Readers comment on MOC, ureteral injury, nonimmune hydrops fetalis
[Regarding “The top 5 challenges physicians face in 2015,” January 2015 Contemporary OB/GYN]:
Many practicing physicians are becoming angered over MOC, finding it not beneficial to their individual practices and quite burdensome. Properly done scientific studies have never proven MOC to improve the quality of care.1
Shouldn't MOC have been scientifically tested prior to its mandate? I am quite worried that MOC is damaging camaraderie in the House of Medicine especially in my field of ob/gyn.
In Los Angeles we are seeing dramatic drop-offs in attendance at our grand rounds, local meetings, and academic symposia. The hours that the non-grandfathered physicians have to spend to meet MOC requirements and complete their CME, and given the hours that we all work, time to partake in what were once very well-attended, high-quality educational meetings is limited. Analysis of attendance data from ACOG national meetings as well as regional meetings shows dramatic drop-offs. My hypothesis is that this is mostly due to MOC.2,3
Membership in our organizations is also markedly decreased.2,3
As in the Libby Zion case, well-meaning people often institute change that actually is more harmful than beneficial. MOC is one of the ideas that need to be put on hold and further evaluated academically. How many of our departments at our leading teaching hospitals are having a hard time dealing with work-hour limits for their resident staff? How many patients have been injured by hand-offs that would not have occurred if not for work-hour limits?
How do we justify damaging physician collegiality, damaging camaraderie, wasting limited valuable hours, and creating a teach-to-the-test mentality without evidence that MOC improves the quality of healthcare? Everyone agrees that physicians must continue their education. We are never done learning. The debate is whether physicians should determine how and what they learn, or should an outside, self-appointed, self-serving board.
As I asked in the February 10, 2012, issue of Medical Economics, why don't lawyers have to be recertified?4 No other profession mandates MOC. It is not required of lawyers, CPAs, dentists, architects, engineers, airline pilots, nurses, or nurse practitioners. Our courts, teeth, buildings, and bridges are not falling apart.
Half of the counties in America do not have one obstetrician to deliver a baby. Perhaps those obstetricians being paid almost $600,000 annually5 (not including other benefits and compensation) to create and administer MOC should leave their ivory towers and actually practice medicine. Perhaps ABOG should take a cue from the ABIM, which recently admitted that they "got it wrong"6,7 and put MOC on hold until well designed scientific studies could demonstrate its effectiveness. Alternatively our subspecialty should find a way to guarantee that all qualified CME is in fact improving the practice of obstetrics and gynecology. The latter scenario should lead to ABOG readdressing MOC, so that it is more in tune with the digital age and not trapped in a one-size-fits-all approach to physician continuing education.
1. Mandel HC. Maintenance of certification. N Engl J Med. 2013;368(13):1262.
2. Personal communication with leadership of the 69th Annual Obstetrical and Gynecological Assembly of Southern California, March 24, 2014.
3. Mandel HC. Recertification and maintenance of certification. Journal of American Physicians and Surgeons. 2011;16(3):65.
4. Mandel HC. Why don’t lawyers have to be recertified? Medical Economics. 2012;
5. Change Board Recertification. The Board’s form 990 income tax returns. http://www.changeboardrecert.com/tax-returns.html. Accessed February 10, 2015.
6. American Board of Internal Medicine. AMB announces immediate changes to MOC program. http://www.abim.org/news/abim-announces-immediate-changes-to-moc-program.aspx. Accessed February 10, 2015.
7. American Board of Internal Medicine. MOC FAQ. http://www.abim.org/maintenance-of-certification/moc-faq/default.aspx. Accessed February 10, 2015.
Howard C. Mandel, MD, FACOG
Los Angeles, California
Thank you for your letter. The article you reference originally appeared in the pages of our sister publication Medical Economics, and your concerns are apparently shared by a number of other commenters on the website MedicalEconomics.ModernMedicine.com .
Some of their comments:
“I am outraged by the unprofessional way that physicians are being treated in my own home country by our own colleagues. MOC has to stop.”
“MOC either has to go completely, or be radically revamped. Fight the power!”
“It will be interesting to see how the future of MOC will look. Right now it is still an ugly duckling.”
“Physicians are no longer afraid to speak their minds about MOC. We are on the right side of the truth here and will not rest until the MOC scam is fully revealed and abolished.”
“The MOC is making money for those who run it and placing a major economic burden on those who have to fulfill it, otherwise we are seen as less qualified physicians. It proves NOTHING.”
Charles J. Lockwood, MD
I read with interested followed by disappointment Dr. Magrina's article on ureteral injury during hysterectomy [“Preventing ureteral injury at hysterectomy: an expert approach,” October 2014 Contemporary OB/GYN] and the subsequent letter to the editor and response that appeared in the January 2015 issue of Contemporary OB/GYN.1,2 Dr. Magrina is a highly respected surgeon and considered by many of us to be an influential thought leader and innovator in our field. It is unfortunate there seems to have been a misunderstanding between Dr. Magrina and Dr. Harmanli and I am concerned readers of the journal may have been left with an inaccurate description of the risks of ureteral injury associated with different routes of hysterectomy.
Dr. Magrina is correct in stating the findings as they were reported in the 1991 study by Stanhope et al.3 But Dr. Harmanli is also correct in pointing out the rate of ureteral injury reported in this study was related to the culdoplasty/uterosacral suspension procedures performed on these patients, not simply the vaginal hysterectomy. Thus it is probably not the best reference for comparing ureteral injury associated with different routes of hysterectomy. It is also important to note that the patients in that particular study did not undergo intraoperative cystoscopy which is routinely done today and significantly reduces the rate of ureteral injury during prolapse surgeries involving uterosacral ligament suspension.4
While Dr. Magrina is correct in stating the rate of ureteral injury may be higher, lower or similar in other reports, readers of the journal should be aware that current best evidence suggests ureteral injury is lowest with vaginal hysterectomy compared to laparoscopic and abdominal approaches.5-7
1. Magrina JF. Preventing ureteral injury at hysterectomy: an expert approach.Contemporary OB/GYN. 2014;59(10):14–27.
2. Harmanli O. Regarding 'Preventing ureteral injury at hysterectomy: an expert approach.'Contemporary OB/GYN. 2015;60(1):39.
3. Stanhope CR, Wilson TO, Utz WJ, Smith LH, O’Brien PC. Suture entrapment and secondary ureteral obstruction. Am J Obstet Gynecol. 1991;164:1513–1517.
4. Gustilo-Ashby AM, Jelovsek JE, Barber MD, et al. The incidence of ureteral obstruction and the value of intraoperative cystoscopy during vaginal surgery for pelvic organ prolapse. Am J Obstet Gynecol. 2006;194:1478–1485.
5. Garry R, Fountain J, Mason S, et al. The eVALuate study: two parallel randomised trials, one comparing laparoscopic with abdominal hysterectomy, the other comparing laparoscopic with vaginal hysterectomy. BMJ. 2004;328:129–136.
6. Nieboer TE, Johnson N, Lethaby A, et al. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev. 2009;3:CD003677.
7. Brummer TH, Jalkanen J, Fraser J, et al. FINHYST, a prospective study of 5,279 hysterectomies: complications and their risk factors. Hum Reprod. 2011;26:1741-1751.
Michael Moen, MD, FACOG, FACS
Park Ridge, Illinois
I read with interest your article on the work-up of nonimmune hydrops fetalis (NIHF) [“SMFM Clinical Guideline: Nonimmune Hydrops Fetalis,” February 2015 Contemporary OB/GYN]. In the differential diagnosis, there is a fairly unusual cause of NIHF that readers may want to keep in mind. I recently did a literature review and case study of a fetomaternal hemorrhage. This condition can result in NIHF caused from a chronic fetal blood loss to the maternal circulation to the point of causing significant fetal anemia and hydrops.
The most consistent presenting symptom in this condition is the mother’s report of decreased fetal movement. Diagnosis can be assisted by a peak systolic velocity on the fetal middle cerebral artery and a Kleihauer-Betke test. Electronic fetal monitoring may or may not show a characteristic sinusoidal pattern consistent with fetal anemia.
The case study in our population was diagnosed postnatally as a fetomaternal hemorrhage. The mother presented with decreased fetal movement. A Doppler flow study done on the umbilical cord was abnormal, and a nonstress test followed which was nonreactive. The mother had an uneventful pregnancy, and had no risk factors for fetal anemia or a fetomaternal hemorrhage. The infant was delivered at 35 weeks via emergency cesarean section, with Apgars of 1, 3, 5, and 7, and an admission hemoglobin and hematocrit of 2.1 g/dL and 7.9%. Through good care and some divine intervention, this infant is thriving and developmentally normal at 6 months.
Although our case did not develop hydrops, fetomaternal hemorrhage is one cause of NIHF, and should be considered in the differential diagnosis.
Janet C. Place, CNM
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