both variability (more different to manage) and complexity (barriers to comprehension, statistical validity, and participation). 

David Glass, a principal policy analyst for MedPAC opined that "Everyone will seem to have high performance when in fact many of the measures are topped out or appear to be topped out ... and that will limit Medicare's ability to detect meaningful differences in clinician performance," and it is "extremely unlikely that physicians will understand their score or what they need to do to improve it." 

In a really enlightened moment, he came to the same realization that we have felt for some time: "Our most basic concern is that the measures in MIPS have not been proven to be associated with high-value care." Glass and Kate Bloniarz are the staff policy analysts with MedPAC that appear to be the principle architects of the plan.

What are they proposing? The foundation for their alternative policy approach is based upon leveraging population-based measures. It would replace MIPS with elimination of the reporting requirements in the quality, Advancing Care Information (ACI or the old meaningless use), and the Clinical Practice Improvement domains. Instead, the program would assess clinical quality that these are based on large populations of patients — not patients with a specific condition (e.g., infection rates, avoidable readmissions), patient experience (better be a “5 star), and value. So the only leg of MIPS to survive as a component in VVP is cost (AKA Resource Use, value-based payment modifier, etc.). 

While fee for service would remain, all clinicians would see some portion of their payments withheld and placed into a pool. While the amount has not been determined, the figure of 2% has been mentioned in the past. In the final iteration of the proposal, they left the “withhold” up in the air. The specific recommendation does not require a withhold though the text is going to mention that one way to move forward would be with a withhold. Unfortunately, MedPAC then presented and “illustrative” example that does include a 2% withhold. 

 Under their plan, clinicians would have one of the three options: 

  1. Join a "sufficiently large entity" (e.g., physicians affiliated with a single hospital or one geographic area) of clinicians and be eligible for value payments, which would then be collectively measured using a set of population-based measures. The entities must be "sufficiently large" in order to have "statistically detectable performance on the population based measures."
  2. Choose to participate in an advanced APM model.
  3. Lose the withheld fee schedule dollars. Since this option would almost certainly generate a groundswell of opposition, especially among vulnerable practices that don’t feel either of the other two options are a realistic in their community, it is possible that this end goal be achieved without a frontal assault. Perhaps this bucket would just not be eligible for any financial bonuses. Another variant in the beginning would be to use the $500 million MIPS has authorized for exceptional bonuses to draw physicians into the VVP. Bottom line, there is no inkling of how this might evolve and what other factors might be in play at the time.

Bloniarz observed that all of the proposed measures could be pulled from Medicare claims data or "centrally conducted patient surveys" which avoids the current main complaint by physicians of the reporting burden with MIPS. The devil is always in the detail and claims-based versus clinical-based is already a known impediment in other areas. While popular in some areas of the country, many in this caucus do not find the phrase “centrally conducted” a reassuring term. Part of the concern by both positive and negative votes would be a negative effect on existing health care disparities and dual-eligible who already have significant barriers.

What could possibly go wrong? There is a lot of debate on repeal and replace or just repeal; sound familiar? The issues of claims-based data, universal survey validity, and yet another learning curve begin the list. The other risk is that legislators will identify some risk amount, such as the previous 2% value, and adjust it upwards or take the withhold and not establish a way to distribute it. In fact, various members at the monthly meetings since November have advocated in one form or another to repeal the MIPS program, withhold the funds from the clinicians who aren't participating in an advanced APMs, and then reallocate the withhold to reward APM performance. The underlying goal would be to actually increase the penalty and make it less attractive to stay in MIPS. Transparency, timing, attribution, and supporting infrastructure are also material hurdles; black boxes yield results based on their programming!

What is the impact of their recommendations? It is important to understand that they only make recommendations; they do not mandate acceptance or implementation. Acceptance is often dependent upon whether CMS or Congress have any interest in moving in a suggested direction. However, they often provide a frame of reference and starting point for legislative and regulatory members and staff. Their withhold concept could rapidly become an object of interest and potential source of funding for any number of possibilities. So the impact of their recommendations may be indirect and unintended if incorporated as part of other initiatives.

When is MIPS gone? Thus far, their recommendations have not created any momentum. Thus far, Congress has shown no interest in changing the program before it has even gotten off the ground; and right now Congress has trouble passing anything, which for us is a key prerequisite! So while it may initially seem enticing, consider the impediments discussed above, and I suspect your smile may be fading a bit. 

Short answer, probably no time soon. So, neither delete your MIPS files nor cease your efforts to comply with MIPS. I think that you are going to need to report it after all! 

Next steps for MedPAC are for staff to develop a revised voluntary replacement program similar to the one discussed above and suggestions on how to make the advanced Alternative Payment Models more accessible for physicians, which actually could be a silver lining in the discussion. We need options that are realistic, manageable, and sustainable. 

Asa Lockhart, MD, is an anesthesiologist in Tyler.

This post originally was published in the AMA Southeast Delegation Newsletter

What Do You Really Think About MOC?

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Hampel300x200Update April 24: 

The deadline to participate in a survey on Maintenance of Certification (MOC) has been extended from April 30 to May 11.

Original story: 

As Texas Medicine Today reported recently, leaders of the boards that run the Maintenance of Certification (MOC) programs have created a commission – the “Vision Initiative” – to develop “a set of recommendations about the future of continuing board certification.”

And the Vision Initiative says it wants to hear from you. And you have until April 30 to share your deepest thoughts. 

As we pointed out, the commission is stacked with people with close ties to the certifying boards and physicians who work in academic settings. Perhaps naively, I am hoping that practicing community physicians can right that imbalance by flooding the commission with real-world comments about how MOC is an expensive, time-consuming process that has little applicability to your day-to-day practice.

Here’s your chance. The commission has opened a survey on its website, inviting you to “help envision the future of continuing certification.” Among the open-ended questions:

  • What would you like the commission to consider in the coming months as it reviews specialty boards’ maintenance of certification programs?
  • Do you have ideas about the future of continuing certification? If so, what are they?
  • Do you have any other thoughts on board certification?

In a slanted bit of survey design, the commission also included this question before the broader ones: “Do you believe there is a difference in the quality of care provided by Board Certified physicians and non-Board Certified physicians?”

Finally, as several MOC-reform advocates have pointed out on Twitter, this isn’t an anonymous survey. The last question (answer required) is this: “The Commission may have follow-up questions. What is the best email address to reach you?”

The Vision Initiative announced last week survey will remain open until April 30. 

So let loose. Now. How would you “envision the future of continuing certification”? They asked. It’s the least you can do to answer.

The plan is for the commission to release a draft report in November and submit its final recommendations to the American Board of Medical Specialties in February 2019.
 

 Revised March 26, 2018

Picture This: You at One of TMA’s Annual Conferences

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You might not have come to the Texas Medical Association’s 2018 Winter Conference in January, and that’s fine.

You’re busy. Trust me, as the editor of TMA’s magazine and website, I understand how busy you are.

But more than 500 of your colleagues, including medical students, did come to Austin for the two-day conference, which featured:  

  • The chance to catch up with colleagues and to make new friends.   
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  • Panel discussions and presentations on critical issues such as cybersecurity, how to speak with patients in an era of fake news, and ways to improve health care access.  

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  • And board, council, committee, and section meetings featuring discussions on the future of Texas medicine.   

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Now that’s entertainment. 

The two-day conference, held in Austin, is one of three big meetings TMA hosts each year. 

If you didn’t already know, attendance at TMA conferences is free to TMA members and your practice staff. So it’s a bit of a no-brainer to attend them all.

But if you only have time to go to one this year – and, again, I know how busy you are – you might want to make it TexMed 2018, scheduled for May 18 and 19. 

The conference, to be held at San Antonio’s JW Marriott San Antonio Hill Country Resort, attracts several thousand physicians, students, alliance members, and more.

This year’s annual meeting has got so much going on we can barely contain our excitement: 

  • Keynote speakers Zubin Damania, MD, also known as ZDoggMD, and Gordon Hartman, the founder of Morgan’s Wonderland in San Antonio and the Gordon Hartman Family Foundation;
  • More than 20 standalone CME programs with more than 100 talks to choose from;
  • TMA Foundation’s 25th anniversary gala celebration that will feature dinner, auctions, and live music; and
  • Exhibits and information from hundreds of vendors at the Expo Hall. 

What’s not to love?

Registration is now open, and hotel discounts are still available.

Find out more on the TMA website or by calling the TMA Knowledge Center at (800) 880-7955.

Photos: Matt Lemke Photography

 

 

 

MOC Commission a Stacked Deck

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 Private practice physicians have been leading the national outcry against maintenance of certification (MOC), but those physicians are woefully lacking on a commission charged with developing “a set of recommendations about the future of continuing board certification.”

 

The “Continuing Board Certification: Vision for the Future” campaign this week announced the names of the 28 women and men who will craft those recommendations. The commission membership is long on people with close ties to the certifying boards and physicians who work in academic settings, but it certainly doesn’t meet the original promise of a “variety of practice environments.”

To be fair, that list includes one outspoken MOC critic: Philadelphia-area internist Charles Cutler, MD, the former president of the Pennsylvania Medical Society. Dr. Cutler led several forums addressing physicians’ concerns with MOC – especially its expense and lack of relevance to daily practice – and exposing the finances of the American Board of Medical Specialties (ABMS) and some of its member certifying boards.

I found one other private practice physician on the commission: Paul E. Johnson, MD, an otolaryngologist in Laramie, WY, and a past president of the Wyoming Medical Society. And Donald Palmisano Jr., who runs the Medical Association of Georgia and serves with me on the board of the American Association of Medical Society Executives, certainly has heard and can articulate all the MOC horror stories.

But the rest?

Using just the biographical information that the Vision Initiative provided, here’s the breakdown of the commission members’ background:
  • 20 of the 28 commission members are physicians;
  • 17 of those 20 are academic physicians or have served on or worked for one of the certifying boards;
  • Seven of those 17 are both: academic physicians who also have a board connection;
  • Three of the eight non-physicians work or worked in academia or for one of the boards;
  • One of the commission’s cochairs is Christopher Colenda, MD, the former president and CEO of West Virginia University Health System, and former treasurer and vice chair of the American Board of Psychiatry and Neurology; and
  • The other cochair is William J. Scanlon, PhD, a former public member of the American Board of Surgery.
 

That stacked deck isn’t surprising – despite the lofty goals for diversity that the Vision Initiative announced when it solicited nominations for the commission – when you look at the background of the Planning Committee members who picked the commission. Once again, the committee was way heavy on physicians who’ve spent most of their careers at academic institutions or the certifying boards, not in private practice.

So why does all of this matter? It matters because the certifying boards have been staunch advocates for the status quo. (ABMS actually spent more than $25,000 last year on a lobbyist to fight TMA’s MOC reform bill in the Texas Legislature.) 

It matters because the physicians in academia on the commission and the Planning Committee – several of whom I know to be outstanding individuals, very good doctors, and excellent at what they do – have a totally different experience of a medical practice. And that’s why academic physicians have not been the ones leading the fight against MOC. Their perspective and expertise are important, but they’re no replacement for the point of view of the doctors who are outraged over it.

And it matters because the Vision Initiative’s objectives are to “assess the current state of continuing board certification and envision its framework for the future as a process that is valued by physicians, patients, hospitals and health systems.”

Assessment and envisioning are in the eye of the beholder. Bricklayers don’t build wooden homes. Unless the Vision Initiative replaces at least half of the new commission with physicians who practice like the vast majority of U.S. doctors, its “framework for the future” is likely to be just as onerous, just as costly, and just as irrelevant to daily practice as MOC is.

Help Keep TMA’s Blogged Arteries Flowing

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How do you like the changes we’ve made to TMA publications so far?

Are you enjoying the updated look and livelier content of Texas Medicine magazine?

Do you enjoy receiving timely, relevant news targeted specifically to your email inbox every day?

Did you even notice the Texas Medical Association rolled out a host of changes in January?

No matter how you answered those questions – just please tell me you noticed – we hope you’re finding some value in our efforts to provide you with timelier, more engaging content.

Because we certainly value your input in how we communicate to you and other Texas physicians.

In fact, we value it so much that we’d like your direct input into our communications.

In so many words, we’re inviting you to write for our blog, Blogged Arteries.

Now, the name alone should get you excited. I’ve been here almost a year, and that name never gets old. It’s clever, reasonably funny, and is clearly involved in medicine. 

Hey, that’s a pretty good description of you.

You see, here at TMA, we’ve got a team of great reporters and editors who work every day on stories and issues that are important to physicians. However, nobody on this staff has a medical degree, so we can only write about medicine as an outsider.

But not you.

You are directly involved in the practice of medicine every day. You have stories, opinions, gripes, praises, and insight into medicine that we just don’t have. 

We want to give you an outlet to make your voice heard to more than 51,000 of your colleagues throughout the state.

What should you write about?

Anything related to the practice of medicine. Seriously, that’s it. Almost everything is on the table: insurance hassles, practice management tips, personal stories, legislative issues, the best color to paint a waiting room wall. As long as it’s medicine, we’ll consider it.

Now, obviously, you’ll have to stay HIPAA compliant, and we’d edit stories for things like grammar, style, and overall readability. But don’t let any of that worry you. You just write, and we’ll take care of the rest.

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My Battle with Guideline Fatigue Syndrome

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2.2 guidelines

It started slowly. My former resident and present colleague Terry Shaneyfelt first authored, "Are Guidelines Following Guidelines? The Methodological Quality of Clinical Practice Guidelines in the Peer-Reviewed Medical Literature."

CentorThis paper alerted us to the problem. But guideline fever continued to rage. Almost every specialty and subspecialty society decided that they needed to join the guideline movement. They needed to tell us the right way to practice medicine.

While I understood the problems of guidelines (I had found a 40-page guideline on cerumen), it had not yet become visceral. Then the great pharyngitis controversy of the early 21st century made it personal. In 2001 the ACP (endorsed by the CDC and AAFP) published, "Principles of Appropriate Antibiotic Use for Acute Pharyngitis in Adults."

This guideline endorsed the Centor score to exclude testing or treatment for 0 and 1, test 2, and either test or treat with narrow-spectrum antibiotics 3 or 4. The next year, the IDSA published, "Practice Guidelines for the Diagnosis and Management of Group A Streptococcal Pharyngitis."

That guideline argued for testing 2-4, again neither testing nor treating 0 or 1. Some authors of that guideline then published an editorial that "took the ACP to task" for suggesting empiric treatment of some patients: "We must conclude, therefore, that the algorithm-based strategy proposed in the ACP-ASIM Guideline would result in the administration of antimicrobial treatment to an unacceptably large number of patients with non-streptococcal pharyngitis.”

I strongly disagreed with the IDSA position but remained puzzled how two reputable organizations could review the same data in an evidence-based manner and have such disparate recommendations. And then it gets even worse. The Annals of Family Medicine published this article from Europe, "Differences Among International Pharyngitis Guidelines: Not Just Academic:"

"Although the evidence for the management of acute sore throat is easily available, national guidelines are different with regard to the choice of evidence and the interpretation for clinical practice. Also, a transparent and standardized guideline development method is lacking. These findings are important in the context of appropriate antibiotic use, the problem of growing antimicrobial resistance, and costs for the community."

That 2007 study preceded this 2011 study, "Analysis of Different Recommendations from International Guidelines for the Management of Acute Pharyngitis in Adults and Children." That study compared 12 guidelines and found great disparities in recommendations.

Now, I was certain that the guideline process had a major limitation. For the occasional question, the data are clear, and all parties agree, but too often different guideline committees have differing values. And values influence how we view data and certainly what we value in developing our guidelines.

You likely know several examples of "dueling guidelines" – breast cancer screening, prostate cancer screening, and goals of diabetes control. Recently, we have guidelines for hypertension that give significantly different recommendations.

I realized that I had Guideline Fatigue Syndrome (GFS), when I wrote about an excellent IDSA article, "The IDSA takes an admirable position in not endorsing the new Sepsis Guidelines."

So what causes this syndrome? We want to believe that guidelines come from evidence, but we forget the famous Nietzsche quote, "There are no data, only interpretation." Depending on our belief system, we value outcomes differently. In the sepsis example, the critical care doctors want sensitivity (few false-negatives) and do not see problems with lower specificity (i.e., giving antibiotics to some patients who do not need them). The IDSA worries (appropriately) about antibiotic resistance and antibiotic side effects. So they prefer to maximize specificity and wait for more data in some patients.

Too often guidelines are considered rules. They were always meant to be guides, and clinical judgment should always trump the guides. But each time a major guideline appears, we read about it in The New York Times. Practicing physicians do not know what to believe because of guideline bloat and controversy. We do not need 12 pharyngitis guidelines. We should not even call specialty and subspecialty opinions guidelines. They are making recommendations based upon their view of medicine. We all have biased views of proper medical care.

Guidelines can have serious unintended consequences. When we label our opinions as guidelines, we put all physicians in an uncomfortable and even untenable situation.

So, I have no idea how to evaluate the seemingly never-ending supply of guidelines. I have no idea how to interpret them recognizing the biases involved in creating them.

Please join me and admit that you too have GFS. I fear this syndrome has no cure. It is pervasive and growing. It is not a rare disease.

Robert Centor, MD, is an internal medicine physician who blogs at DB's Medical Rants.

This post originally appeared on KevinMD.