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Regarding Part IV of Recertification in Neonatology: A Consensus Perspective of 69 Academic Neonatology Section Heads

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Disclosures: no information in this manuscript has been previously published. The authors had no pertinent conflicts of interest to disclose. All participants approved the wording of the manuscript after participating for more than two weeks in an online forum to draft this perspective. The author’s names on the manuscript should be seen by the e-journal and its readership as the equivalent of a signature in testimony to this. The author order is according to that in which their signatures were given after reaching consensus.


Dear Editor,

We, a substantial portion of the leadership in academic neonatology, are generally supportive of maintenance of certification (MOC) and of the American Board of Pediatrics (ABP). However, the ABP’s approach to MOC has drifted away from verification of individual accountability and professional performance towards a system-based measure of quality improvement with the new Part IV requirement in neonatology. This is a marked deviation from other medical boards and represents a fundamental change in the concept of assuring professional competence.  While assessing quality improvement in the practice setting is conceptually appealing, in the systems-based setting of in-patient medicine, rarely would this activity actually reflect an individual’s professional performance. Participation in an approved quality improvement initiative might imply an individual’s conceptual understanding of that process, but does not assure, nor measure “satisfactory performance in practice,” which is the stated goal of Part IV MOC.  In actuality, most clinicians will participate in accredited projects simply for the purpose of maintaining certification, taking time away from more important professional activities. In light of this inherent conflict, we feel that this approach is fundamentally flawed.

Within the in-patient setting, effective quality improvement is commonly accomplished by the leadership of a few physicians and nurses, with more passive participation by  collaborating clinicians who may be productive professionally through other equally important avenues, including activities measured in Part II of MOC, advocacy, hospital and regional committees, journal editorships, oversight of facility-based improvements, basic research, clinical research, fellowship education, NRP certification of staff, and long term outcome projects. Part IV should encompass professionalism in all of its forms, each of which directly or indirectly contributes to improved patient care.  For the purpose of assuring the public of an individual’s “performance in practice,” one should be able to include the above activities plus some measure of an individual’s clinical competency, as many other boards have required for certification.  Such a change should result in improvement in the MOC process, which, under current rules, puts some academic and smaller private practice neonatologists at a disadvantage relative to those participating in corporate-based collaboratives, those whose institutions can afford to participate in costly national network collaboratives, or those few who can participate in state network collaboratives (all of whom have clear financial and logistic advantages under current rules). The simplest methods for this (and those currently used by most other medical boards) would be through third party verification of administrative and advocacy activities; parent testimonials or chart reviews of clinical proficiency; and submission of publications and funded grants.

None of these alternatives excludes the option of quality improvement as a certifiable professional activity when it is an active pursuit, but we object to the emerging concept that our professional status as individual practitioners can be tied to quality improvement initiatives through our institutions. Institutions are not board certified; individuals are. That is a critically important distinction in this discussion. Neonatologists who receive accreditation for MOC by passively participating in network-based quality improvement initiatives may not actually be demonstrating satisfactory individual performance in practice.  Others, who devote much of their professional time to activities which improve patient outcomes, may not receive MOC credit because their activities do not comply with the rigid ABP MOC requirements.   We are extremely uncomfortable with this precedent. Specifically, we do not think that corporate or network-based quality improvement initiatives should be viewed by the ABP as being synonymous with adequate professional performance by the individual.  While we applaud the ABP’s goal to require an individual’s commitment to improved patient outcomes as part of the certification process, current expectations and measurements in Part IV of MOC are inadequate to meet that goal.  We urge that the outcome measures of this process be revisited.

Signed,

1. Phillip V. Gordon, Tulane Children’s Hospital and Tulane School of Medicine

2. Steven R. Seidner, University of Texas Health Science Center at San Antonio

3. Jonathan M Davis, Tufts University School of Medicine

4. Robert Schelonka, Oregon Health and Science University

5. David J. Durand, Children’s Hospital & Research Center Oakland

6. Jeffrey Segar, University of Iowa Children’s Hospital

7. Kristi Watterberg, University of New Mexico School of Medicine

8. Karen D. Hendricks-Munoz, New York University School of Medicine

9. Gary A. Silverman, University of Pittsburgh School of Medicine

10. Henry J. Rozycki, Children’s Hospital of Richmond and Virginia Commonwealth University School of Medicine

11. James F. Padbury, Women & Infant’s Hospital of Rhode Island

12. Siva Subramanian, Georgetown University Hospital

13. Lewis P. Rubin, University of South Florida College of Medicine

14. Dennis Davidson, Steven and Alexandra Cohen Children’s Medical Center of New York

15. Wally Carlo, University of Alabama at Birmingham School of Medicine

16. Billie Lou Short, Children’s National Medical Center

17. Joan Richardson, University of Texas, Medical Branch of Galveston

18. Francis J. Bednarek, University of Massachusetts Medical School

19. Ian Gross, Yale University School of Medicine

20. Leif Nelin, The Ohio State University and Nationwide Children’s Hospital

21. David G. Oelberg, Eastern Virginia Medical School

22. Cynthia Bearer, University of Maryland School of Medicine

23. Neil N. Finer, University of California at San Diego School of Medicine

24. Robert A. Sinkin, University of Virginia School of Medicine

25. Eduardo Bancalari, University of Miami Leonard M. Miller School of Medicine

26. James Greenberg, Cincinnati Children’s Hospital Medical Center

27. Rita M. Ryan, University at Buffalo Women and Children’s Hospital of Buffalo

28. Jeffrey M. Perlman, Weill Cornell Medical School

29. Alan D. Bedrick, University of Arizona Health Sciences Center

30. Stella Kourembanas, Harvard Medical School

31. Rashmin C. Savani, University of Texas Southwestern Medical Center at Dallas

32. Edmund F. La Gamma, New York Medical College

33. Ramasubbareddy Dhanireddy, University of Tennessee Health Science Center

34. Feizal Waffarn, University of California at Irvine School of Medicine

35. Deborah Campbell, Albert Einstein College of Medicine and Children’s Hospital at Montefiore

36. Robert Lane, University of Utah

37. Michael K. Georgieff, University of Minnesota School of Medicine

38. Robin H. Steinhorn, Children’s Memorial Hospital and Northwestern University

39. William H. Edwards, Children’s Hospital at Dartmouth

40. David H. Rowitch, University of California at San Fransisco School of Medicine and Children’s Hospital

41. Ronald N. Goldberg, Duke University Medical Center

42. Daniel R. Dirnberger, Wilford Hall Medical Center

43. Robert Arrington, University of Arkansas Medical Center

44. Micheal Horgan, Albany Medical Center

45. Ganesh Konduri, Medical College of Wisconsin

46. Nazeeh Hanna, Winthrop University Hospital

47. David Burchfield, University of Florida College of Medicine

48. John J. Moore, Case Western Reserve University School of Medicine

49. Jay Milstein, University of California at Davis School of Medicine

50. Suma Pyati, John H. Stroger, Jr. Hospital of Cook County

51. Howard Kilbride, Children’s Mercy Hospital, University of Missouri- Kansas City

52. William Meadow, University of Chicago Pritzker School of Medicine

53. Istvan Seri, Childrens Hospital Los Angeles and The LAC+USC Medical Center, Keck School of Medicine, USC

54. Kathleen A. Kennedy, University of Texas at Houston Medical School

55. Henrietta S. Bada, University of Kentucky

56. De-Ann M. Pillers, University of Wisconsin-Madison School of Medicine and Public Health

57. Brian Barkemeyer, Children’s Hospital of New Orleans and Louisiana State University Health System

58. Ian R. Holtzman, Mount Sinai School of Medicine

59. Charles Palmer, Penn State Children’s Hospital

60. James Cummings, East Carolina School of Medicine and Pitt County Memorial Hospital

61. Ira Gewolb, Michigan State University College of Human Medicine

62. Venkataraman Balaraman, John A. Burns School of Medicine, University Of Hawai‘i

63. Jacob V. Aranda, Children’s Hospital of Brooklyn and State University of New York Downstate Medical Center

64. Jahtinda Bhatia, Medical College of Georgia

65. Shanthy Sridhar, StonyBrook University Medical Center

66. Virender Rehan, University of California at Los Angeles Medical Center, David Geffen School of Medicine

67. David P. Carlton, Emory University School of Medicine

68. Seetha Shankaran, Wayne State University School of Medicine

69. Michele Walsh, Case Western Reserve University

PII: eJNR21606072v1i1p7y2011

THIS LETTER IS OPEN TO MODERATED COMMENTARY. USE THE COMMENTS SECTION BELOW TO SEND A COMMENT YOU WOULD LIKE THE EDITOR TO CONSIDER FOR PUBLICATION.

Written by Dr Phillip Gordon

March 29th, 2011 at 4:35 pm

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  1. The word individual comes up again and again in the neonatologists’ letter. Yes, individual responsibility and skills are important to evaluate. However, studies of medical errors reveal that communication, coordination and teamwork are critical conditions for reducing errors, not the skills of one individual. We all need to check our egos at the door and work together in multidisciplinary teams to assure that all of our patients receive the highest quality and safest care modern health care delivery can provide. The board is to be commended for taking a stand against the status quo that continues to emphasize the individual over the team.

    DR. Frederick S. Southwick

    24 Jul 11 at 2:03 am

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