It is astonishing with how little reading a doctor can practice medicine, but it is not astonishing how badly he may do it.
—Sir William Osler, 1901
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Explore This IssueMarch 2012
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Last August, I became the proud grandfather to two amazing kids (see photograph at right). I have to admit, there really isn’t anything better in life than having grandchildren, and after this year is over I hope to really enjoy them. When you experience it, you will understand what I’m talking about.
On the other hand, I have never been less proud of the label “grandfather” than when it is associated with the American Board of Internal Medicine (ABIM) Maintenance of Certification (MOC) requirements.
I certainly am relieved to know that I will never need to recertify, but this feeling is shadowed by a deep sense of shame. As I have always told my kids, “never is a long time,” and it is particularly true here where the consequences could result in less than optimal patient care. This point has been especially troubling to me because of my role as an internal medicine program director for the last quarter of a century.
As a program director at the University of Nebraska Medical Center, I have been preaching education and preparation for the ABIM exam—I’m proud to say that our program leads the nation in pass rate—and teaching residents the important habits of lifelong learning, while I myself have been “above the law,” so to speak. It seems unfair that the oldest among us are immune to this requirement because our certificates are dated earlier than 1990 or because we had enough political power to make sure we were immune when this requirement was passed.
Unfortunately, without a real commitment to lifelong learning, our skills and knowledge might quickly become out of date (as opposed to UpToDate). Osler’s quote is many times truer today than it was a century ago. So, I decided to step up, confront my hypocrisy, and take advantage of all the wonderful recertification programs the ACR has to offer. I wanted to see if an old guy could walk in the shoes of the next generation and really do this!
My Recertification Experience
I have to admit that when I started this process, I was a little smug. I thought I was already up to date. After all, I teach both a board review and the ACR MOC course every year; write textbooks, papers, and guidelines; read at least some of our journals; and go to all the ACR meetings. However, I was humbled by the process in a very healthy way.
Working my way through questions from the ACR’s self-assessment modules (CARE) for the last three years, all of which are reviewed each year at the annual ACR MOC course, not only got me 80 of my 100 recertification points, but taught me many valuable things, some new and some more familiar. I also reviewed in detail the handouts from the MOC and board review course. Who knew that so much was known about autoinflammatory syndromes? For example, while etanercept may be magic in tumor necrosis factor (TNF) receptor–associated periodic syndrome, monoclonal antibody TNF inhibition is contraindicated; testicular torsion is a complication of Henoch-Schönlein purpura; probiotics can cause lactobacillis sepsis in immune compromised individuals; B-blockade, lithium, and angiotensin-converting enzyme inhibition can exacerbate psoriasis; and statins can induce an autoimmune myositis with antibodies directed against HMG CoA-reductase—to highlight just a few tidbits of knowledge. I could literally go on for pages about the disease states and clinical practice tools I reviewed.
By the time I showed up for the secure exam. I felt ready to ace the test. (By the way, they are not kidding about the secure part. I felt like it was a “strip” search—I was relieved of my watch, belt, keys, billfold, and ring. My palms were so sweaty that I was afraid they would somehow mess up the “Star Wars” like venous scan that is required to get in and out of the testing facility.)
Although the ABIM fees and time spent completing modules and studying are not inconsequential, there is no denying that I am a better rheumatologist and teacher today than I was a year ago, now that I’ve gone through recertification. This knowledge refresher has already led to better patient care. For example, I recently made a diagnosis of piriformis syndrome, quickly recognized the inadequate bisphosphonate treatment in a veteran with Paget’s disease, and found vitamin D deficiencies in several bisphosphonate treated, but poorly responding, patients that I might have missed without completing MOC.
It seems unfair that the oldest among us are immune to the MOC requirement based on the age of our certificates … So, I decided to step up, confront my hypocrisy, and take advantage of all the wonderful recertification programs the ACR has to offer.
MOC Tools from the ACR
For its part, the ACR has worked hard to help make the recertification process as educational—and painless—as possible for members. The ACR has a full lineup of rheumatology-focused learning modules that can earn you the full 100 self-evaluation points needed for MOC, including the Continuing Assessment, Review, and Evaluation (CARE) Program, the ACR’s online self-assessment tool for medical knowledge that include relevant clinical case-based questions reflecting the content areas ABIM uses for the rheumatology MOC exam. Each CARE module contains 75 unique questions and grants 30 MOC points upon successful completion. There are always three CARE modules available; each September, a new module is released and an old one is retired.
Assess, Improve, Measure (AIM) modules are the ACR’s online self-assessment tools for practice performance and improvement. In AIM, physicians develop and implement an improvement plan for their practice based on their de-identified patient data and evidence-based quality measures. Physicians can choose to enter rheumatoid arthritis (RA) patients with AIM:RA or gout patients with AIM:Gout. Twenty MOC points are awarded for successful completion of an AIM module, and it is free to participate.
In addition to its online modules, the ACR also provides two live settings for MOC exam preparation. Each spring, the ACR holds the Rheumatology Maintenance of Certification Course, an interactive review course that provides an in-depth look at 14 rheumatology topics and reviews the newest CARE module (I am the RA speaker for this course). This year’s course is in Baltimore. There is also a preconference course at the annual meeting, where clinical experts lead attendees through 25 case-based questions from the ABIM’s latest Update in Rheumatology module.
A Happy Ending
Prior to receiving my exam results, people asked me, somewhat incredulously, “Are you really recertifying?” My standard answer was, “I will let you know when I get the results of the exam.” That is the one perk of being this type of grandfather: if you fail the quiz, you are still certified. I am happy to report that I did pass the exam! In that regard, I want to thank the faculty at both the University of California, San Francisco (UCSF) board review course and the ACR MOC course for preparing me for the exam. I especially want to thank the ACR for putting together rheumatology self-assessment tools, such as CARE and AIM, that make it possible for even grandfathers like me to successfully navigate recertification.
The good news is if I can do it, you can do it! With recertification behind me, perhaps forever, I can go back to being a great grandfather to my grandchildren and a great rheumatologist to my patients.
Dr. O’Dell is director of the Internal Medicine Residency Program and division chief of rheumatology at the University of Nebraska, Omaha and the Omaha VA medical centers. Contact him via e-mail at [email protected].