Letters

MOC triggers resignation

To the Editor:

A fter reading "Are You Ready for Maintenace of Certification?" [January 2005, page 42], I believe the American Board of Family Medicine is out of touch with practicing family physicians and the pressures we face today. The current certification and office record review requirements are more than adequate to assure the public of qualified family physicians. The new maintenance of certification program is unnecessary. The board has voted; the membership now needs to vote.

I will not participate in the maintenance of certification program, and I regret that after many years of membership, I have resigned from the American Board of Family Medicine.

Stephen Welk, MD
Holland, N.Y.

MOC implementation unfair

To the Editor:

I took and passed the board exam this summer. Except for the registration process, the computer test went pretty smoothly. Later this year I'll take the first self-assessment module.

My complaint is about the way the new requirements have been rolled out. Two of my partners and several other doctors I know took the boards in 2002 and will not have to start self-assessment modules until 2010. My unlucky partner and I will have taken a collective 22 self-assessment modules before those doctors even begin. My partner has so far refused to take his 2004 module. I guess I will take mine, but I am concerned I will be wasting my time and money if this requirement is changed.

Glenn Mizarch, MD
Richmond, Va.

Grace period could make MOC less time-demanding

To the Editor:

Once again family physicians need to stand united. We failed to do so against the large insurers and managed care, and look where that got us. Now we need to band together and explain that if not for the diplomates there would be no American Board of Family Medicine.

I would like to know how many in the ABFM hierarchy have to bother with the maintenance of certification requirements. I suspect many have given up active practice. Perhaps if more had to be subjected to the process there would be improved communication and responsiveness on the part of the organization.

Perhaps we could ease our burdens by allowing the maintenance of certification process to be completed in a seven- to 10-year cycle. If a diplomate manages to fulfill those requirements in six years, he or she could have a one- or two-year grace period in each cycle to lay low before recertification starts all over again.

The ABFM needs to think outside the box, look at what is being required by other boards and find some middle ground. I am all for practicing great medicine and improving care, but at what cost?

Karen Suttle, MD
Irving, Texas

Days too short for MOC

To the Editor:

I think the members of the American Board of Family Medicine must have forgotten what it's like to work 12-hour days, make hospital rounds, see 35 to 40 patients in the office, dictate charts, answer patient calls, respond to nursing home faxes and get home in time to say good night to your family. Add the issues of declining reimbursements, escalating overhead costs and rising malpractice premiums, and you've got a formula for disaster.

I became board certified in 1983 and recertified in 1990 and 1997, but I have opted not to pursue MOC under the new guidelines because of time constraints. The best way I can serve my patients is to continue to get CME hours that I deem pertinent to my practice, work long hours and be available to meet my patients' needs, and refer them to the appropriate specialist for those problems beyond my abilities.

Paul Houston, MD
Brazil, Ind.

Enough is enough

To the Editor:

After 23 years of practice and four board exams, I feel despair about the new maintenance of certification process. Why do we want to further complicate our already stressed lives? Is it not enough to comply with the old recertification requirements, in addition to completing 150 hours of CME every three years? I say enough is enough!

We should concentrate on more pressing issues such as maintaining control in decision making in the context of intrusions by insurance and government organizations, addressing the malpractice crisis, and ensuring that our patients have access to affordable prescription drugs. The AAFP should be our voice. The American Board of Family Medicine should be our certifier, not our dictator.

Luis Garcia-Rivera, MD
Jacksonville, Fla.

Asthma Days worth further chronicling

To the Editor:

"Asthma Days: An Approach to Planned Asthma Care" [October 2004, page 43] left me feeling that I was reading the first chapter of what may become a really good book. Dr. Kurtis Elward and his colleagues have taken the courageous step of trying something new in the care of asthma patients and then exposing their results to critics like me.

Beginnings are always messy, as the old saying goes, and the published report asks as many questions as it answers. I would like to thank Dr. Elward for providing me with the following information, which adds context to his published report: Family Medicine of Albemarle is a three-physician practice (now adding a fourth) with 1.5 FTE physician assistants and a patient population of about 10,000. The project began with identifying patients with asthma who had not visited the practice in the previous year. They also included some who had been seen more recently but not often enough to meet their asthma care needs. The intent was to improve the effectiveness of asthma care through a structured, focused program of evaluation, education and fine-tuning of treatment.

Dr. Elward's report indicates that the initial Asthma Days generated increased revenue, but it does not provide parallel data on the staff, overhead and material costs that would have been incurred if his associates had lacked free time to conduct the program. Also, we generally assume that increased expenses for tests and medicines are justified by their benefit to patients, but the correlation between price and benefit is sometimes weak, and the continuing explosion in health care costs puts a burden on us to think seriously about the financial impact of our approaches to patient care.

Did the program reach the people it should have reached? Sixty percent of patients invited to attend the first round of Asthma Days did so. Of these, 65 percent attended at least one timely follow-up visit. It would be instructive to find out who the non-attenders were: Persons with only mild, infrequent bronchospasm? Hard-core noncompliers? Timid people who are reluctant to talk about their problem in public? There may be a need to reach out to some nonattenders, perhaps by telephone, to identify and address their concerns.

One final question for consideration: Did the program improve outcomes? Simple "happiness scores" and unsolicited comments aren't enough. The evaluation process might look at emergency department visit rates, calls for rescue medicine prescriptions, serial peak flow rate measurements and days lost from work or school. It would also be good to demonstrate that Asthma Days participation helps patients enough that they feel less burdened by their disorder and more in control of it.

There is room for improvement in any program, and Dr. Elward's is no exception. However, the foresight he has demonstrated in establishing such a program leaves me with little doubt that he will continue to fine-tune it over time.

As yet another old saying goes, the turtle never gets anywhere until he sticks his neck out. We need more family physicians like Dr. Elward and his associates, who will ask the right questions and then pursue the answers diligently.

Robert D. Gillette, MD
Poland, Ohio

Author's response:

I appreciated the interest shown in "Asthma Days" and the keen attention to the essential questions we as family physicians face in developing clinical quality improvement ideas. The article was not intended to be a research study, and many of the details of interest to Dr. Gillette lie outside the scope of the article. However, I would like to respond to several important questions.

First, the only additional costs for the program were the mailings ($1 each) and three nurse orientation/training meetings that were held at noon. The program was designed to fit into normal patient care hours.

Second, we did not increase expenses for patients as a result of the program. We provided the standard of care according to evidence-based medicine and national guidelines, not by performing excessive testing. This approach helped us do for asthma what all studies should: decrease costs for a population of patients.

I also share concerns about making people "feel good" without improving their care. In fact, as the article mentions, in addition to happiness scores, rates of classification and prescriptions of inhaled steroids were markedly increased.

We are developing a more formal evaluation of the Asthma Days concept, one which I hope will address the excellent questions raised and, more important, better define ways to enhance the care of our patients with asthma.

Conflict of interest

To the Editor:

It is hard for me to overlook the major conflict of interest in Dr. Robert Rowley's article boasting about his clinic's wonderful experience with their electronic health record ["Practicing Without Paper Charts," March 2005, page 37].

If the view was from anyone else except the founder and chairman of the software company, then the article might have some credibility. The way it stands, it sounds too much like a free advertisement for his electronic records system.

Song Y. Lee, MD
Colleyville, Texas

Editor's response:

FPM asks every author to complete a form disclosing conflicts of interest. We alert readers to conflicts that we consider to be material and reject articles where we deem the conflict to be too great.

Because Dr. Rowley's article focuses more on the workflow changes that accompanied the introduction of an electronic health record system than on the merits of any given system, we did not consider the conflict of interest he had sufficient to justify rejection of the article.

EHR vendor rating tool

The instructions in the EHR vendor rating tool published in the February issue ["How to Select an Electronic Health Record System," page 55] included instructions that may have confused some readers. A more user-friendly version of the form, with modified instructions, is available on the FPM Web site at http://www.aafp.org/fpm/20050200/ehrvendorrating.pdf.

Send comments to fpmedit@aafp.org.

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