Do What’s Right

Posted on December 8, 2023 by marylbrandt

I have the extraordinary of gift of sitting with my father in hospice this week. His (beautiful) heart is failing, but his mind is still sharp, and his spirit is completely at peace. The following is his last lecture as a professor (to his graduate seminar in Business Ethics)

It gives me great joy to share it with you.

Retiring is a little like having your first child. There is nothing particularly unique about the exercise except it is a first time experience that requires no specific skills or expertise and arrives with an unknown outcome .

The initial inclination while preparing comments for a last class is to draw from all the literature and all of one’s experiences to craft some statement filled with lasting words capable of shaping the hearts and minds of students for their remaining years.

Shortly after entertaining such a prospect, it became immediately apparent that teaching has taught me that that while the words may be forthcoming, the impact is not likely to be so resounding. Given that reality, the best course of action is to make a few short comments and say good-bye.

The closing line from Stephen Sondheim’s song “Send in the Clowns” came to mind. “Isn’t it rich, isn’t it queer, losing my timing so late in my career.”

In these last few minutes of the last organized university class that I will teach, I would like to suggest to each of you:

Define what is important to you. Attempt to determine what you are worshiping, because without that understanding, you are adrift and likely to be pushed ever-which-way.

Come to terms with the finite and the infinite dimensions of your being. Until you come to terms with the end of your existence, you will find living in the present to be difficult.

Cultivate the disciplines necessary to contend with the vagaries of the world around you. Perhaps the most important are the disciplines of the mind and of the spirit. The first step is often that of finding a quiet place to meditate and contemplate.

Learn the significance of uncertainty, choosing, and evaluating and then celebrate them. The definition of who you are is largely a product of the questions you ask and the choices you make. It is difficult to learn that the choices made today are the offspring of choices made yesterday.

Experience the joy of thanksgiving. Recognize that joy and hope are rooted in faith in the belief that what you have and what you are is a gift. As much as possible expunge the demons of comparison and competition and accept that sweeping out the harpies circling round the “enthroned self” never ends.

But then how does one end a last class in ethics except to recall that ethics is obedience to the unenforceable; a product of what you ask of yourself and not what others ask of you.

And finally, do whatever is right.

Things I Wish I’d Known From the Beginning: Informed Consent

Posted on August 3, 2023 by marylbrandt

“Can you go get the consent?”

New interns and their more seasoned senior residents are asked this almost every day. So let’s talk about this for a minute and what that question really means…

What you are being asked to do.

The hospital requires a signature on a consent form (always printed with very small font and several pages long). This part of the consent process that has a long history guided primarily by legal counsel for hospitals and, yes, you need to get the signature. But…

The signed form isn’t the consent.

Maybe I should say that again….

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So what is?

Photo credit – from a great article on disclosing the presence of learners in the OR

There are five things that must be present for informed consent. If any of them is missing, it’s not informed consent.

The patient must have the capacity and ability to understand. (No intoxication, translation when needed, etc).

The patient must actually understand. (This means you have to confirm they understood with a conversation – Can they explain it to another family member? Do they have questions?)

The person performing the procedure (or their designee) must describe the procedure and must discuss alternatives, risks (and how likely they are) and the expected benefits (and how likely they are).

The patient has to agree without coercion. (If you aren’t sure about this, don’t proceed)

The consent has to be documented.

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There are questions that every intern would like to ask about this process but can’t/won’t. Here are a few that come to mind…

What if you’ve never performed (or even seen) the procedure yourself? It’s hard to get truly informed consent if you aren’t competent in doing the procedure. But – you know (intellectually) the alternatives, the potential risks and benefits, and the “big picture” of the procedure. Particularly for complicated procedures, you can assume that the attending has discussed these (and therefore is the person who actually got the consent!). Here’s a way to make this easy… “Hello, I’m Dr [xxx}. I know that Dr. Attending has already talked to you about your surgery. I’m here to go over the alternatives, risks and benefits again – to make sure you don’t have any questions I can take back to Dr. Attending for you.”

p.s. If you are “Dr. Attending” in this scenario, you are the one who is ultimately responsible for the informed consent (and liable if it’s not done properly).

Is it important to get the consent just before the procedure? No, in fact it makes it legally more sound and much more efficient to document informed consent when you first see the patient. For elective or semi-elective surgery, it takes no time at all for “Dr. Attending” to put this phrase (or one like it) in their clinic (or ED) note: The procedure including alternatives, risks, and benefits was discussed with the patient, all questions were answered, and informed consent was obtained. This documentation often holds more water than the signed form (at least according to most attorneys I’ve talked to). Best yet – do both. Get the consent form signed at the same time! It’s easy to scan into the medical record to be there for the day of surgery, which is a win-win for almost everyone involved.

What if It feels like you are scaring the patient/family when you review the list of the possible complications? First of all, that’s a normal feeling. But we have to learn to handle the anxiety that is always part of this process. In addition to trying to be really calm and supportive, here’s how I handle that: “When we decide about doing surgery, we always ask which is riskier… to do it or not do it. For you, we’ve decided together that it’s risker not to do the surgery… which is why you are here. But because there are risks, I want to make sure you understand them and we can talk about them before the operation.”

What if they don’t speak English but the family says they can translate for you? It’s not informed consent unless it’s translated into their language by a professional medical translator. Imagine the shoe on the other foot. What if your best friend the artist was travelling in a country where none of the doctors or nurses spoke English and they needed surgery? They would be terrified and so would any family member who was with them (even – or maybe especially – if they were being asked to translate). Don’t cut this corner. Please.

Isn’t this blog post oversimplified?

Yes!

Informed consent is a fascinating and rapidly changing area of medical ethics. I hope I’ve hit the critical highpoints and addressed a few unspoken questions many trainees have, but it’s unquestionably a “30,000-foot view”.

p.s. If you have more questions, even ones that seem naïve, please comment on this post or email me (if you don’t want them to be public).

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Here are some other great resources to learn more:

American College of Surgeons educational pdf on informed consent

ACS and Association of Surgical Education student curriculum on informed consent

Informed Consent for Academic Surgeons: A Curriculum-Based Update (with links to all the slides for the course!)

Whose Decision Is It? Teaching Students and Physicians About Informed Consent

Informed Consent and Shared Decision Making in Obstetrics and Gynecology

Fantastic You Tube video on obtaining informed consent

Treating Patients as Partners, by Way of Informed Consent – column by Pauline W. Chen in the New York Times

Compassion, #COVID19, and @Twitter

Posted on September 13, 2020 by marylbrandt

No one listens, learns, or changes their mind when they are being attacked. As healers, we know this. We deal with patients and families all the time who don’t understand or are so traumatized that the last thing we would think of doing is yelling at them as we try to help them on their journey to health.

We’ve all seen the videos of mobs of people without masks rushing to get to the front of a crowd to hear @realDonaldTrump. We’ve all seen the photos of people in crowds at bars, parties, and on college campuses with no one wearing masks. If you are tempted to think this is ok, I have two things I’d like to share…

It’s not about you.

I totally agree that, as an adult, if you want to not wear a seatbelt, you have that right. But you don’t have the right to drive drunk and kill or injure someone else. If you want to drive 80 miles an hour on your ranch and ignore safety, go for it! But if you want to speed and run stop signs on our shared roads, that’s not ok. Why? Because the person you hit with your car could be a family member or friend… and they will unquestionably be a neighbor (because we are all neighbors).

Masks are about compassion.

If you come down with COVID19, it’s also not just about you. If you do get sick with COVID19 (and I hope you don’t), it’s not about “getting over it” like a cold. You could have a lifetime of consequences… but if it was just about you, that would be your choice. But that’s not how this works. If you are COVID19 positive (with or without symptoms), you can infect your elderly family member, the kid next door who is on chemotherapy for cancer, the nurse who takes care of you when you go, frightened and alone (since no one will be allowed to stay with you), to the hospital.

Since my new friend on Twitter asked me about the science, I’m happy to help with some of what we know:

Masks decrease the spread of COVID19 in a community.
Masks do not cause low oxygen levels.
Masks do not cause an increase in carbon dioxide.
COVID can be spread for up to 6 days before you develop symptoms.
There are people who have the virus, can spread it to others, but never develop symptoms.
The virus is small, but it travels on droplets (that’s how others get infected) – and that’s why masks work. (That’s also why it’s not cool to put on masks made of lace, gauze or other things with holes)
We can’t rely on herd immunity, unless we think its ok to have up to 2 million dead Americans.

p.s. I changed how I interact with folks on social media after I listened to Nadia Bolz Weber’s interview with Megan Phelps-Roper on her podcast, The Confessional. Megan Phelps-Roper was a member of the Westboro Baptist Church who became the voice of her family on Twitter, spreading their particularly venomous message. But a funny thing happened … there were people on Twitter who, instead of yelling at her, responded to her venom with compassion and curiosity… and it changed her life.

Don’t Eat the M&Ms

Posted on July 28, 2020 by marylbrandt

As a former Program Director, I couldn’t help but imagine the conversations that occurred after this event…

After “WHAT WERE YOU THINKING?????” – which would have probably been my first sentence – I would have been upset, but I also would have realized that these residents were meeting in the way that residents and students have met forever. They were having a goodbye party for people who were leaving. Probably not outside, and probably not socially distanced, judging by the outcome, but I totally get it.

But the consequences of a casual party like this are real and it’s worth thinking about this by asking three questions…

1. What are the chances you’ll get infected at a party?

This one is easy. You have 100% chance of getting infected… unless it’s 0%… and there is no way to know which way it will go.

A recent report of 32,480 nursing home residents and staff showed that “Of the individuals who tested positive, 70.8% of residents and 92.4% of staff lacked symptoms at the time of testing.” The authors also showed that the viral load (which helps predict whether or not the individual is infectious) was the SAME in people who had symptoms and those who didn’t; “In a large cohort of individuals screened for SARS-CoV-2 by qRT-PCR, we found strikingly similar distributions of viral load in patients with or without symptoms at the time of testing.”

What this means in practice is that every single person we encounter has to be considered infectious. And that means every event and every encounter has to be carried out in a way that will prevent transmission of the virus.

2. What are the chances you’ll get really sick or even die if you get COVID19?

Based on data from the CDC, for 20-40 year old people with no underlying medical conditions, here’s the answer to my hypothetical M&M question:

700 of the M&Ms will give you fever, cough, and/or shortness of breath. Lots of patients describe it as having “lungs on fire.”
440 of the M&Ms will give you some pretty awful muscle cramps and aches.
120 of the M&Ms will make you lose you sense of smell and taste. It usually comes back, but not always
3 or 4 of them will put you in the hospital (that goes up to around 20 M&Ms if you have an underlying medical condition)
1 of them will put you in the ICU unless you have an underlying medical condition. In that case, 5 of them will put you in the ICU
It’s unlikely you’ll die unless you have an underlying medical condition, in which case 3 of the M&Ms will kill you. If you carry this home to your 70 year old grandparent with an underlying medical condition, they have a 20% chance of dying (the equivalent of 200 M&Ms for you).

3. If you are in health care, what effect will this have on your patients and your colleagues?

Whenever I struggle with a decision as a doctor, I go back to my “rules”, which serve as the reference point for my moral compass.

Rule 1: Do what’s right for the patient.

Rule 2: Look cool doing it.

Rule 3: Don’t hurt anything that has a name.

If, as a healer, you decide that “just this once” won’t be much of a risk and you end up with COVID19, you break all three rules. You will be infectious for a long time before you get symptoms… which means you will expose patients, friends and colleagues (who all have names) to this potentially deadly disease. And – there is nothing less “cool” than creating a avoidable situation that ends up with colleagues having to cover for you while you are in quarantine and/or recover from COVID19.

We all want this to end… and it will.

We have a special calling – and responsibility – as healers (which includes all healthcare workers since healing takes a team). It’s what makes our work so filled with awe, and so rewarding. It’s also a burden sometimes. But we all took an oath, we all made a promise, and when we are past this point in history and looking back, it will mean something that we held true to that promise.

Loving Us Back to Together

Posted on May 25, 2020 by marylbrandt

I have such sorrow, such a heavy heart. How, on the same day we mourn those who died fighting for our freedom should we have to mourn 100,000 mostly preventable deaths from #COVID19?

Link to video of the NYT front page

How can people justify gathering together like this party in Missouri?

Parties like this will almost surely lead to COVID19 infections…. and deaths. Probably not death for the people who attended parties like this one, but the death of their grandparents, their friends recovering from cancer, the doctors and nurses who see them and take care of them when they fall ill from COVID19.

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This is not hard. COVID19 is a very infectious virus that spreads between us when we breath, cough, sneeze or sing near each other. We just have to decrease the time we are together, the distance between us, and cover our nose and mouth when we are with other people if we want to protect each other.

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Disregarding the science behind how to deal with this pandemic is like standing in front of a burning building and telling the firefighters as they arrive that there isn’t really a fire.

There is a fire, friends. It will stop eventually, as we get better and better at treating and preventing the spread of COVID19, but for right now… our house is on fire.

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I recently listened to the first episode of Nadia-Bolz Weber’s new podcast ““The Confessional”. In that episode, she interviewed Megan-Phelps Roper who grew up in the Westboro Baptist Church. Megan’s “job” for the church, along with picketing synagogues, the LGBTQ community and the funerals of American soldiers killed in the Middle East, was to use Twitter to spread the hateful beliefs of the church. And boy was she successful.

But then something changed. Instead of being yelled at on Twitter by people who (justifiably) found the behavior of the Westboro Baptist Church abhorrent, she was befriended by someone who was kind to her. I’ll let you read this article, her book, or listen to the podcast, but through the kindness of her new Twitter friend she was able to have space to think without being judged… which led her to a place of love rather than hate.

As I thought about the angry responses to some of my recent Twitter posts, some of which I can’t even share here because of the language, I realized that “yelling”, in person or online never leads anywhere. If we are to get through this time together, and alive, we have to be kind to each other – in person and online. We have to see through the rhetoric and understand that anger often comes from a place of fear. We have to acknowledge that we are all afraid… and that we are all in this together.

Wear your mask. Stay home when you can. Stay at least 6 feet apart. And, please… be kind.

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What Medicine Needs to Know About Social Location

Posted on June 9, 2019 by marylbrandt

I want to share a concept I recently learned …

But first, a story.

A few days ago I was talking with a male colleague who is a leader in his department. He is a good friend, so we often talk about a variety of things. He brought up the issue of equity in his department. He told me (and I wasn’t surprised) that he was working hard to make sure that there was salary equity for the women in the group. I asked him if they knew he was doing that. He responded, after a pause, that only he and his second in command knew.

“You need to tell them.”

He paused and said, “That’s a really good idea. I didn’t think of it.”

So let’s talk about social location.

Each of us has a “social location” that is a composite of our social identities e.g. gender, race, sexual identity, etc. There is usually a perceived (and totally constructed) “hierarchy” of these social identities. In the United States, at this moment, it’s pretty clear that the “dominant” social location would be: White, Male, Heterosexual, Cis-gendered and Able-bodied (I’m leaving it there without adding other social identities such as immigrant status, age, education… etc. etc.)

Here’s the main point I want to make. If you are in the “dominant” social location (i.e. White, Male, Heterosexual, Cis-Gendered and/or Able-bodied), you most likely cannot “see” the location of others that are not “dominant”… even though you think there is no way you are less than supportive of people that aren’t like you.

Huh?

David Foster Wallace probably describes this phenomenon best in his amazing commencement address “This is Water”.

“There are these two young fish swimming along and they happen to meet an older fish swimming the other way, who nods at them and says “Morning, boys. How’s the water?” And the two young fish swim on for a bit, and then eventually one of them looks over at the other and goes “What the hell is water?”

Let me give you some specific examples from the world of medicine…

When a Lantinx colleague walks into Grand Rounds and notices they are one of three people of color who are there, their response is probably very different than mine. Being white is never something I’m aware of when I’m sitting in Grand Rounds.

If you are a man, you are most likely not aware that when I or other women attend a meeting, that we are completely aware of our identity as a woman as we speak out (or don’t). It probably never crosses your mind, as you get up to a microphone, that you are a man. You probably also don’t realize that you may unknowingly introduce your male colleagues as “Doctor” and your female colleague by their first names.

When we, as leaders, only acknowledge Christian holidays on our calendars, and even worse, when we schedule important classes, tests, or events on Yom Kippur, Eid al-Fitr, or Dewali, we are not discriminating intentionally, but we are acting from a place of not “seeing” students and residents who are not Christian.

I think that’s why my friend didn’t realize how important it would be to let the women in his group know that he had their back. I also think it explains the genuine confusion of many leaders in medicine who truly believe they are equitable and fair … and who are then at a complete loss when they learn they somehow “stumbled” into acting in a way that differed from that perception.

Here’s another wonderful fact. Once you learn about “the water” (i.e. social location) it will change everything…for the better. Because – once you see it you can’t ever go back.

“Try to learn to let what is unfair teach you.”

David Foster Wallace, Infinite Jest

Blessing before the #APSA50 banquet

Posted on May 24, 2019 by marylbrandt

Click here for more information about the American Pediatric Surgical Association

Compassionate Care for Non-Conforming Teens

Posted on October 27, 2018 by marylbrandt

I take care of non-conforming teens, but I have many colleagues who are “uncomfortable” with what they call the “new” issues of sexuality. I am convinced it’s because they don’t know the science, the vocabulary and how to speak to non-conforming teens.

This presentation was put together for my pediatric surgery colleagues as a project for a course I’m taking, but several of them asked me to make it more available so they could share it, which is why I’m posting it here.

Research has demonstrated that most aspects of sexuality are far from binary (either-or). We now understand that sex, gender, identity, expression and attraction are separate aspects of sexuality – and that they can be quite varied and fluid (i.e. can differ over time or in different situations).

Pediatric surgeons are among the professionals who care for babies who are born with ambiguous genitalia or, more correctly, what is known as “disorders of sexual development“. For pediatric surgeons, it’s been clear for a very long time that there are three categories for “sex” – male, female and intersex. Almost 2% of children are intersex (which, by the way is the same percentage as the number of people who have red hair).

Gender refers to the identity we hold as an individual. I love this particular diagram with “Barbie” on the left and “GI Joe” on the right. What a delight that we have people all along this spectrum! It’s also true that there may be days you are a 5 and other days your are an 8… whether your sex is male, female or intersex.

Because it’s such a spectrum, there are different ways to describe someone’s identity. This chart represents the most common words used. Cis-gender may or may not be familiar to you, because it is the correct way to describe what is usually (but sometimes not correctly) assumed – i.e. that a person’s gender is the same as their sex.

When we have patients, friends or colleagues who are non-conforming, it is our responsibility to address them in a way that affirms them as human beings. For those who have a clear gender identity (whether its cis-gender or transgender) it is fairly straight forward. When addressing non-binary folks, the correct pronouns to use are they/them/theirs. This is hard for most people because it’s new. It’s perfectly ok to tell them it’s hard but that you are going to try your best. The other important take home message is that if you aren’t sure, it’s ok to ask.

To add even more to the amazing diversity of human beings, how you express your gender is also completely separate from your sex and your gender identity! So, you can be born with female genitalia (sex = female), identify as a girl (cis-gender) but still choose a gender expression that is more typically “male” in terms of behavior and dress. Gender expression is also amazingly fluid, since there are other times this same individual may prefer to express as “Barbie”, somewhere in the middle, or “GI Joe”.

Although most people are familiar with bisexual, homosexual and heterosexual as concepts, the fact that there are people who are asexual may be a new concept to many.

The Genderbread person is a wonderful visual representation that sex, gender, expression and attraction can all be independent of each other.

So what prompted this presentation and now this blog post? Gender dysphoria is real, although not common, and it is a state of suffering. There is so much stigma in our society around sexuality that these children and young adults feel ostracized and isolated. As professionals who care for children and young adults, it is important that we understand these issues, learn to speak openly with patients and families experiencing the effects of gender dysphoria and refer them for appropriate medical and psychological care.

It’s hard to know what to say, but it’s so important to say it. Being open – even admitting that you don’t know much about sexual fluidity – is key. More importantly, caring enough to ask and learn may save a life.

BTW – if you are teen reading this and I’ve messed up, please contact me!

Does the Fetus Feel Pain?

Posted on March 11, 2018 by marylbrandt

I teach embryology to wonderful first year medical, nurse anesthetist and PA students. Last week, one of my students asked me, humbly and thoughtfully, if (and when) a fetus feels pain. Because of recent publicity concerning late term abortions, I knew this was a question about more than fetal physiology.

Let’s talk embryology.

I am very, very confident that the blastocyst doesn’t feel pain. I am equally confident that babies at the time of birth do feel pain. So, there must be a moment during development when nerves to sense the pain, nerves to transmit the pain, and a brain to perceive the pain come together to make it possible to perceive noxious stimuli. I’m not a developmental neurologist, so I can’t claim to be an expert, but based on published research, those three things are present somewhere around 22-24 weeks gestation. For those that are concerned about abortions that happen after 22-24 weeks, It’s important to realize that only 1.3% of abortions occur after 21 weeks gestation and 80% of these for serious birth defects.

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Let’s talk suffering.

As healers, we seek to relieve suffering. Let’s be clear – that’s not the same thing as the “pain” I mentioned above. Let me give you a couple of (real life) examples.

A developmentally delayed 15 year old is raped by her cousin who threatens her if she tells anyone. Over the next two months, the girl becomes progressively withdrawn, depressed and even suicidal. Her mother takes her to her pediatrician who is able to convince the girl to tell her what happened. She sends the appropriate labs, including a pregnancy test, which is positive. Her pediatrician recommends termination of the pregnancy, and refers her to a gynecologist and a pediatric psychiatrist. Because of her depression and suicidality, both of these physicians also recommend termination of the now 14 week pregnancy.

A young couple comes to their gynecologist for a routine screening ultrasound. Something isn’t quite right, so they are sent to the maternal-fetal medicine clinic for a more detailed ultrasound. They are at 18 weeks gestation, which means 22 more weeks until term. They receive horrible news. The fetus they are carrying has a fatal disorder and will not survive after birth. After a few weeks, they return to their doctor in tears. The emotional burden of carrying the pregnancy to term is causing them immense suffering.

Let’s talk ethics.

We teach our medical students to take complex situations like deciding to terminate a pregnancy and use an “ethics workup” to help guide decision making. The ethics workup starts with defining everyone who might be affected by the decision. For example, in the first case I mentioned above, that would be the 15 year old patient, the fetus, the patient’s mother, and the doctors. Then, based on the possible outcomes (to terminate or not to terminate the pregnancy), we consider the outcomes with appeals to consequences, professional obligations, ethical rights and virtues. What this process does is allow us to understand the complexity of the situation and the choices being made, rather than just going with our “gut reaction”.

Let’s talk about listening.

When I was Dean of Student Affairs, the “Pro-Life” group on campus invited a speaker that the “Pro-Choice” group felt strongly should not be allowed to speak. I asked the leaders of both groups to meet with me. They were pre-clinical students who had not yet experienced dealing with patients and families facing complex and heartbreaking decisions. I recognized that their conflict was a great learning opportunity, a chance to learn to work through a situation where colleagues disagreed. I asked them to develop a plan together on how speakers should be invited, a plan that I insisted reflect the culture of tolerance at our medical school. They did not disappoint. Their plan was amazing and included attending each other’s meetings and reviewing speakers for each other before invitations were issued. They also wrote a beautiful statement to be read at the beginning of each meeting explaining that they were there to learn from each other and to listen. They went even further and added that disrespectful comments or intolerance would result in being asked to leave the meeting. What a great example for us all – to listen to learn, and to do so with kindness and tolerance.

As physicians we are absolutely allowed – even encouraged – to include our personal views when making a thoughtful, ethical decision about caring for a specific patient. Although it’s not a common event, physicians are allowed to choose not to care for a specific patient as long as they refer them to a different doctor. What physicians are not allowed to do is to impose our views on our patients, or our colleagues.

Why is there a battle going on about MOC … and why should you care?

Posted on May 18, 2017 by marylbrandt

Everyone hates exams. Most of us hate regulations. But, exams and regulations in medicine came about because of abuses in the past that led to the public distrusting doctors. It’s a fascinating, and somewhat terrifying history that starts with changing “medical schools” from for profit (and horrible!) businesses into what we know today. As general doctors started doing ophthalmology, surgery, or obstetrics full time, it was became clear that defining what constituted a specialty, and demonstrating that practitioners were competent was important.

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What does it mean to be “board certified”?

Being “board certified” means that one of the 24 specialty boards in the United States attests that you have met all the requirements and have passed rigorous exams to show that you are qualified to practice in that specialty.

Does the board certification last forever?

Short answer, no. Family Medicine was the first specialty (in 1970) to realize that initial certification was not enough. As the public continued to ask for evidence that physicians remained up to date, Surgery (1976), Emergency Medicine (1980) and Ob/Gyn (1986) added a recertification examination. As of 1990, the remaining boards became “time-limited” which means board certification expires after 6-10 years, unless physicians take and pass the recertification examination. So, many internists who are now in their 60s and 70s didn’t have to do anything other than pass the initial examinations. (This is referred to as being “grandfathered”).

Who makes up “the board” for the specialties?

The members of most boards are volunteer physicians in the specialty. In surgery, which I know the best, the board members are called “directors”. There are 41 directors of the American Board of Surgery who represent a variety of organizations and specialties in surgery. These volunteer surgeons spend 20+ days a year away from their practices with no pay (although their expenses are paid) to give the oral examinations in surgery, and to design and validate the written examinations. They also have a variety of committees and projects which focused on one critical question: “What do we need to do to make sure we maintain the public trust in surgeons?”

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How do the specialty boards decide if specialists are up to date?

Since 1990, boards have to be “maintained”. If you don’t maintain your board, you lose it. Hence the term, Maintenance of Certification (MOC). So what do you have to do for “MOC”? In addition to having a license, most boards have requirements to document hospital privileges and provide letters of reference. Here’s a summary of the other requirements for four of the largest boards:

	Continuing Medical Education (CME)	Recertification examination	Practice Assessment	Cost
Internal Medicine	Must do some CME every 2 years. Must get 100 MOC points every 5 yrs. (roughly 20-25 hrs/yr)	Recertification examination every 10 years (counts as 20 hrs MOC points)	Nothing required. Can earn MOC points by QI or by teaching.	$1940 ($194/yr) for General Medicine. $2560 ($256/yr) for specialties.
Ob/Gyn	Read at least 30 of the 45 articles provided by the board annually and answer four questions/article (=25hrs CME credit)	Exam every 6 years but may be exempt if excellence demonstrated by answers to articles. (pilot program)	Completion of ABOG practice improvement modules QI projects Presentations/publications	$265/year. Additional fee of $175 if exam is required.
Pediatrics	100 MOC points/5yrs. At least 40 in CME, 40 in practice assessment “Question of the week” delivered by email. 20 questions = 10 MOC pts.	Recertification examination every 10 years (counts as 60 hrs of CME)	Institutional or practice QI projects	$1300/5yrs ($260/yr)
Surgery	90 hrs in 3 yrs. (30 hrs/yr) of CME (lectures or online) 60 hrs (20/yr) have to be Level 1(test questions involved)	Recertification examination every 10 years (counts as 60 hrs of CME)	Participation in an outcome or quality improvement program	$1600 ($160/yr)

What happens if doctors decide to not do MOC?

Being board certified is voluntary and so is maintaining a board. But, if doctors choose not to do MOC, they will lose their board certification.

Here’s some of the possible implications if a doctor loses board certification:

Hospital bylaws almost universally require staff members to be board certified. These bylaws will have to be rewritten for doctors who have lost their boards in order for them to work in these institutions.
The ACGME requires that faculty that teach residents are board certified.
The American College of Surgeons requires that all doctors are board certified who work in ACS accredited Trauma Centers or Children’s Surgery Centers. .
The American Academy of Pediatrics requires that all doctors in the NICU are board certified in order for the NICU to be verified prior to accreditation.

My bottom line on MOC

Since the new MOC requirements went into place I have increased both the quantity and quality of the materials I use to stay up to date, which I strongly feel has made me a better surgeon. I still don’t like taking exams, but every time I do (I have three boards, so I take a lot of them!) I learn so much that I find the experience invaluable. (Yes, that’s after the exam, not before or during… that hasn’t changed since medical school.)

MOC isn’t perfect, but it’s evolving, and the reason it exists is a good one. Passing laws state by state to make MOC “optional” has the risk of hurting the public’s trust in physicians – and the risk of creating quite a bit of chaos for hospitals, training programs, and others. For what? Saving $200 a year? Not having to take the test every 10 years? Not having to log the CME that is required by almost all state medical boards?

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“Here’s what’s at stake: we physicians are granted an extraordinary amount of autonomy by the public and the government. We ask people to disrobe in our presence; we prescribe medications that can kill; we perform procedures that would be labeled as assault if done by the non-credentialed. If we prove ourselves incapable of self-governance, we are violating this trust, and society will – and should – step into the breach with standards and regulations that will be more onerous, more politically driven, and less informed by science. That is the road we may be headed down. It is why this fight matters.” Robert Wachter, MD