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New Mexico Governor's Newsletter December 2018

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Betty Chang, MDCM, PhD, FACP, FACCP, ACP Governor

Betty Chang, MDCM, PhD, FACP, FACCP, ACP Governor

 


Congratulations to Our New Governor-elect Designee

Our new Governor-elect Designee is Heather Brislen, MD, FACP. Heather will take over as Governor in April of 2020. For those of you who don't know her, Heather is a General Internist in the Albuquerque area in her own direct primary care practice. She is a local New Mexican, who attended medical school and residency at The University of New Mexico.

Welcome, Heather.

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ABIM Recertification – Two Perspectives

Betty Chang – 10-year recertification at a testing center

After a long debate with myself, I opted to take the 10-year recertification. As a subspecialist, if I pass the 10-year, it is probably the last time I take the IM boards. There were only 4 dates available for my exam, at the Pierson-Vue Testing Center – October 19, 22, 24, and 26. I had patients scheduled on the 19th, I was post night call on the 22nd, I was flying to Philadelphia for an ACP meeting on the 24th, which left the 26th open. But, I had to trust that I could get back from Philadelphia on time to not miss the test.

Luckily, my sister wisely suggested I take the test in Philadelphia rather than trying to get home. I had been stressing out about how I could fly through Denver or Dallas, which had a lower likelihood of bad weather. So I booked my hotel another two nights and scheduled my test in Philadelphia.

My OCD kicked into high gear in June after a board review course, and I started studying. I was able to study between 2-10 hours per week, depending on my work obligations. I used MKSAP digital on my laptop, work desktop, and my phone. Standing in the grocery store line or waiting in the car to pick up my kids, I could do one to two questions, or keep reading.

I started with a topic I thought I would be okay with – Cardiology. It wasn't. If A, B, and C, then you do a vasodilator nuclear medicine study, if B, D, and F then a stress echo … I quit half way through and moved onto ID. There, I discovered that I don't use antibiotics the way they do elsewhere in the country, but persevered. It took me until early October to get through all MKSAP books. During this time, nearly every non-family, non-work moment was taken up by studying. Then I started creating MKSAP tests of questions that I had gotten wrong. I got to the point, I think I memorized many of the questions.

I stopped studying two days before the exam, and tried not to stress out about a one time, everything at stake exam. On my flight to Philadelphia, I realized I only had credit cards and my NM driver's license on me, which induced another panic attack that I didn't have 2 forms of photo ID. Didn't sleep well the next two nights, despite melatonin.

On the morning of the exam, I walked to the testing center, which helped me wake up. When I got into the exam, there were people taking all kinds of exams – NOT just IM recertification. Turns out my picture credit card and driver's license were what I needed. Got fingerprinted, frisked, showed my arms (nothing written on them), nothing in my hair, nothing in my hoodie, now I can go in. I got assigned a cubicle, the chair was a little short, and it took me a while to get it to the right height. Then, begin.

Freaked me out, but the system allowed me to look up normal values, medication names, basic formulas, AND UpToDate!!!! May be they told me this, and I was not paying attention. Why did I spend all that time trying to remember all my –mumabs, -cept, -gliptin, and –atide drugs?!?

Of course, the worst thing you can do to a crazy OCD person is give them open access to a double-checking resource. So, I started checking every answer. When my first 10 questions, took me 30 minutes of my first 120 minutes, I mentally slapped myself. From there on out, I flagged the ones I didn't know and went back later to look those up. I had 120 minutes per section of 55-60 questions.

After section one, I left the testing room to use the bathroom. This process takes about 15-20 minutes depending on who else may be out of the room. You have to check out, get a key, down the hall to the bathroom, return the key, and check back in (fingerprint, frisking, arm check, hoodie inspection, hair lifting). After the second break, I thought about going out to lunch, but instead decided to eat the snacks I had in my purse. After the third book, I felt okay, and not tired, so I powered through to the end without a break.

I finished my exam at 2pm. It took me just under 6 hours. It felt like a lot longer. It was good I had made dinner plans before I took the exam, because I wasn't capable of decision making afterwards.

In hindsight, I would do the 10-hour exam again. If I had known that I had UpToDate access, I would not have bothered studying the MEN syndromes, and my RTAs, which I have forgotten within minutes of reading since I started medical school. It was a hassle fitting the testing date into my life, given there are only 4 dates to choose from.

I found out 5 weeks after my exam that I passed.

Liz Lawrence - Two year knowledge check-in at a testing center

I ignored the millions of e-mails about changes in the MOC process until I was faced with the need to recertify this year. When I finally reviewed my options, I chose the new knowledge check-in exam because:

  • Assessment drives learning: I liked the idea that I would be accountable for reviewing the broad field of internal medicine every two years rather than every ten years, particularly as my scope of practice as a general internist has narrowed over time.
  • MOC is changing: I imagined that there would be additional options for maintaining my certification by 2020.
  • Life happens: I was not sure I had the time to devote to studying for the 10-year recertification this fall because of other commitments I had already made.
  • Open book: Initially, the check-in was the only open book option. I could not imagine memorizing the glomerulonephropathies and the clotting cascade again.
  • Immediate gratification: I liked the idea of knowing whether I had passed as soon as I completed my test.

Now that the ten-year certification allows for access to UpToDate, I am wondering if I made the right decision to take the knowledge check-in. Being a compulsive internist, I ended up studying as hard as I would have studied for the traditional exam. I worked my way through all 11 MKSAP books and all of the MKSAP questions in the 4 months leading up to the exam. I did not take a board review course, but might have felt compelled to do so if I had chosen the 10-year recertification exam. I was much less anxious about the check-in than I would have been for the traditional exam, and this lower stress level was beneficial for me and my family. I do believe being tested every 2 years will strengthen and broaden my knowledge of internal medicine. Finally, I really did like receiving my passing grade on exam day.

Whichever option for recertification you choose, anticipate some surprises. I was astonished to see MKSAP questions on smallpox and anthrax; there is a whole section in ID now about bioterrorism. I was even more surprised by the near absence of questions about the opioid epidemic and appropriate pain management. Nothing was more shocking, however, than to realize that all of the 50-something patients who present with significant pathology in MKSAP questions are actually younger than I am. When did that happen?

On balance, I would choose the knowledge check-in again: less pressure, less anxiety, better for my practice, and immediate results. BUT… ask me again in 2020, when Betty is hanging out with her family and I am hanging out with MKSAP.

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NM ACP Legislative Update

The NM legislative session runs January 15-March 16 this year. The New Mexico Medical Society hosted an event recently for physician stakeholders to share their legislative priorities with Rep. Bill Pratt MD (D-27) and Rep. Gregg Schmedes MD (R-22) and I attended as a representative for NM ACP. There are many impactful health bills that will be on the docket in the coming year. NM ACP is planning a legislative visit day in Santa Fe, tentatively set for February 21 (more details to come soon!). Also, Save the Date for ACP Leadership Day in Washington, DC, May 14-15, 2019.

Here is a sample of legislation we expect to see at the state level:

  • Medical Malpractice Act (MMA) is expected to be amended soon and there will be a memorial introduced that would call for the creation of a Professional Liability Act Task Force to organize important stakeholders to collectively study the MMA in the 2019 interim prior to amendments expected in 2020.
  • New Mexico Health Security Plan - a request to study this state based single payer proposal via fiscal analysis and other options for provision of health security plan.
  • Palliative Care Council - will be proposed by Sen Craig Brandt to tie in with Medical Aid in Dying bill. Services for out of Albuquerque are lacking yet very needed, this would create a council to advise the secretary of insurance, department of finance and HHS on provision of palliative care.
  • Medical Aid in Dying - would legalize MAID and establish guidelines. No person subject to civil or criminal liability or professional disciplinary action for participating or for refusing to participate. Annual report available to the public of the activity of MAID.
  • Medicaid Buy-In - Establishes a mechanism for coverage for New Mexicans without insurance.
  • Prior Authorization - to standardize and streamline prior authorization process for all health insurance. Adopt uniform prior authorization form medical care and prescription drugs. Adopt list of all medications for no prior authorization ... and many other provisions.
  • Scope of Practice - would establish an interim committee to ensure that all expanded scope of practice legislation thoroughly vetted prior to session.
  • E-Cigarettes (4 Bills) - via clean indoor air act (no vaping inside). Limit sales to over 21. Include E-cigarettes as tobacco product for tax purposes.
  • Surprise Billing – prevents refusal of coverage in emergencies.
  • Decriminalization of abortion - seeks to repeal pre-Roe v Wade law threatening abortion providers with felony charges

Any NMACP members interested in attending a legislative visit in Santa Fe in February, please contact me. NM ACLU will be working on the abortion decriminalization bill and has a training coming up. Any interested RESIDENT physicians in particular, please contact me for details.

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Wellness Column

by Dr. Liz Lawrence

I experienced my first Iron Man last month. I was exhausted and sore after the 2.4-mile open water swim, the 112-mile bike ride, and the 26.2-mile run … and I was just a spectator. I wonder how the athletes felt.

For those of us who do not aspire to finish Iron Man races, here are some tips on how to work exercise into our busy schedules.

  1. Think about your goal. The newly-released second edition of Physical Activity Guidelines for Americans calls for adults to complete at least 150 minutes of moderate-intensity exercise, 75 minutes of vigorous activity, or an equivalent combination of moderate and vigorous activity every week. We should also engage in strength training twice weekly, and older adults should do balance training. You can read more in JAMA .
  2. Gretchen Reynolds reports on the latest science of fitness in the NY Times almost weekly. Her columns are well written, funny, and motivating. You can start to explore her work on the NY Times website. Here is a sample article.
  3. The Mayo Clinic has a helpful article on “fitting in fitness” – you can use this yourself, or share with patients: Fitting in Fitness
  4. View the video from the Mayo Clinic for 5 desk exercises. I recommend that you have a pen and paper handy to jot down the exercises.
  5. WebMD published a list of helpful desk exercises to relieve low back pain.

Wishing you all a happy and healthy 2019.

Best,

Liz Lawrence, MD, FACP
Associate Professor of Internal Medicine
Director, Physician and Student Wellness
UNM School of Medicine

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