Limit Recertification to Subspecialty
Subspecialists should be required to recertify only in their own subspecialty (“Subspecialists Recertifying Only in Own Field,” June 2005, p. 21). Further, I think this should be done through take-home modules that we can complete at our pace.
The idea behind recert is for us to keep our knowledge and practice current. General medicine MDs who do core internal medicine every day say that they feel the test questions are often esoteric and do not have much to do with the actual practice of medicine. And the answers can be different based on who wrote the question, whether they were looking for last year's information (when the test was made) or last month's information (when a new article stated something different), etc.
Most subspecialists practice with some internal medicine that is related. But to ask every subspecialist to keep up with every advancement in every field including their own becomes impossible. Physicians send their patients to us because they think we know more about a certain aspect of medicine than they do. To be a good doctor—general or specialist—one has to have gained a good fundamental knowledge of medicine during medical school and residency. Hence, I feel that the time commitment, stress, and cost of certifying in both internal medicine and a subspecialty do not achieve the goal of making better, more updated physicians.
Also, the physicians who certified many years ago and are still practicing are not asked to recertify in medicine!
Recertification in one's own subspecialty should be done through required CME from subspecialty meetings and realistic test questions that can be completed in an open book/literature search fashion. A sit-down exam in a hall is not what I look forward to when I am 50, 60, or 70!
Fear of Lawsuits Can Cloud Objectivity
I read with great interest Dr. Sidney Goldstein's editorial on implantable cardioverter defibrillators (“Who Should Receive an ICD?” March 2005, p. 2).
Recently I had a patient who qualified for one. I try to go over the pros, cons, and the indications for the procedure itself. I would have liked to have been fully objective as to my recommendations with respect to this therapeutic intervention. But I could not help but think that I should discuss with the patient the possibility that this might not be a good idea for him; that, God forbid, should the patient die of sudden cardiac death, some distant relative would appear with a malpractice lawyer.
As much as I do not like to admit this to myself, this fear and concern is playing more and more of a part in the medical decision-making process.
Logic vs. 'Knee-Jerk' Guidelines
I enjoy Dr. Sidney Goldstein's columns, and I especially appreciated his comments about guidelines (“Practice Does Make Perfect,” Heart of the Matter, April 2005, p. 2).
He remains upbeat when certain aspects of the medical profession can look so dismal. In spite of all the hype, so often monitoring the patient is superior to the knee-jerk guidelines that we are compelled to follow. I thank Dr. Goldstein for his unusually logical perspectives on the profession, and even on life.
Data Collection Takes Time
Your article on the development and impending use of clinical performance measures in the ambulatory care setting sent chills down my spine (“Coalition Defines Set of 26 Clinical Care Measures,” June 2005, p. 20).
I don't want to suggest that development of the performance measures is an unworthy goal or that we aren't all interested in improving quality of care—of course, we are. The chilling part is the sad truth about who is going to pay for and expend valuable time on the collection of these data—it's you and I! We can just add this to the rest of the busywork we already spend 50% of our days on (Medicare equipment forms, [Family and Medical Leave Act] papers, disability paperwork, patient drug assistance forms, etc.).