The State of Pulmonary and Critical Care in the Southwest

Sunday afternoon at the American Thoracic Society International Conference has two sessions we usually attend – the Great Cases Conference and the Awards Session. These are fun sessions. The Great Cases Conference is a chance to test your diagnostic acumen against master clinicians. The awards session is when leaders in pulmonary, critical care and sleep are acknowledged for their accomplishments and/or public service.

The Great Cases Conference was co-chaired by Dona Upson from New Mexico. The master clinicians included Marvin Schwarz from Colorado, Tom Colby from Arizona, and John Newell, who until recently was from Colorado. Sharon Rounds from Brown was another of the master clinicians and did her pulmonary/critical care training in Colorado.

The awards session was chaired by Monica Kraft, who was a pulmonary fellow and later faculty member at the University of Colorado and National Jewish Health (NJH). Jonathan Samet, a former resident, faculty member and division chief at the University of New Mexico, was presented the Edward Livingston Trudeau Medal. The Amberson Lecturer was David Schwartz from the University of Colorado. Polly Parsons, a graduate of the University of Arizona College of Medicine, who did her residency and pulmonary fellowship at Colorado, and later was a faculty member at Colorado, was presented the ATS distinguished service award. Allen Thomas was a resident and pulmonary fellow in Phoenix and practices at the Phoenix VA, and was presented the ATS Clinician of the Year. Abderrahmane E. Amine Temmar from Albuquerque was one of the other two finalists for clinician of the year. Kay Kreiss, the recipient of the Public Health Service award, was on faculty at NJH /University of Colorado for more than 14 years.  Paul Noble, a former University of Colorado fellow, was presented with a recognition award for scientific accomplishments. Although not presented until the Women’s Forum on Monday, the list is not complete without acknowledging the Elizabeth A. Rich, MD Award to Suzanne Lareau of the University of Colorado, having moved there from the Albuquerque VA.

Arizona, New Mexico and Colorado’s 13.9 million residents represent only 4.4% of the United States’ 313.9 million inhabitants. Why so many good physicians, and other clinicians, trained or reside in the Southwest is unclear. Perhaps it was pioneers in the field such as Tom Petty in Denver, Benjamin Burrows in Tucson and William and Randy Lovelace in Albuquerque who inspired so many young physicians. Regardless, the Southwest seems to be overly blessed with great pulmonary, critical care and sleep physicians. We at the Southwest Journal of Pulmonary and Critical Care wish to recognize their accomplishments and note that the state of pulmonary, critical care and sleep in the Southwest appears very good indeed.

Richard A. Robbins, M.D.

Dona J. Upson, M.D.

Carolyn H. Welsh, M.D.

Reference as: Robbins RA, Upson DJ, Welsh CH. The state of pulmonary and critical care in the Southwest. Southwest J Pulm Crit Care. 2013;6(5): 246. PDF

Doxycycline and IL-8 Modulation in a Line of Human Alveolar Epithelium: More Evidence for the Anti-Inflammatory Function of Some Antimicrobials

Beta blockers for severe systolic dysfunction; antibiotics for peptic ulcer disease.  These are just a few examples of the many unpredicted consequences of medication intervention.  Rheumatology has known of the disease modifying anti-rheumatic drug (DMARD) capacity of second generation tetracyclines including doxycycline (1). This has actually led to investigations attempting to identify organisms possibly serving as substrates for inflammatory processes including rheumatoid arthritis and even atherosclerosis. Generally, this has been unsuccessful and the conclusion that doxycycline has intrinsic anti-inflammatory properties has become suspect (2,3).

Experience with higher generation macrolides like azithromycin further lends credence to this concept of antibiotics as intrinsically anti-inflammatory (4). There is a body of data suggesting inhibition of cytokine expression by this drug. In diseases like cystic fibrosis where even very high intracellular concentrations of macrolide have no significant activity against pseudomonas species but the drug therapy does appear to modify disease course further supports this anti-inflammatory contention (5). 

Published work has suggested the beneficial anti-inflammatory effect in COPD relating this broadly to doxycycline’s inhibition of matrix metalloproteinases, MMP(s) (6).  MMP(s) have been postulated to rise as a function of the oxidative stress recurrently demonstrated in chronic obstructive pulmonary disease (COPD).  Additionally, doxycycline has demonstrated the ability to impair neutrophil migration in LPS stimulated alveolar macrophages harvested from bronchoalveolar lavage. Hoyt et al. (7) have now nicely demonstrated ex-vivo that doxycycline is capable of inhibiting IL-8 expression in a line of human lung epithelial cells stimulated by a cytomix, a potent combination of inflammatory stimulators. Importantly, this is a demonstration of measureable inhibition of an inflammatory cytokine by the tetracycline in mammalian cells.

The biologic significance of this still remains to be fully determined. In the large ECLIPSE TRIAL, the major discriminator of inflammatory modulators in COPD with inflammation was IL-6 and not IL-8 which actually decreased in the cohort of individuals with evidence of inflammation (8). Further study may reveal that doxycycline also has a suppressive effect on the former cytokine.

Broadly, MAP kinases are a group of protein kinases that participate in the signaling of stress related mediators like cytokines. A finding reported by Hoyt et al. (7) that will require further investigation concerns the decrease in p38 mitogen-activated protein kinase (p38 MAPK) in response to doxycycline. The data in this regard remains conflicting with reports suggesting p38 MAPK is involved in IL-8 transcription in a human monocyte model with exposure to Clostridium difficile toxin (9). Hoyt et al. (7) found a decrease in p38 MAPK along the absence of change in mRNA by reverse transcription-polymerase chain reaction (RT-PCR) suggesting that effect of doxycycline on IL-8 elaboration is post transcriptional. Others have reported data supporting the concept of post transcription modulation of IL-8 by doxycycline as suggested by Hoyt et al. (10). While validation with repeat studies will be necessary, the finding that IL-8 mRNA by RT-PCR was not affected by levels of doxycycline that inhibited IL-8 is noteworthy. One may conclude that IL-8 assembly at the level of the ribosome could be operative.  While it was previously presumed that the tetracyclines specifically targeted bacterial ribosomes, Robbins et al along with all the other studies support the anti-inflammatory effect of tetracyclines in human disease and demonstrates that mammalian cells are also affected by this moiety.

So Hoyt et al. (7) have added to the knowledge base by definitively demonstrating the non-antimicrobial properties of doxycycline by ex-vivo inhibition of IL-8 production in a line stimulated mammalian alveolar epithelial cells. If the RT-PCR data can be further confirmed, this inhibition of IL-8 by doxycycline appears to be a post-transcriptional mechanism. Whether p38 MAPK is a transcriptional or post-transcriptional cytokine modifier remains to be determined.

Jay E. Blum, M.D.

Chief, Pulmonary and Critical Care

Phoenix VA Medical Center

References

1. Stone M, Fortin PR, Pacheco-Tena C, Inman RD. Should tetracycline treatment be used more extensively for rheumatoid arthritis Metaanalysis demonstrates clinical benefit with reduction in disease activity. J Rheumatol. 2003;30:2112-22.
2. Anderson JL, Muhlestein JB, Carlquist J, et al. Randomized secondary prevention trial of azithromycin in patients with coronary artery disease and serological evidence for Chlamydia pneumoniae infection: The Azithromycin in Coronary Artery Disease: Elimination of Myocardial Infection with Chlamydia (ACADEMIC) study. Circulation.1999;99:1540-7.
3. Webster G, Del Rosso JQ. Anti-inflammatory activity of tetracyclines. Dermatol Clin. 2007;25:133-5.
4. Kanoh S, Rubin BK. Mechanisms of action and clinical application of macrolides as immunomodulatory medications. Clin Microbiol Rev. 2010;23:590-615.
5. Equi AC, Davies JC, Painter H, Hyde S, Bush A, Geddes DM, Alton E. Exploring the mechanisms of macrolides in cystic fibrosis.  Respir Med. 2006;100:687-97.
6. Greenwald RA, Moak SA, Ramamurthy NS, Golub LM. Tetracyclines suppress matrix metalloproteinase activity in adjuvant arthritis and in combination with flurbiprofen, ameliorate bone damage. J Rheumatol. 1992;19:927-38.
7. Hoyt JC, Ballering JG, Hayden JM, Robbins RA. Doxycycline decreases production of interleukin-8 in a549 human lung epithelial cells. Southwest J Pulm Crit Care. 2013;6:130-42.
8. Celli BR, Locantore N, Yates J, Tal-Singer R, Miller BE, Bakke P, Calverley P, Coxson H, Crim C, Edwards LD, Lomas DA, Duvoix A, MacNee W, Rennard S, Silverman E, Vestbo J, Wouters E, Agustí A; ECLIPSE Investigators. Inflammatory biomarkers improve clinical prediction of mortality in chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2012;185:1065-72.
9. Warny M,  Keates AC, Keates S, Castagliuolo I,  Zacks J,  Aboudola S et al. p38 MAP kinase activation by Clostridium difficile toxin A mediates monocyte necrosis, IL-8 production, and enteritis. J Clin Invest. 2000;105:1147–56.
10. Li J, Kartha S, Iasvovskaia S, Tan A, Bhat RK, Manaligod JM, Page K, Brasier AR and Hershenson MB.  Regulation of human airway epithelial cell IL-8 expression by MAP kinases.  Am J Physiol Lung Cell Mol Physiol. 2002;283:L690-L699.

Reference as: Blum JE. Doxycycline and IL-8 modulation in a line of human alveolar epithelium: more evidence for the anti-inflammatory function of some antimicrobials. Southwest J Pulm Crit Care. 2013;6(4):184-6. PDF 

What to Expect from Obamacare

“I predict future happiness for Americans if they can prevent the government from wasting the labors of the people under the pretense of taking care of them.”

-Thomas Jefferson

The Supreme Court decision is in and the election is over. Obamacare, or the Patient Protection and Affordable Care Act (ACA), will become reality, but questions remain on what it will look like. ACA had three goals: 1. Expand coverage to the poor; 2. Control costs; and 3. Improve care. These are all laudable goals but it is unclear if they can be achieved. Experience from Federal-run health systems such as Center for Medicare and Medicaid Services (CMS) and the Veterans Administration (VA) provide some clues as do recent Federal actions and the Massachusetts health care system.

Expand Coverage to the Poor

The US has about 60 million uninsured and one of the ACA goals is to come as close as possible to achieving universal healthcare coverage. In order to do this, the ACA depends heavily on Medicaid, a joint Federal-state health benefits program, to reach the goal of near-universal health care. If every state participated, 17 million uninsured people would gain coverage through Medicaid and the Children's Health Insurance Program between 2014 and 2022, according to the Congressional Budget Office (CBO). These are often the poorest of the poor. The Federal government usually pays for about half to two-thirds of the cost of Medicaid. To encourage states to participate in the ACA, the Federal government upped payment to 100 percent of the cost of covering newly eligible people from 2014-6, after which the share will gradually go down to 90 percent in 2022 and later years.

However, the Supreme Court decision in June, which mostly upheld the ACA, gave states the right to opt out of the Medicaid expansion. At the time of this writing, roughly a third of the states have decided not to participate, a third will participate and a third are undecided (Figure 1).

 

Figure 1. State commitment to expand Medicaid eligibility as of 12/12/12.

Some governors have asked Health and Human Services if they partially expand Medicaid will the Federal Government still pay for the expansion. In response, Health and Human Services Secretary, Kathleen Sebelius, has written a letter to the Nation’s governors saying it is all or nothing. According to the CBO this lack of participation leaves up to 3 million of the poorest Americans without health coverage. Placement of bureaucratic obstacles to discourage eligible persons not to sign up as well as political bickering and their inevitable subsequent lawsuits are likely to further delay care for the eligible. Therefore, it is unclear to what extent the ACA will increase coverage to the poor but it seems unlikely to bring the US any where close to universal healthcare.

Reduce Costs

Clearly medical care costs too much. In order to control the growth in costs it is necessary to know where the growth in spending has occurred. The latest data available is from 2010 and has been the subject of a previous editorial (2). Although there are many categories of health care expenditures, the four largest and their percentages of healthcare expenditures are hospital care (31.4%), physicians (16.1%), pharmaceuticals (10.0%), and net cost of insurance (5.6%). The largest increase in absolute costs was in hospitals which accounted for 39.4% of the increase of the $101.15 billion increase compared to 2009. The largest percentage increase was in net cost of insurance at 8.4% which was much higher than the 3.9% increase overall. Drug costs were not markedly increased at a1.2% increase but the top 12 companies had 310.8 billion in sales and 49.3 billion in profits in 2012 suggesting that the pharmaceutical industry is healthy and profitable (3). Although the Obama Administration often talks tough about reducing costs, especially insurance company costs, it seems unlikely based on their history that there will be a reduction in any of these three categories.

On the other hand, physician salaries have fallen. While the income of dentists, pharmacists, registered nurses, physician assistants, and health care and insurance executives rose by an average 10.2% in 2005-10 compared 2000-4, the income of physicians decreased by 5.8% (4). Although the hourly wage of physicians remains high ($80.00/hr) and remains higher than dentists ($70.64/hr) and lawyers ($54.21/hr), the gap is closing (5-7). This is despite a shortage of physicians (5). Even though the greatest physician need is in primary care physicians, pediatricians, family practioners and general internists remain the lowest paid physicians (8).  

Based on these trends, it seems likely medical costs will continue to rise. However, payments to physicians will probably remain static or decrease. Although the consequences are unclear, the cuts in payment to physicians are not sustainable and will likely drive many physicians, especially primary care physicians, out of private practice. The other consequence may be that some physicians, most likely specialists, may not take insurance with low reimbursement such as Medicare and Medicaid. This would mean that those that can afford to pay out of pocket will receive health care while the poor, the very people the ACA was intended to help, may not. Regardless, it is unlikely that the continual focus on physician reimbursement to control costs will be successful in controlling overall medical expenditures. The 16.1% of healthcare costs attributable to physicians is simply not large enough to reduce the overall costs, especially since physicians have born the brunt of the cuts for the past few years.

The ACA also proposes to reduce costs by paying only for value- and evidence-based care based more for outcomes than procedures. However, this is the approach that has been in place for some time at CMS and has yet to reduce costs. Committees far removed from medical practice have often made poor decisions. For example, patients who need self-catherization were at one time allowed only 4 catheters per month. Some patients had excessive and expensive hospital admissions for urinary tract infections. Presumably the catheters were not properly cleaning their catheter prior to reuse which resulted in the excess hospitalizations. The policy has now been changed to allow up to 200 catheters per month.

Another example is computerized healthcare records. In a January speech, President Obama evoked the promise of new technology: “This will cut waste, eliminate red tape and reduce the need to repeat expensive medical tests," he said. However, rather than reduce costs, the opposite happened. With better documentation, physicians billed at higher levels actually increasing costs (9). Response blaming physicians was swift implying physicians committed fraud (10).

Physicians and their patients may find themselves directed to cheaper care even when evidence points to a better but more expensive alternative. As a personal example, I have congestive heart failure and take carvedilol. My insurance company, Blue Cross and Blue Shield, has denied payment for the carvedilol despite evidence that it is superior to their recommended alternative, metropolol (11). The VA and Medicare have had similar policies in place. The difference in cost is about $1/day. I pay for my carvedilol out-of-pocket because in the COMET trial it reduced mortality from 40% to 34% (11). My judgment was that a 6% increase in survival was worth the extra cost. Patients are likely to find themselves in similar situations where if they want care that is not in the guidelines, they will need to pay for it themselves whether it is evidence-based or not.

Improvement in Care

A clue to how the Obama administration plans to improve care was in the 2010 summer recess appointment of Don Berwick as Administrator of the Centers for Medicare and Medicaid Services. Prior to his appointment he was President and Chief Executive Officer of the Institute of Healthcare Improvement (IHI). IHI was a group who convinced many hospitals to adopt a number of their guidelines. These guidelines had two common themes-most were physician focused and many very weakly evidence-based (12,13). CMS began tying reimbursement and compliance with the guidelines. The financial disincentive to accurately report data induced many hospitals to lie about their data (14). Not surprisingly, compliance improved but there has been little evidence for an accompanying improvement in outcomes (14,15). Witness the recent example of central line associated blood stream infections (CLABSI). Based on hospital self-reported data, CMS announced its program reduced the rate of CLABSI (16). Within a month an article appeared in the New England Journal of Medicine reporting the program did nothing to reduce infections or any other outcomes (17).

However, there may be a glimmer of hope. Although there is a continued reliance on weakly evidence-based surrogate markers, CMS has begun looking at mortality, morbidity, length of stay and readmission rates. These patient-centered outcomes have real meaning to patients as well as affecting costs. This may finally force health care administrators to address real care issues rather than performance of surrogate, weakly evidence based guidelines such as administration of pneumococcal vaccine to adults, telling smokers not to smoke without any follow up and providing discharge instructions.

Conclusions

Overall it appears that the ACA will have minimal impact on its goals of expanding care to the poor, reducing costs or improving care for the foreseeable future. It will likely continue to cost shift reimbursement away from physicians while costs continue to rise. Almost certainly it will be entangled in political bickering, eligibility challenges and lawsuits reducing many of the benefits of the law. However, we can probably be assured that CMS will continue to rely on inaccurately reported data, quickly declare their programs successful and stay their course, despite the programs doing little to nothing for patients. When their programs focus on outcomes such as mortality, morbidity, length of stay and readmission rates, real progress can be made in improving patient care rather than “spinning” dubious results.

Richard A. Robbins, MD*

References

1. Kliff S. White House to states: on Medicaid expansion, it’s all or nothing. Available at http://www.washingtonpost.com/blogs/wonkblog/wp/2012/12/10/white-house-to-states-on-medicaid-expansion-its-all-or-nothing/  (accessed 12-13-12).
2. Robbins RA. Follow the money. Southwest J Pulm Crit Care 2012;4:19-21.
3. Fortune. Available at: http://money.cnn.com/magazines/fortune/fortune500/2012/industries/21/ (accessed 12-13-12).
4. Seabury SA, Jena AB, Chandra A. Trends in the earnings of health care professionals in the United States, 1987-2010. JAMA 2012;308:2083-5.
5. US Bureau of Labor Statistics. Avaiable at: http://www.bls.gov/ooh/healthcare/physicians-and-surgeons.htm (accessed 12-13-12).
6. US Bureau of Labor Statistics. Available at: http://www.bls.gov/ooh/healthcare/dentists.htm (accessed 12-13-12).
7. US Bureau of Labor Statistics. Available at http://www.bls.gov/ooh/legal/lawyers.htm (accessed 12-13-12).
8. Medscape. Physician compensation report 2012. Avaiable at: http://www.medscape.com/sites/public/physician-comp/2012 (accessed 12-13-12).
9. Haig S. Electronic medical records: will they really cut costs? Time 2009. Available at: http://www.time.com/time/health/article/0,8599,1883002,00.html#ixzz2FF0XBf5d (accessed 12-16-12).
10. Carlson J. HHS inspector general's office quizzes providers about EHR use. Modern Healthcare 2012. Available at: http://www.modernhealthcare.com/article/20121023/NEWS/310239946 (accessed 12-13-12).
11. Poole-Wilson PA, Swedberg K, Cleland JG, Di Lenarda A, Hanrath P, Komajda M, Lubsen J, Lutiger B, Metra M, Remme WJ, Torp-Pedersen C, Scherhag A, Skene A; Carvedilol Or Metoprolol European Trial Investigators. Comparison of carvedilol and metoprolol on clinical outcomes in patients with chronic heart failure in the Carvedilol Or Metoprolol European Trial (COMET): randomised controlled trial. Lancet. 2003 ;362:7-13.
12. Padrnos L, Bui T, Pattee JJ, Whitmore EJ, Iqbal M, Lee S, Singarajah CU, Robbins RA. Analysis of overall level of evidence behind the Institute of Healthcare Improvement ventilator-associated pneumonia guidelines. Southwest J Pulm Crit Care 2011;3:40-8.
13. Hurley J, Garciaorr R, Luedy H, Jivcu C, Wissa E, Jewell J, Whiting T, Gerkin R, Singarajah CU, Robbins RA. Correlation of compliance with central line associated blood stream infection guidelines and outcomes: a review of the evidence. Southwest J Pulm Crit Care 2012;4:163-73.
14. Meddings JA, Reichert H, Rogers MA, Saint S, Stephansky J, McMahon LF. Effect of nonpayment for hospital-acquired, catheter-associated urinary tract infection: a statewide analysis. Ann Intern Med 2012;157:305-12.
15. Robbins RA. The emperor has no clothes: the accuracy of hospital performance data. Southwest J Pulm Crit Care 2012;5:203-5.
16. Agency for Healthcare Quality and Research. Available at: http://www.ahrq.gov/qual/clabsiupdate/ (accessed 12-13-12).
17. Lee GM, Kleinman K, Soumerai SB, Tse A, Cole D, Fridkin SK, Horan T, Platt R, Gay C, Kassler W, Goldmann DA, Jernigan J, Jha AK. Effect of nonpayment for preventable infections in U.S. hospitals. N Engl J Med 2012;367:1428-37.

*The views expressed are those of the author and do not necessarily represent those of the Arizona, New Mexico or Colorado Thoracic Societies.

Reference as: Robbins RA. What to expect from Obamacare. Southwest J Pulm Crit Care. 2013;6(1):23-28. PDF 

The Terrific Twos! Annual Report from the Editor

With the end of 2012, the Southwest Journal of Pulmonary and Critical Care (SWJPCC) completed its second year of operation. Our first manuscript was posted on November 11, 2010. We posted 8 manuscripts our first year, 68 during 2011, and 113 during 2012 (Table 1).  

Table 1. Postings by SWJPCC 2010-2.

 

Accompanying our increase in manuscripts, our readership has steadily grown to about 3000/month unique IP addresses and about 9000/month page views (the number of files that are requested from a site, also known as “hits”) (Figure 1).

Figure 1. Growth of unique IP addresses and page views by month during 2012.

We had some big changes in 2012. Some of which are listed below:

• New Mexico and Colorado Thoracic Societies partnered with Arizona in SWJPCC.
• SWJPCC is listed in the Directory of Open Access Journals.
• The Case of the Month was expanded to cases by including a Pulmonary and Critical Care Case of the Month in addition to Imaging.
• A Sleep Board Review Question section was added.
• A “News” section was launched.
• A Medical Image of the Week section was inaugurated.

Many need to be thanked. First, thanks to our authors. You took a chance on a new journal and we appreciate the opportunity to publish your work. Second, thanks to our reviewers.  SWJPCC, like all journals, relies upon expert reviewers in order to publish the highest quality manuscripts. We thank the reviewers for their time and effort in the prompt submission of their reviews. A list of reviewers for 2012 is below.

• David Baratz
• Lee Brown
• Richard Carlson
• John Costantino
• Steven Curry
• Thomas Daniels
• Venu Gopal
• Michael Garrett
• Mark Gotfried
• Michael Habib
• Michelle Harkins
• Steve Klotz
• Kenneth Knox
• Manoj Mathew
• Rakesh Nanda
• Huw Owen-Reece
• James Parish
• George Parides
• Lillibeth Pineda
• Stuart Quan
• Robert Raschke
• Richard Robbins
• Clement Singarajah
• Allen Thomas
• Dona Upson
• Laszlo Vaszar
• Zahid Virk
• Carolyn Welsh
• Lewis Wesselius

Our gratitude goes to the Arizona, New Mexico, and Colorado Thoracic Societies for their support. Thanks to our associate editors who have put in much more work than we had the right to ask. A special note of thanks to those who continue to do regular features in SWJPCC-Bob Raschke and Manoj Mathew for the critical care and pulmonary journal clubs; Mike Gotway, Lew Wesselius and Bob Raschke for the cases of the month; Rohit Budhiraja for the Sleep Question of the Month; and Ken Knox for the Medical Image of the Week; and Peter Wagner for his wine column, Slurping Around with PDW. SWJPCC acknowledges the Phoenix Pulmonary and Critical Care Research and Education Foundation which has provided the monetary support for SWJPCC. Last, and most importantly, thanks to our readers. Please visit as often as you can and feel free to provide us with your input.

What’s ahead for 2013? Yogi Berra was probably right, “It's tough to make predictions, especially about the future.”  We hope to improve the content, especially the scientific content, for 2013, but we will continue to emphasize clinical medicine and education. With the help of Ken Knox, Skip Harris, Mike Gotway, Lewis Wesselius and Clement Singarajah, we hope to begin offering Continuing Medical Education (CME) in the early part of 2013. Although we have learned that the is future hard to predict, we sincerely believe that with your help the SWJPCC will continue to grow and improve.

Richard A. Robbins, MD

Editor, SWJPCC

Reference as: Robbins RA. The terrific twos! annual report from the editor. Southwest J Pulm Crit Care 2013;6(1):1-3. PDF 

Maintaining Medical Competence

“I am free, no matter what rules surround me…because I know that I alone am morally responsible for everything I do.”― Robert A. Heinlein

I recently renewed my Arizona medical license and meet all the requirements. I far exceed the required CME hours and have no Medical Board actions, removal of hospital privileges, lawsuits, or felonies. None of the bad things are likely since I have not seen patients since July 1, 2011 and I no longer have hospital privileges. However, this caused me to pause when I came to the question of “Actively practicing”? A quick check of the status of several who do not see patients but are administrators, retired or full time editors of other medical journals revealed they were all listed as “active”. I guess that “medical journalism” is probably as much a medical activity as “administrative medicine” which is recognized by the Arizona Medical Board. This got me to thinking about competence and the Medical Board’s obligation to ensure competent physicians.

Medical boards focused on preventing the unlicensed practice of medicine by “quacks” and “charlatans” in the first half of the Twentieth Century. The Boards evolved over time to promote higher standards for undergraduate medical education; require assessment of knowledge and skills to qualify for initial licensure; and develop and enforce standards for professional practice. Beginning with New Mexico in 1971, nearly all state medical boards require a prescribed number of continued medical education (CME) hours with Colorado being a notable exception. Colorado’s lack of CME requirements goes against the recent trends. In 2010 the Federation of State Medical Boards (FSMB) House of Delegates voted to adopt a framework for maintenance of licensure to address concerns among policymakers and regulators (1). The FSMB’s framework contains three components: 1. reflective self assessment; 2. assessment of knowledge and skills; and 3. performance in practice.

Self-reflection has long been a mainstay of good medical practice. However, the requirement is vague and most evidence suggests that physicians are not very good at it (2). Assessment and reassessment of knowledge and skills has been present in most medical specialty and subspecialty boards for some time. Furthermore, actively practicing physicians are required to undergo periodic peer review and reapplication for hospital privileges. Further testing and assessment seems costly and largely unneeded. However, medical licensure is above all about seeing and treating patients. What is new is FSMB’s recognition of the importance of active medical practice in determining medical competence. In many instances, policymakers such as chiefs of staff, hospital board members, administrators or members of guideline writing committees have been non- or very limited practicing physicians. Their decisions have often been fundamentally flawed. Quality has been frequently politically defined rather than patient centered and evidence based. In too many cases, hastily adopted guidelines are proven wrong and even potentially dangerous to patients (3).

A physician who directs care should be subject to the “Continued Competency Rule” which is used in Colorado (4). This rule requires that a physician, “if not having engaged in active practice for two or more years…be able to demonstrate continued competency”. It needs to be recognized that those who meet this standard are only competent in their own area of practice. For example, a pulmonary and critical care physician has no business directing neurosurgical care or formulating orthopedic guidelines. Administrative medicine, and for that matter, medical journalism, would do not meet this standard of competency since neither involves taking responsibility for the care of patients. The requirement for physician administrators to be really active in the practice of medicine may be one key to improved medical care and competence. At least it should make them think about directing care or mandating a guideline that they, themselves have to follow.

Richard A. Robbins, MD*

References

1. Chaudhry HJ, Talmage LA, Alguire PC, Cain FE, Waters S, Rhyne JA. Maintenance of licensure: supporting a physician's commitment to lifelong learning. Ann Intern Med 2012;157:287-9.
2. 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.
3. Robbins RA, Thomas AR, Raschke RA. Guidelines, recommendations and improvement in healthcare. Southwest J Pulm Crit Care 2011;2:34-37.
4. http://www.dora.state.co.us/medical/ (accessed 11/5/12).

* The views expressed are those of the author and do not necessarily represent the views of the Arizona, New Mexico or Colorado Thoracic Societies.

Reference as: Robbins RA. Maintaining medical competence. Southwest J Pulm Crit Care 2012;5:266-7. PDF