Bored Recertification

Don't forget about ascariasis, strongyloidiasis, and schistosomiasis as less common causes of myocarditis.  Less common?  No kidding?  I wouldn't have thought.

I'm sitting in a cardiology board review course in a hotel in Skokie, Illinois.  Every 10 years my colleagues and I have to take an exhaustive competency examination if we want to continue to remain "board certified," a descriptor of great importance in the modern healthcare environment.  I'm currently in day 3 of a 5-day marathon, having just sat through a lecture on congestive heart failure and cardiomyopathy that lasted an astounding 5 hours (you have to give the speaker points for stamina).  As part of his tutorial he gave us a list of infectious causes of cardiac muscle inflammation, a menu that includes words like leptospirosis and actinomycosis—terms that I haven't heard since my infectious disease rotation in residency.

They tell us they hold this course in Skokie instead of downtown Chicago to keep the costs down, but I think it's because they don't want us to be tempted to shopping on Michigan Avenue.  We start at 7 in the morning and sit in a cramped conference room for 12 hours straight while we review every aspect of cardiovascular disease.  As my head spins with information and calluses form on my caboose I've come to believe that time actually slows down in situations such as these—five days in Skokie ages me by 6 months.

When you suspect Chagas cardiomyopathy don’t forget to ask the pathologist to run indirect hemagglutination and fluorescence assays on your biopsy specimen.  Thanks.  I'll be sure to do that when I come across Chagas while trekking through central America.

When I have to see a proctologist for all the new hemorrhoids I'm developing at least I’ll know where to send the bill: Dr. Michael Aaronson.  You see, I hadn't planned to attend a board review course until I got on the subject of recertification with Dr. Aaronson who just last year was ten years out from fellowship and took his nephrology recertification exam. Dr. Aaronson, a prolific blogophile, happens to be one of the smartest guys I know, but even he struggled with the arcane minutiae that shows up on the test and which we obviously don't see in daily practice.  He had taken a review course and strongly urged that I do the same.

We doctors gripe about having to do this sort of thing.  Why, we ask, when we practice our specialty day in and day out, do we have to go back to the basics and study the type of stuff we haven't seen or heard of since our days in fellowship training?  Why do I need to know what the cellular pattern of cardiac rejection looks like under the microscope if I don't even know where to find a microscope in my hospital, let alone a patient with a transplanted heart?  How important is it for me to understand the genetic difference between immunoglobulin light chain amyloidosis and transthyretin amyloidosis?

When I open up the coding portion of my practice's electronic medical record system I can click a button that gives me a list of my most commonly employed cardiac diagnoses.  Using this as an informal gage I can get an idea what sorts of diseases I see on a regular basis.  My most commonly coded diagnosis is hypertension, followed closely by coronary artery disease and high cholesterol.  Rounding out the list of the type 10 are atrial fibrillation, cardiomyopathy, congestive heart failure, palpitations, chest pain, valvular heart disease, edema, and diabetes,   I don't have any data to support this but I would guess that these diseases are responsible for about 98% of what I do for non-hospitalized patients.   Pretty much any cardiologist you find will be not just competent but likely very skilled at treating the disorders on my top-ten list.  The reason is simple: you get good at what you do most frequently.

And don't forget about the role drugs like phenytoin and aminophylline can play in eosinophilic hypersensitive myocarditis.  Thanks.  I'll be sure to remember that whenever I write Dilantin prescriptions for my seizure patients.

So why the recertification every ten years?  I don't know what goes through the minds of the experts who make such rules, but I can tell you two reasons why I think it's a good idea.

The first relates to feedback.  As a doctor in training (medical school, internship, residency) you always have someone looking over your shoulder telling you if your judgment is correct.  Do you have the right diagnosis?  Are you starting the right treatment?  Did you consider all the possibilities?  When you're a medical student you can count on being wrong much of the time, but that likelihood diminishes as you progress through your training.  Still, even in the final year of your subspecialty training you've got someone reviewing your work and making suggestions and corrections.

Once you get out into practice it's a different story.  With no one telling you that some of your choices are wrong you begin to believe—slowly, imperceptibly, and erroneously—that you are always right.  When you arrive at this point you begin to become a little dangerous.  Believing yourself to be always right leaves you unable explore other possible approaches to therapy or to adapt to new information.  To make matters worse, medical science progresses unrelentingly as you remain mired in your static knowledge base.

Forcing us to repeat our board certification test—to make us effectively start from scratch every ten years—compels us to dust off the textbooks, revisit the latest medical guidelines, and keep up (or at least try) with ongoing advances.  When we do this we begin to have some insight into the fact that we may not indeed have a solid knowledge about all aspects of our specialties.

The second reason relates to the odd, rare illnesses that don't fall into my 10 most commonly coded diagnoses.  Living in Nebraska it's highly unlikely that I'll run across a case of Chagas cardiomyopathy, but who knows?  Since I left fellowship 10 years ago I've encountered a number of oddities that don't typically find their way into my Omaha clinic.

More compelling are the rare diseases that slip past me.  A few years back I missed the diagnosis of sarcoidosis in a patient I saw with congestive heart failure.  Just this year I failed to correctly diagnose and treat a man with fascicular ventricular tachycardia.  Who knows, maybe if I had been studying for my board test in the weeks before these encounters I may have been more accurate in my clinical assessment?  These are cases where I know I got it wrong because another doctor figured out the right answer.  How many times have I missed the right answer and was never even aware?

Despite my urge to lay my head onto my thick binder, drift into a recuperative coma and drool on my notes, I'll stay focused and alert.  I owe it to all the future patients with strange syndromes and rare diseases who rely on me to figure out their problems—especially those I encounter while trekking through the jungles of Central America.