Reconsider PPS Recertification Exam

Dear Colleagues,

I have recently become aware of some discouraging developments in the field of Pediatrics in the Philippines. The Philippine Pediatric Society (PPS) has started to require all diplomates board certified from 2005 onwards to take recertification exams every 5 years until one becomes a fellow at the end of 10 years. The only other option to decrease the number of recertification exams is to be the senior author of a research paper which can prove to be challenging financially and time-wise for the newest batch of pediatricians trying to start their own practice after years of hard work and sacrifice.

The recertification for the first batch of diplomates did not push through last year, leading to questions about the whole process and leading to the petition that I have included here. The letter of appeal addressed to the PPS officers and Board of Trustees is quite lengthy, obviously borne out of a passionate concern for the future of the field of Pediatrics and the quality of care provided for the patients. If you feel that it reflects your sentiments and opinions related with this matter, I implore you to sign and to lend your support to these young doctors.

Sincerely,
Lee Camarillo-Villanueva MD
UPCM 2000
PGH Pediatrics 2003

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To the PPS Officers and Board of Trustees:

This is a letter of appeal regarding the implementation of recertification of diplomates.

We understand that there is a need to constantly upgrade the level of care that every pediatrician offers to every Filipino child and that the Philippine Pediatric Society continuously comes up with innovative ways to take on this challenging responsibility.

However in this particular venture of the Society requiring diplomates from 2005 and onwards to get recertification every 5 years, we find this an additional burden which we believe to be superfluous. We already went through the lengthy and rigorous process of graduating from medical school, passing the board exam to acquire a license from the PRC, finishing a residency training program accredited by the PPS and finally being board certified. Yes, the medical field is a never ending learning process but does it really require another exam, another certificate to ensure that such continuous learning is actually being obtained by all? What is the evidence that this will actually translate to better management skills and not just add one more burden to the young doctors whose training is in fact actually more current? This is the conclusion of a study published in the Journal of Evaluation in Clinical Practice (Vol12, Issue 5, pages 473481, October 2006 Does specialty board certification influence clinical outcomes? by Eric N. Grosch MD) No evidence supports the touted clinical benefit of specialty board certification. Specialists in clinical medicine and surgery are unamenable to simplistic evaluation by examination, yet specialty board certification remains an ersatz standard of doctors clinical quality in the absence of supporting evidence. Intuitively, regular assessments are obviously in itself good. If it is that good, why not make it applicable to all.

Although we were informed before we became diplomates that our certificates will now carry a limited validity period, we are regretful that it is only now, after being in actual practice that we fully understand the implication that such recertification entails. We were so focused on overcoming that last hurdle to finally become full-fledged pediatricians, attaining board certification, that we didnt give any thought regarding the new policy. We also noticed that the more recent certificates did not contain any expiry date so we thought that the Society reconsidered its implementation. Furthermore, when there was no news regarding the recertification exam last year, we were misinformed that the PPS will not push through with it anymore and that a new certificate will be furnished for those whose certificate already expired.

Seeing an expiry date on our certificate somehow belittles and negates all the hard work that went into becoming a certified diplomate of the Society. What will be our status then if we are not able to take the recertification exam? The need for a recertification program somehow implies a measure of distrust in physician qualifications. The diplomate board exam is the culmination of all those years of training, from the very basic skills of auscultation, palpation, percussion to the more complex symptom oriented case solving. Is it possible to unlearn these skills and knowledge that already went through validation during the written and oral exams? Once board certified, we strongly believe that nothing should invalidate that status considering the methodical and laborious process that every member had to go through during those long years of training and countless exams to acquire such skills. We are after all products of PPS accredited hospitals which should be more than enough assurance of our core competencies. Inability to comply on our part for whatever reason will surely drive us out of our practice since being board certified is a requirement to obtain both hospital privileges and access to health insurance plans. We would like to believe that such is not the intention of the recertification but it will definitely be the anticipated outcome.

If the Society wants to pattern our policies to that of the American Board of Pediatrics, do we have the resources (time, technology and finances) that they do to be able to implement such an elaborate system? The American Board of Pediatrics provides members with options on how to acquire the necessary points to be certified in the form of web-based modules which tackles several relevant day to day health issues you can choose from based on what you think you need the most help with. Their modules are based on self evaluation of medical knowledge. This is more responsive to the needs of the members which unfortunately also entail a lot of time and collaborative work. Although these on-line modules are most welcome, this is not to say that we agree with the every 10 years recertification being required by the American Board of Pediatrics in compliance with the American Board of Medical Specialists which was actually borne out of government and public policy pressures.

Also, if the Societys purpose for requiring recertification is to constantly update its members in providing sound, evidence-based management, why stop after 10 years once you are granted the status of a fellow? Shouldnt this be a lifelong commitment for all pediatricians and not just for those who became diplomates from 2005 onwards? Longer number of years in practice does not necessarily translate into better clinical skills if the management is not always rational and is not guided by current standards of care. A systematic review of 62 studies showed that most found declines in physician performance with greater numbers of years in practice: decreasing medical knowledge; less adherence to the standards of appropriate diagnosis, screening, preventive care, and therapy; and worse actual health care outcomes. Also, clinical skills tend to decline over time, and more clinical experience does not necessarily lead to better outcomes or improvement of skills. ( Davis DA, Mazmanian PE, Fordis M, Van Harrison R, Thorpe KE, Perrier L. Accuracy of physician self-assessment compared with observed measures of competence: a systematic review. JAMA 2006;296:1094-102.Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: the relationship between clinical experience and quality of health care. Ann Intern Med 2005;142:260-73.) If the Society is determined in its effort to uphold that standard then its activities geared towards such goals should include all members regardless of status.

We understand that the recertification cannot be implemented retroactively; therefore, we urge the Society to consider other measures apart from recertification to ensure that ALL of its members are constantly aware of current protocols and guidelines. Instead of using the certificate as a means to this end, the Society can come up with a teaching tool much like a CME that all members are encouraged to take, but not to lose the board certified status if one is unable to comply. Physicians should be enrolled in activities maintaining medical education but it should not be tied to maintaining certification and the consequences that are attached to that label.

Continuing medical education is fundamental but it can be done without the need for recertification. Meeting the required continuing medical education should be enough to maintain ones certification once obtained. Test taking ability doesnt make one a better physician. It is good to know that there are established guidelines, consensus and policy statements which we can refer to but these are not absolutes. Its purpose is to equip us to be able to come up with well-informed decisions. Ultimately it is the suitability to our patients condition which will dictate our management. Much as we would want to standardize and regulate every doctors decision-making process, such cannot be done because treating patients is still an art which makes it difficult to be evaluated in any exam.

In this age of the internet, most data regarding various treatment options are now accessible and it remains our individual responsibility to translate it into patient care. Recertification when taken in this context actually occurs every day.

Unless there is another reason for the implementation of recertification, we are appealing for reconsideration regarding this matter.

In a paper entitled AAPS (Association of American Physicians and Surgeons) Survey: Physicians Skeptical of Recertification published in the Spring 2009 Journal of American Physicians and Surgeons, Volume 14, No. 1, they concluded that in the view of the majority of physicians belonging to AAPS, recertification as currently performed is not a good measure of clinical competence. Only a minority believe it to be of sufficient value that they would participate if it were fully voluntary. Conflicts of interest, examiners biased opinions on treatment, and political agendas were pointed out as flaws in the process.

We would also like to present the AAPS proposed resolution on mandatory maintenance of certification posted August 11, 2010, seeing as most of the statements here reflect our own take regarding this issue.

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Mandatory Maintenance of Certification

Whereas: physicians are among the nations most rigorously trained professionals, and
Whereas: requirements for maintaining the skills needed to serve their patients vary greatly depending upon their patient population and chosen set of treatments offered; and
Whereas: no one is in a better position than the individual physician to determine how best to maintain the needed skills, and
Whereas: other professionals such as lawyers are not subjected to mandatory recertification requirements; and
Whereas: certification requirements are costly and time-intensive, requiring significant disruptions in availability of the physician for patient care; and
Whereas: there is no evidence that mandatory recertification results in any improvement in patient care; and
Whereas: there are significant conflicts of interest in agencies approved to set the requirements; and
Whereas: more than half of the highly qualified and respected faculty members of one of our best universities failed the mandated recertification examination, without any evidence that the problem was with the examinees rather than the examination; and
Whereas: constant externally imposed study requirements tend to enforce conformity rather than encourage the independence of thought essential for professionals; and
Whereas: mandatory recertification is likely to reduce access to care by encouraging retirement of physicians who are providing excellent, much needed care; and
Whereas: mandatory recertification empowers government and disenfranchises patients and professionals;

BE IT THEREFORE RESOLVED THAT:
AAPS oppose mandatory maintenance of certification, and encourage physician to strive constantly to improve their care of patients by the means they find most effective.
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We are fortunate that physicians from developed countries who have had firsthand experience with this system since the 1980s have already seen the lack of wisdom in requiring recertification and how hospitals and insurance companies have taken it on themselves to impose maintenance of certificate requirements, going so far as to base privileges and reimbursement decisions on recertification in effect, attempting to regulate who practices medicine. We as physicians practicing in a still aspiring to become a developed country neither have the luxury of time and financial resources to adopt a policy whose eventual outcome remains to be uncertain.

To present the practice of medicine in a broader perspective, here is an excerpt from an article entitled The True Value of Board Certification by Keith L. Martin (September 8, 2010)

From Dr. Eric N. Grosch, a former practicing internist and current law school student:

Patients tend to believe that, if only physicians were well-enough educated, well-enough trained, skillful enough, knowledgeable enough, certified enough, all would be well. Physicians could then assure or guarantee clinical outcomes. Because some patients experience bad outcomes, the belief is that their physicians must not be well-enough educated and trained, skillful enough or knowledgeable enough to have produced favorable outcomes, especially if they do not hold board-certification. Comfort through a physicians assurance (i.e., guarantee) of a pre-determined, certain and favorable clinical outcome is an ancient quest. Patients long for deterministic certainty in our stochastic universe. Ierodiakonou K, Vandenbroucke JP. Medicine as a stochastic art. Lancet. 1993 Feb 27;341(8843):542-3

Certified, has Latin roots in certus (true), and facere, (to make), and the term applied originally to attesting authenticity of documents. Certifying authenticity of inanimate documents is rational but certifying physicians in hope of pre-determining their performance is not. Toulmin [2] emphasized the uncertainty and ambiguity that make guaranteeing medical care unfeasible. Toulmin S. (1981) On the Nature of the Physicians Understanding. Journal of Medicine and Philosophy. February:1(1):32-50 @44
Katz addressed the ethics of guarantees in medicine. [Physician and patient] are voyagers on the high sea of uncertainty. . .Acting out of fear that...acknowledgment of medicines limitations will drive patients into the arms of quacks has its own dangers. In promising more than medicine can deliver, physicians adopt the practices of quacks ... Katz J. (1984) Why doctors dont disclose uncertainty. Hastings Center Report. Feb;14(1):35-44

As members of the Philippine Pediatric Society, allow us to make the following suggestions.
1. That the decision and the objective behind the requiring of recertification be reviewed
2. To discontinue putting expiry dates on the certificates and furnish new ones to those who were issued time-limited certificates until such time that the society finishes reviewing this matter
3. If the society still wants to implement recertification, to make it a voluntary activity and offer incentives for those who wants to subject themselves to the process. Again, not to take away something that was already painstakingly attained.

We hope that we were able to efficiently present our viewpoint in a constructive manner. The statements written herein are not meant in any way to disregard the societys efforts in the pursuit of the betterment of its constituents but to merely communicate our reservations and ask that the members of the board give careful consideration to our petition.
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