Maintenance of Certification (MOC) Update: A Health Reform Lesson

The 1967 Corvair. A non-PHB version

Long ago, when the Population Health Blog was courting the future PHB spouse, our unspoken understanding was that if the PHB liked its unsafe-at-any-speed 1967 Corvair, it could keep its unsafe-at-any-speed Corvair.

The sweet perfume of our relationship more than made up for the odor of car exhaust, unsightly blemishes, noisy rattles and rusted floorboards.

Cracking the windows, touches of spray paint, the AM radio volume knob and care where you placed your feet also helped.

It wasn't until courtship turned to relationship that the spouse's true thinking began to manifest itself.

That's why, years later, the PHB was unsurprised by President Obama's disavowal of his you-can-keep-your-health-plan assurances. Substitute Federal minimal essential benefit requirements, narrow networks and unaffordable premiums for spousal safety demands, mocking eye-rolling and intrusive hints about the merits of a new car, and readers should understand the PHB's acquiescence.

So the PHB shrugged off the notification that its life-long American Board of Internal Medicine (ABIM) specialty credential wasn't really a life-long credential.  

Enter maintenance of certification or "MOC."

More background can be found here, but, briefly, the sweet perfume of accomplishment was overcome by the MOC stink of intrusive, unproven as well as expensive documentation, education and testing renewal requirements.

Thousands of the PHB's physician colleagues were less submissive about the matter in print and on-line. There were also competitive threats, lawsuits, online petitions, and websites. The American Medical Association weighed in. And then state medical societies, which have a vital interest in serving their membership, began to sound the alarm.

And it paid off. 

While the PHB would have predicted that the academics populating the ABIM leadership were about as likely as Mr. Obama or the PHB spouse to change their minds, they've issued a "we got it wrong and sincerely apologize" announcement. 

As a result, many of their documentation requirements are on hold, the test is being revamped, fees are being reduced and the education options are being broadened.

Good for the ABIM and good for the practice of internal medicine.

This kind of mea culpa is a good first step in engaging the opposition and is likely to turn many critics into allies. More importantly, this is a great example of the impact of grass roots activism and the advocacy of organized medicine.

If this can happen in this corner health care, perhaps there are other areas of health reform where a well placed apology might be a good first step.

The magnanimous PHB is also happy to admit that, in retrospect, the spouse was right about the Corvair. At one point, highway snow was blowing up into the passenger compartment.  At 60 miles an hour.  Seriously.

Since then, it has gotten to like and keep lots of other stuff.  It makes having to pay so much for its own heath insurance a little more tolerable.

Image from Wikipedia

President Obama Addresses the Ebola Crisis

In this weekly address, President Obama addresses the Ebola crisis.  As we've come to expect from our Chief Executives, it's a perfectly crafted speech that addresses our major concerns. But the Population Health Blog doesn't think it goes far enough.  In its continuing quest to help Mr. Obama overcome his tanking approval ratings, the PHB changed a few words and modestly offers up a slightly edited version of the address.  It believe it speaks more forcefully to the issues at hand.....

PRESIDENT OBAMA: Hi everybody, this week, we remained focused on spinning a favorable White House narrative about Ebola. In Dallas, the natural history of the disease and basic isolation procedures limited spread of the disease to only two among the dozens of health care workers who had been in close contact with the first patient. Now, those two workers are two too many, which is why I've told the CDC that their calm and distant inertia is unacceptable.  As you know, that's my job.

The two nurses who contracted the disease in West Africa were thankfully released from the hospital. I was proud to welcome one of them to the Oval Office to give her a big hug and make sure plenty of photographs were taken.

And in Africa, the countries that did not wait for our help, Senegal and Nigeria, were declared free of Ebola.  Which is probably why New York City also decided to not wait on Washington DC. Local public health personnel there moved quickly to isolate the doctor who recently returned from West Africa. While we deployed one of our new CDC rapid response teams, I wonder what they'll learn from New York City's approach. Maybe a lot. And I’ve assured Governor Cuomo and Mayor de Blasio that they’ll have all the federal support they need as they go forward.  After all, I'm from big government and I'm here to help.

More broadly, this week we've continued to step up our use of words like "efforts" "outreach," "coordinate," and "integrate" across the country. New CDC outreach is helping hospitals coordinate and integrate training. The Defense Department’s new team of doctors, nurses and trainers will outreach, coordinate and integrate if called upon to help with coordination and integration and, you know, outreach and other efforts.

Now, rather than institute an unworkable travel ban, we now have a less unworkable travel measure that directs all travelers from the three affected countries in West Africa into five U.S. airports. Starting this week, these travelers will be required to report their temperatures and any symptoms on a daily basis—for 21 days until we’re mostly hopeful that they don’t have Ebola. Here at the White House, the lawyer I've appointed to coordinate and integrate the government's response will tell the doctors what to do and how to do it. And we have been examining the protocols for protecting our brave health care workers, and, guided by the science, we’ll continue to do everything we can to embarrass the Republican nutjobs who are also using Ebola for political gain.

In closing, I want to leave you with some basic facts. First, you cannot get Ebola easily through casual contact with someone. The only way you can get this disease is by coming into direct contact with the bodily fluids of someone with symptoms. But, if you do get it, your internal organs could liquefy. That’s why health workers must wear total body condoms. That's the science. Those are the facts.

Here’s the bottom line. We can beat this disease. But we at the White House have to stay on message by repeatedly saying that we have to work together at every level—federal, state and local. And we have to give the impression that we're leading a global response, because West Africa is in a world of hurt right now along with other global hot spots like Syria and Ukraine and Hong Kong and Russia.

And we have to be guided by the science—we have to be guided by the facts, not fear. Yesterday, New Yorkers showed us the way. Despite the mainstream media's alarmist reporting, they did what they do every day—jumping on buses, riding the subway, crowding into elevators, heading into work, gathering in parks, ignoring speeches like this and wondering why the Yankees aren't in the World Series.

That spirit—that determination to carry on—is part of what makes New York one of the great cities in the world. And that’s the spirit all of us can draw upon, as Americans, as we meet this challenge together.

What the White House's Diffidence Over Syria Teaches Us About Complex Medical Decision Making

Talk about a no win situation.  After seeing his "red line" go rudely unheeded, the President is facing the prospect of appearing weak if he does nothing or warmongering if he launches an attack.

Medical decision scientists ask: how did it come to this?

Mr. Obama is correctly admired for his "no-drama' informed style of decision-making.  And good physicians, says medical science, should operate the same way.  According to this recent New England Journal article, consciously deliberative and logical approaches to diagnosis and treatment selection are far more reliable than the intuitive shoot-from-the-hip pattern recognition that used to rule the bedside.

Psychologists describe the latter as "Type 1" processing while the former is "Type 2."   Think George W. Bush's gut instincts over Iraq's weapons of mass destruction versus Barack Obama's disciplined rationality when he decided to attack the Bin Laden compound. He undoubtedly used the same methodology when he was pondering Syria.

But, thinks the Disease Management Care Blog, there are limits to brainy decision-making when the choices are overwhelmingly numerous.  In this retail business-oriented TEDTalk, Sheena Iyengar points out that dozens of options lead to procrastination followed by bad choices followed by low satisfaction. 

It can also apply to foreign policy. Given the vast array of pieces and potential moves on the Middle East chess board, little wonder that Mr. Obama would procrastinate for days saying he has "not made a decision," then apparently select an attack option disdained by even the New York Times and then engender even more second guessing by the very Congress that the President has repeatedly criticized as unreliable.

Ditto health care.  The downside to shared decision making is that an overwhelming number of testing and treatment options can lead befuddled patients to a "you decide, doc" mentality that leads the physician to regress to "Type 1" decision-making.

The DMCB isn't too sure how TEDTalk's Dr. Iyengar's suggested solutions can help the folks in the White House Situation Room, but the DMCB wonders if the national security staff shouldn't have done a better job of presenting the Commander in Chief with 1) a limited number of choices that were 2) more "concrete," as well as 3) arranged into categories with the 4) low complexity options offered first. 

That 4-fold approach could help docs and patients too.  The DMCB looks forward to additional research in the area.

In the meantime, there is one additional medical rule that has withstood the test of time that may also be useful in dealing with Syria. The DMCB offers it up to business and politicians alike: primum non nocere.