CardioExchange Archive

My father, now in his third decade of practicing family medicine, is always willing to give me advice. But his greater joy seems to come from showing me how much I don’t know. He leaves CME clippings from academic journals on my desk or the kitchen counter, to read when I’m home for the holidays. The American Family Physician journal’s photo quiz is a favorite of his, and while I am frequently stumped, occasionally the answer actually is chalazion. He, on the other hand, is quite adept, and I haven’t seen him get one wrong.

Considering my father’s broad knowledge of all things primary care, I was surprised when we got into a discussion about aspirin over dinner at a restaurant known for its extensive salad bar.

“You eat well and are health conscious,” I said. “But given your age and our family history of MI, would you benefit from taking aspirin for prevention?”

His response was a negative: “There wouldn’t be any benefit, and it would expose me to the risk of gastrointestinal bleeding.”

So I broke dinner etiquette and placed my smartphone on the table. I accessed the Agency for Healthcare Research and Quality’s Electronic Preventive Services Selector (ePSS). The ePSS is a well-constructed application that aggregates U.S. Preventive Services Task Force (USPSTF) recommendations so that they are relevant to the patient in front of you and easy to read on the spot.

I entered the few required variables — on age, sex, pregnancy status, tobacco use, and sexual activity — and showed him the level A recommendation: aspirin. A helpful link to the NIH’s cardiovascular disease risk calculator is also embedded in the application, and within a few moments we could determine that his expected benefit from taking aspirin outweighed his risk for bleeding.

Our dinner reminded me of the perplexing inverse relationship, which this Annals review article seemed to detect, between increasing physician experience and a variety of performance measures. If I use age less than 40 as a rough estimate for when things start going downhill, and assuming I work until age 65, I’ll reach my professional peak as a doctor in 13 years, with the next two-thirds of my career spent in slow decline. Presumably, I’ll start ordering prostate-specific antigen tests for all my male patients, tell my female patients to do routine self-breast exams at home, and order MRI of the lumbar spine for anyone with back pain.

Could it be true that as my time away from medical school graduation increases, the likelihood of my adherence to standards of care decreases? One review article lists 293 potential barriers to adherence, broadly listed under categories of knowledge, attitude, and behavior. From a regulatory perspective, testing someone’s knowledge is the easiest way to assess competence, and formal interactive CME sessions have some evidence of improving physicians’ performance.

But even if dwindling knowledge were to explain aging-related declines, the Institute of Medicine and many others nonetheless believe that the CME system is a very poor way to address the knowledge deficit. I wholeheartedly agreed with this when I examined various states’ CME requirements and realized I would be halfway done with certification in Arkansas after completing 10 AMA PRA Category 1 Credit™ opportunities. My list:

1. Is Employment the Only Alternative? Improving Care Coordination through Clinical Integration
2. Delivery Reform Implemented? Payment Models that Reward Your Performance
3. The Final Piece of the Puzzle: Customizing the Payment Model to Fit Your Practice
4. Health IT Adoption Online Modules
5. Health IT Workflow Analysis Tutorials
6. Principles for Physician Employment
7. Organized Medical Staff Section Webcast
8. Doing the Right Thing for Our Patients — Leading as a Professional
9. Physician Employment Agreements (AMA Models)
10. Physician Leadership during Challenging Times

It isn’t entirely clear how my choices from this list would translate into better patient care, but I’d certainly know more about physician employment agreements. So I find myself wondering whether CME will ever improve doctors’ ability to care for patients. Suppose that we learn the most up-to-date way to approach a medical condition upon first encounter, when we have no pre-formed mental heuristics, and that with increased exposure the need to consult the literature decreases. Bias begins to set in, and the benefit of future knowledge exposure diminishes.

Consider, instead, if the Centers for Medicare and Medicaid Services and insurance companies were empowered to detect deviant prescription and billing practices that indicate poor-quality care. This information could then be sent to each state’s accrediting body, to determine whether a formal interactive class is appropriate. With this approach, behavior rather than knowledge is the trigger, which makes for a more targeted intervention.

Incidentally, my father still does not take aspirin. He refuses any medication and prides himself on not having used a pain reliever since 1975.

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