There are things a Doctor shouldn’t say

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By: Justin Vandergrift

Just before Christmas I was forwarded a New York Times ‘Op-Ed’ piece written by Dr. Danielle Ofri.  Dr. Ofri argues against re-certification for physician specialties that occurs once a decade. 

This article made my blood boil.  Essentially Dr. Ofri’s article can be simplified down to the following:  she believes her time is worth more than the value of re-certification to her patients.   Remind you that re-certification takes place only once every ten years, two months of studying during 120 months of practicing medicine.  To the consumer of healthcare re-certification means more than simply taking a test.   In fact the real benefit of re-certification for the patient comes not from the test but from physician involvement in quality improvement.   This was a vital point that Dr. Ofri failed to mention in her article.

Background 

I am always weary of the perfect example and in this case my story is indeed just that – I am the parent of a child with Crohn’s disease.  I have first-hand experience with both board certification and the benefits of maintenance-of-certification.  I have seen the difference it makes in the quality of care for so many nameless and faceless families who suffer in silence.

In February 2011 my wife and I took our daughter to a gastroenterologist (GI) at a children’s hospital in our hometown.  Her pediatrician sent over her blood work to the GI in advance of our visit.  The GI mentioned to me that her blood work indicated she might have Inflammatory Bowel Disease (IBD) but it was inconclusive.  He performed an endoscopy (a scope of the throat, stomach and a small portion of the upper small intestines) and sent us home with Omeprazole in prescription form, a common acid reducer available over the counter at any pharmacy.

Through the spring my daughter continued to get sick and he increased the dose of the medication.  Finally in August we went to another children’s hospital in town, Levine Children’s Hospital, and met with Dr. Ricardo Caicedo and his team.  The clinic performed a battery of tests, one of which was a colonoscopy (a scope of the colon and a small portion of the lower small intestines).  These tests confirmed that she did indeed have very active Crohn’s disease throughout her GI Tract.

Last Christmas Eve marks the third anniversary of my daughter’s bowel resection.  My wife and I sat in a waiting room at 3:00 pm on Christmas Eve 2011 hoping that our little Kathryn would come out with her trademark smile intact.  Kathryn’s resection was the result of active disease left untreated for months.  I will always wonder if the issues she has on an ongoing basis are footed in those months where she was treated with only a common acid-reducer.

I bear the guilt of failing my daughter because I later learned the first GI was board eligible, but not board certified.  (In fact, I later learned he failed his boards and is no longer practicing medicine as a gastroenterologist.)  I assumed the first GI had the qualifications necessary to treat my daughter.  My assumption cost my daughter things I can never replace.   The pain she suffers on an ongoing basis shames me because I feel I failed her as a parent.

Dr. Caicdeo is board certified and participates in a learning healthcare network (ImproveCareNow) which helps with maintenance-of-certification for gastroenterologists, the process the Dr. Ofri disagrees with.  One of the requirements of maintenance-of-certification is evidence of meaningful work in quality improvement.  (For full disclosure I am the Assistant National Parent Lead for ImproveCareNow’s parent working group and the co-leader of the Strategy Council for ImproveCareNow.)

Quality Improvement

To a patient there are no better words than quality improvement.  Quality Improvement means just what it implies – improving the quality of care delivered to your patients.  Having a chronically ill child opened my eyes to what healthcare has become.  I live in a moderately large city, and the two hospitals I mentioned above are less than four miles from each other.  Geographically they are close, yet the care received at each was drastically different.  In 2015 it should not matter if you live in a rural part of the United States or in a large city, your care should not be different – but in many cases it is.  This is why maintenance-of-certification and quality improvement is so vital to the patient.  It can offer all patients, regardless of geography or social-economic standards, the same type of care.

I can attest that my daughter’s care is better with her current doctor and his team.  We see the face of Dr. Caicedo at each visit, behind him is ImproveCareNow, a community of improvers—clinicians, parents, patients, and researchers—armed with knowledge from a database of 19,000+ children with IBD.  He can reference and use the data from this group to better treat my daughter and the rest of his patients.  Through ImproveCareNow  Dr. Caicedo has access to data, best practices, and a community of those working with thousands of kids like Kathryn, in hospitals around the country.

The proof is in the data

One point Dr. Ofri references is a marginal difference in outcomes from the re-certifying group.   When someone you love is sick 2.5% might be the difference between a good day and a bad, maybe even life and death.  When people throw around statistics it is often an attempt to desensitize the true impact of them.  It doesn’t matter what the unemployment rate is if you are the one that is unemployed.  Chances are that you or someone close to you will suffer from a chronic condition during their lifetime.  You might fight daily for a 2.5% difference.  Given a large enough sample size and 2.5% could mean impacting the lives of tens of thousands of people.

Speaking specifically to IBD, outcomes are improving substantially.  Remission rates for Inflammatory Bowel Disease patients treated at ImproveCareNow centers have increased dramatically since 2007.  Less than 10 years ago the remission rate (remission meaning non-symptomatic) for pediatric GI clinics was around 50%.  Your child had coin-flip odds on whether they would be in remission or not.  Today that number is approaching 80%.  (https://www.youtube.com/watch?v=1nVabFuOWho)

Another chronic disease which has seen dramatic improvements in outcomes is Cystic Fibrosis (CF).  The Cystic Fibrosis Foundation has been collecting data on CF patients since the 1950’s.  In the 1950’s most CF patients were not expected to finish elementary school, however today the life expectancy is approaching 40 years.  Compounding the ‘marginal 2.5%’ Dr. Ofri dismisses makes huge differences over time.

The trust factor

Most patients expect three things when they visit a doctor.  These things are trust, qualification and commitment.  You trust they have your best interest at heart.  You assume they are qualified to speak with authority and you assume they are committed to your best outcome.  I trusted our first GI doctor, I assumed he was qualified to speak with authority and that he was committed to our best outcome.  He might have been committed to my daughter but he did not have the authority to treat her.

The maintenance-of-certification process ensures the patient’s vision is aligned with the physician’s professional standards.    Certain occupations have higher responsibilities because they touch the lives of so many people.  Healthcare, education, clergy and law enforcement are a few of those occupations where there is substantial trust given to those that hold the position.

Would you want your child to be taught by a teacher who did not keep up with advances in math and science, or who stopped teaching history that happened AFTER they graduated from college?  Would you want a police officer who argued against gun safety classes?  Short cuts should not exist when lives matter.

Why would a doctor publicly argue against making themselves better?

 

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