Update Nov. 26: great news! In today’s NY Times is Gynecologists May Treat Men, Board Says in Switch! Their reason for the change is still totally doctor-centric – even the mention of patients is about “the doctor-patient relationship,” not about the patients’ best interest. But at least they were willing to change their minds. Great!
In the participatory medicine movement, patients learn to be careful, informed partners for their clinicians, and careful informed shoppers for medical services. One thing to look for is board certification. While there’s much controversy (see Bob Wachter’s blog) about the details of the process, board certification is intended to weed out docs who are seriously out of date. And that’s important to patients – more on this below.
But whose interests are top priority? The doctors’, or patients’ and families’?
There’s outrage over a new case in which a top doctor may lose her certification because she’s extending her skills beyond what her board allows. She’s a gynecologist treating men who have a problem where she’s an expert – a non-gyn problem – based on her experience treating women with the same problem.
Caution: for non-medical people, the biological facts may make you cringe. If that happens, don’t think in pictures. But do think about it as striking someone you care about.
It’s about anal cancer, the disease that killed Farah Fawcett four years ago. The disease isn’t the issue – the big question is, for whose benefit do boards certify?
First, a word about why certification matters.
Certification is important
I assert that certification in principle is important, because as the Institute of Medicine published long ago, on average it takes 17 years for half of physicians to adopt a new method. That surely causes harm to patients who go to a doctor trusting they’ll get the best medicine has to offer. But as that study showed, it’s not at all sure that every doctor knows the latest, or will check.
Imagine if your mother (or child) had a severe diagnosis and died. Then imagine, after the death, you learned she could have been saved by new knowledge that was published 15 years earlier. But this doctor happened not to know. This happens, even if the doctor is a wonderful person – it’s not like some docs are Schweitzer and some are schlocks. (A comment on that “long ago” post noted that this is part of a historical trend – the book The Fourth Paradigm notes that it took 264 years for the scurvy cure to become universal!)
Part of the remedy for this is for patients and families to engage in their care, learn what they can, and ask questions. As our e-patient white paper said in 2007:
… adopting the traditional passive patient role and putting oneself in the hands of a medical professional may be considerably more dangerous than attempting to learn about one’s medical condition on the Internet.
The other part of the partnership is for clinicians to learn what they can, ongoingly. And that’s part of why certification exists: you can’t pass certification if you’re out of date.
(And mind you, the 17 years is for half of doctors to get on board. Who knows how long the rest take. I read one doctor’s comment on the subject (I can’t find it now) where he said “I was licensed to practice 32 years ago. How dare you suggest I don’t know what I’m doing??”)
As I said above, there’s lots of argument about how certification is done. But for this case the point is that certification is of value to patients.
Should other purposes outweight patient need?
I’ve heard that the certifying boards often point to an additional value: certification is a way for a specialty to ensure its own integrity. For instance, what if a skilled and certified physician also indulges in shady side businesses?
- Should that physician be allowed to sport the badge of board certification, as a claim of his/her trustworthiness?
- What if the shady side business is within the speciality?
- What if it’s outside the specialty?
And even trickier, what if it’s for a skill within the specialty, being applied to someone else?
And that’s what’s up in the current case: Boston OB/GYN Dr. Elizabeth Stier is an expert at treating anal cancer in women, and has been applying the same skills to men. As you can read in the NY Times piece, this affects not only current practice but a major new study that will be delayed (or even prevented) if those most expert in the field (OB/GYNs) are barred from participating.
I’m open to discussion, but here’s my concern:
If certification becomes seen as focusing on doctors’ needs, not patients, it will no longer be clearly relevant for patients. It will become ambiguous: “Maybe I need to also seek good docs outside the certification rules.” That would be tragic.
I’m not for a moment disputing the need for a profession to enforce its integrity. I’m simply saying, when patient needs and professional needs collide, which outweighs the other?
I think the answer goes back to Hippocrates – “first do no harm” – and I hope the leaders of this board will agree. They are faced with what must be an unprecedented leadership challenge. It will be true tragedy if more deaths result because a profession inadvertently put a higher priority on its own needs than those of patients – patients of all sorts.
I mean, isn’t is wonderful if a profession’s skills suddenly benefit more patients?
The American Board of Gynecology’s decision is about protecting the image of gynecologists as doctors for women. It’s probably a good thing for women that there is a specialty dedicated to preserving their health and treating diseases unique to their sex. It’s also a good thing that pediatricians dedicate their efforts to treating children. However, many pediatricians continue to follow patients with childhood chronic diseases into adulthood. Although a transition to adult care is desirable, in some cases the value of the long-term care relationship supersedes the expediency of transitioning these patients to adult primary care physicians.
Many patients may be surprised to learn that some medical boards issued life-certificates to its diplomates (see http://www.abim.org/) and do not require all of their diplomates to recertify. I certainly know outstanding physicians who continue to practice under their original certification despite 30 years lapsing since achieving certification. However, I don’t think these boards had patients in mind when they grandfathered some of their members into life-time certification.
Thanks, Jorge – good to meet you.
What do you think about the question, of what to do when a profession’s needs collide with patient needs? Or in this case do you feel that’s the wrong question to be asking?
I think a professional society needs to advocate in tandem for the needs of patients along with the needs of its members. I don’t think the American Board of Gynecology needs to make a specific statement about the fact they only treat women. It turns out that they make exceptions to the “female only” rule. Their website states “In addition, to remain certified by ABOG the care of male patients is prohibited except in the following circumstances:
a. Active government service,
b. Evaluation of fertility,
c. Genetic counseling and testing of a couple,
d. Expedited partner treatment of sexually transmitted diseases,
e. Administration of immunizations,
f. Management of transgender conditions,
g. Emergency care when the Diplomate is required by their hospital to participate in general emergency care,
h. Family planning services, not to include vasectomy, and
i. Newborn circumcision.” http://www.abog.org/definition.asp
The exception to allow OB/Gyns to perform circumcisions seems arbitrary and is likely provided for the convenience of the mother in hospitals that may have no other qualified physician to perform this procedure.
I think your question is appropriate. Dr. Stier is an exception that could be overlooked or they could specifically add her expertise to the list. The list reveals that they gave considerable thought to the needs of patients in specific situations.
Thanks for the detailed and thoughtful note, Jorge! I appreciate the effort you put into it.
Very thoughtful post. Thank you for bringing up several sides to an argument. Well done.
Amazing reversal of the ABOG’s decision. “Dr. Kenneth L. Noller, the board’s director of evaluation, said board members had reconsidered and realized that gynecologists had a long tradition of treating sexually transmitted infections in both men and women, and that HPV and problems related to the virus fell into that category.” nyti.ms/1fHq6lb
Dr. Stier is calling her male patients back and having them reschedule their appointments.
Appreciate post and discussion – very important topic. Nice the OB/Gyn Board modified their stance and decided to be patient centered (and member centered, too).
I believe in certification (full disclosure: I’m one of those grandfathered old buggers..). Important thing is for physicians to represent and meet the needs of communities, focused on knowledge and clinical decision-making – with excellent communication and partnership skills. So I think key questions are:
1. On what core knowledge and skills should physicians be certified?
2. Who determines content/skills, and how they are measured?
3. How agile and representative are these methods, for community at large and locally (both patients and physician members)?
4. What role do patients and families play in contributing to these methods? Is there participatory design?
My personal preference is that boards let docs get back to people-focused care – medical knowledge and communication skills. Let health systems (who privilege docs) be in the business of population quality improvement (and something they can complete on). There’s only so much time in a visit, on a phone call, in a secure email; if physicians are expected to do everything all the time…something won’t get done. It can never be that patients will lose.