Relevance of Recertification for Primary Care Physicians

IN RESPONSE:

In response to Dr. Aleali's letter, I agree that it is important to stay current to avoid, as he warns, becoming a dinosaur. But I wasn't implying that physicians don't need to stay current and informed. What I suggested was that the current methods of recertification for generalists, particularly family doctors, are burdensome and out of sync with the real world of medicine. This is particularly true for family physicians, but it applies to all physicians who consider themselves providers of primary care.

Most primary care physicians customize their practices over time and according to the types of patients they see, procedures they do, and diseases they feel comfortable treating. This customization even includes the number of patients they see per day, whether they use or do not use physician extenders, and the number of specialists in the area.

The point is that after 10 or 15 years, if not sooner, some skills and knowledge that a physician had at the end of residency are no longer relevant. Physicians are much too busy dealing with regulations, the ever-increasing demands of patients, and administrative red tape to take time off for board review courses, and many of them cannot afford the time off and the costs involved.

As Dr. Aleali says, many unusual diseases may present, and it is important to be aware of them. But these are matters of judgment more than rote memory. If a physician's judgment is good, he or she will recognize when a patient with an unusual set of symptoms or signs presents and will seek consultation. Most errors in medicine are not because of lack of knowledge but because of poor judgment or poor timing in getting consultations.

It seems ironic that trying to conform to the boards' vision of what a generalist is has caused many generalists to come close to the “dinosaur” status that Dr. Aleali mentioned. How? Because by trying to do it all and know it all—in the hospital, intensive care unit, office, and nursing home—many generalists have spread themselves too thin. This creates a vacuum that has been filled by physician assistants and advanced practical nurses. In this context, maybe generalists are already on the way to becoming dinosaurs. As the saying goes, the road to hell is paved with good intentions. In fact, the “generalist” of the future just may be one of these midlevel providers, and current generalists may end up being medical managers.

For generalists in particular, the boards need to change their focus. They should uncover areas of weakness in a physician's practice and offer remedial study, and they need to move away from the current pass/fail approach. If a physician has passed initial certification or is board-eligible, that should be sufficient to take the tests and qualify for remedial education.

The very name “board certification” implies a degree of excellence that is not necessary to deliver good medical care. Its significance is more academic than practical and is more appropriate for teachers in medical schools or residency programs and anyone who simply strives to acquire certification as a personal accolade.

Finally, although the boards are said to be voluntary, many doctors are afraid of being dropped from HMO panels if they are not board-certified. In this sense, the boards are anything but voluntary. In fact, they are coercive. Many primary care physicians believe that the boards need to change.