Maintenance is the process of maintaining or preserving someone or something, or the state of being maintained.
Our certification documents that we have trained (in my case in internal medicine) and that we can pass a test on the breadth of internal medicine knowledge. We accept that the ABIM has developed a test the evaluates our entire exposure to the many diseases and treatments that reflect our patients.
The idea of maintenance of certification is that over time knowledge changes and thus we need to update our knowledge, our diagnostic processes, and our treatments. Internists often care for differing types of patients in 2015 than when they trained. Most internists have now differentiated into hospital-based, office-based or subspecialty based practice. Each type of internist, therefore, has different maintenance needs.
As I have written previously, and actually discussed with ABIM leadership, I favor focusing primarily on what we need to maintain our excellence.
How can one do that? We, as a profession, need to have practicing physicians prioritize new information as essential knowledge. After defining this list, many organizations can develop educational activities to help us learn these advances. Finally, the ABIM can construct testing (perhaps open book) that documents that we have learned the new stuff.
Several examples that I might include:
1. For inpatient medicine, fluid resuscitation for acute pancreatitis has advanced dramatically. Some articles suggest that lactated Ringers might trump normal saline. We need this information synthesized and learned.
2. For inpatient medicine, we care for so many MRSA patients, that we should now all the options and a process for choosing among them, as well as what side effects to consider.
3. For outpatient medicine, we need to update our knowledge of resistant hypertension. Should we use chlorthalidone rather than hydrochlorothiazide? When do we add spironolactone?
4. For diabetes, we need guidance on the myriad of oral hypoglycemics. We need to review contraindications for metformin, contraindications that have decreased over the years.
5. For all internists, we need updated knowledge on referral to electrophysiologists for AICD placement or biventricular pacing.
You can develop a rather long list. Subspecialists should suggest inclusions, but we need thoughtful practicing physicians to review the suggestions and prioritize those suggestions.
I hope that most internists would find such a process a growth process that would actually lead to true maintenance.
Given the ABIM’s recent bold and admirable declaration, I offer this concept as one that they might consider. I suspect that this proposal has some flaws, but I hope that it could provide a framework for some discussions.
Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.
