TO: American Board of Internal MedicinePhiladelphia, PA
FROM: Mikkael A. Sekeres, MD, MS
Leukemia Program, Cleveland Clinic Taussig Cancer Institute
In the spirit of Henry David Thoreau and Martin Luther King, Jr., both of whom penned essays while they were serving jail time—Thoreau for failing to pay his taxes and King for his part in a non-violent protest—I too am writing from the emotional jail of post-traumatic stress disorder from having studied to recertify my medical oncology boards. Lest you think this is simply another missive from a disgruntled consumer of one of your psychometrically appropriate tests, I did actually pass my Boards, so my comments are intended not to be retributive, but rather constructive, to offer suggestions moving forward.
While I could complain about the exorbitant cost of taking the exam, I do see the health benefit of redirecting monies that would have gone towards buying meat for my family for the next year, and as our local supermarket sells Ramen noodles in a variety of flavors (shrimp, chicken, mushroom, beef) at the low, low price of six packages for $2, we certainly won't starve. Besides, your website offers ample space for comments, and others have raised their hackles about these economic issues.
First, some words of support. Doctors who continue to regularly see patients should be required to demonstrate that we have kept up on current diagnoses and therapies. The vast majority of us do, of course—the impetus for entering this chosen field is the opportunity to continue learning, and improving, throughout our careers. We are of course primarily motivated to do the best for our patients, and this requires us to read, attend conferences, and adapt as new treatments and tests become available. Still I can see why, from a public health perspective, we should have to prove this knowledge formally, and regularly.
I take issue, though, with the relevance, in the year 2013, of a closed-book/closed-computer/closed-PDA exam. While it is theoretically possible that an oncologist moonlighting as a Sherpa will discover a tumor in the upper altitudes of the Himalayas and will have neither Web access, nor room in his pack for his DeVita textbook, and while I readily acknowledge that some would prefer such a location to a trip to my hometown of Cleveland, it is an unlikely scenario. I am not all-knowing, and my memory may not be 100% accurate (my wife puts it in the 20% range, when she's feeling kind).
Thinking that I might be an outlier, I took a straw poll around the workroom the other day, and it turns out that none of the docs knew everything. We turn to each other to ask questions, and we all use PubMed or a similar search engine to find articles to guide our therapies, and make use of resources like Lexicomp or our pharmacist clinical specialists to answer questions about drugs, dosing, and interactions. We do it all the time, because hubris in medicine is deadly, memories are fallible, and none of us is so arrogant to believe we are always right, without checking, first. So, why make us sit for six hours in isolation to practice medicine?
The practice of oncology has become highly sub-specialized, as we have come to recognize that “cancer” represents hundreds upon hundreds of increasingly molecularly defined distinct diseases. As a result, my practice consists exclusively of patients with myeloid and some lymphoid malignancies. I read sub-specialized journals, and attend the sub-sections of conferences germane to my disease focus. It's the only way I can be at the top of my game in these diseases. Yet I had to sit for a general oncology exam. And guess what? My best score was in…drum roll…Genitourinary Oncology. That's right. According to the ABIM, I am a certifiable GU oncology rock star. Yet I haven't treated a GU oncology patient in over a decade, since my fellowship. You wouldn't want me to, and if one of my patients develops a GU malignancy, I refer them as fast as possible to one of my colleagues who does specialize in GU oncology, just as they quickly refer to me their patients with bone marrow malignancies. Yet, the test said I am fully capable of treating these patients. But I'm really not, and I wouldn't want a test score deceiving me or my patients into thinking I was.
When I started this essay, I promised to be constructive. In this spirit, the maintenance of certification requirements does make a lot of sense. These are “open book/computer/PDA”; test the latest in diagnosis, staging, and therapy; or require chart audits to make sure we are meeting minimum quality standard for oncology practice. As opposed to the Boards test—which rewards us with a score and a percentile two months after the fact, without insight into what questions we aced or totally misunderstood—the maintenance of certification modules give immediate feedback that is question-specific, and guidance on how to improve our practice of medicine.
Do I enjoy sitting down and engaging in hours of chart audits? No. But I accept that it makes me more conscious of the clinical decisions I'm making, and probably makes me a better doctor.
One other suggestion. How about Board certification for medical oncology subspecialists? You could divide these into categories like hematologic malignancies/breast and GU/upper aerodigestive/gastrointestinal, or something like that. There is some precedent for this—in the field of family medicine, sections of the examination in pediatrics or internal medicine or obstetrics and gynecology can be chosen by the test-taker. That way, there's no pretending what we know or don't know, and our patients can pick and choose true specialists.
Yours Very Truly,
Mikkael A. Sekeres
Medical Oncology Board Certified through 2022
More ‘Second Thoughts‘!
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