In a span of just 20 years, medicine has done an about face on how chronic pain should be managed. The spike in opioid prescriptions that occurred following the publication of some falsely reassuring insights helped fuel the rise of addiction disorders. Indeed, drug addiction remains a serious concern in any cohort of patients who are prescribed opiates. How did we err so badly? Small clinical trials, retrospective reviews and anecdotal case reports were blended together to generate conclusions that seemed to be inherently true, although they, too, proved to be illusory. The lack of prospective randomized studies in this field was costly, leading physicians to miss the forest for the trees.
Many examples exist of medical care being based on supposition and false assumptions. Whether it was advising extended bed rest for relieving bouts of sciatica or following an acute myocardial infarction, prescribing chronic high-dose NSAID therapy for the management of osteoarthritis or promoting the prolonged use of bisphosphonate therapy to treat low bone density, we often missed the mark. Medical progress stagnates or regresses when doctors rely on intuition or gestalt rather than solid scientific evidence to support their hypotheses.
Where Are the Data?
Physicians and their patients more readily accept decisions that are evidence based, and the paucity of such information creates voids and, hence, confusion. The lack of clear, concise data is currently clouding the highly contentious issue of medical recertification—or how doctors demonstrate to the regulatory authorities and the public that they are up to date in their training and knowledge of their specialty. Proponents of the maintenance of certification (MOC), which is required of all physicians who have gained specialty certification since 1990, maintain that this process more closely links learning goals with the delivery of better medical care and measures of greater accountability.4 MOC requires most specialists to seek recertification on a periodic basis, typically every 10 years, by successfully completing a four-part assessment designed to test their medical knowledge, clinical competence and skill in communicating with patients. The MOC program was initiated in 2000, but the pace of recertification has accelerated since 2009. Approximately 375,000 board-certified specialists and subspecialists, or about half the number the 24 specialty boards certified initially, meet MOC requirements, according to the American Board of Medical Specialties (ABMS).4
The debate has grown acrimonious, with opponents of MOC setting up online petitions urging physicians to boycott the entire process. They argue that the process is onerous, time consuming, too costly (approximately $3,000) and lacks value. For example, one activity requires candidates to document how the quality of care they provide compares with that of peers and national benchmarks. They must then apply the best evidence to improve the care they deliver with the use of follow-up assessments. Although these are worthy goals, there is currently little consensus among rheumatologists regarding what constitutes true quality care and how it can be properly measured. This whole field is still in its infancy and must still pass several hurdles before it can gain widespread acceptance.
