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Cool picture of Kingfisher above from Wikimedia Commons – has nothing to do with the post.

by: Alex Smith, @AlexSmithMD

It’s been 10 years since I became certified in Internal Medicine, and that means it’s time for me to re-certify.  My clinical practice is small, as I’m mostly a researcher.  The entire focus of my clinical practice is palliative care.  I used to attend on the wards, but I don’t anymore.

Can I just say how much I hate studying for the boards…again?  MKSAP again?  Really?  Why am I reading about some obscure disease that I have no interest in remembering as a palliative medicine physician?

Hospice and Palliative Medicine is one of the few sub-specialties to require board ongoing maintenance of certification in the clinician’s primary area of specialization – be it internal medicine, family medicine, pediatrics, radiation-oncology – whatever it may be (medicine subspecialties count – you could be certified in Oncology and Palliative Medicine, without maintaining your internal medicine certification).  Cardiologists, gastroenterologists, oncologists, you-name-it-“ologist” are not required to maintain certification in their primary area of specialization.  Same goes for Geriatricians – they’re not required to maintain primary board certification either.  You can be a geriatrician and never re-take the internal medicine or family medicine boards again in your life.

Some people are starting to question if palliative medicine physicians be required to maintain certification as well.  Maybe we should only be required to maintain certification in hospice and palliative medicine.

Seeming tangent: A recent article in the New York Times decried social media as stifling debate.  We surround ourselves in our online worlds with like minded people, contributing to the polarization of America.

Therefore, in the spirit of promoting debate in social media, I will now debate myself about requiring palliative medicine physicians to maintain certification in their primary specialty.  I will enumerate points, as my brother (a debater) might do on debate cards.

Palliative medicine physicians should be required to certify in their primary specialty

1. Requiring primary specialty certification is less politically threatening to specialty boards and societies.  Palliative medicine is not “stealing” their business.  Without this requirement, many people would abandon certification in their primary specialty.  This might jeopardize these important relationships and support from our specialty societies.  Palliative medicine becomes a competing specialty, from their perspective, rather than a sub-specialty.

2. Palliative medicine doctors have to be grounded in a specialty.  Palliative medicine is unique in that people come to the profession from so many diverse specialty backgrounds – in fact palliative medicine set a record for the number of sponsoring boards when it went up for accreditation.

3. We are better doctors with our specialty certification.  Grudging admission – some parts of studying for the boards have been refreshing.  There are things I feel happy re-learning that may be important to the care of my patients.  I read a MKSAP question about osteonecrosis of the hip yesterday, and was reminded of patient with a cancer who had been on long term steroids and developed hip pain.  Without the broad differential, we would have assumed it was due to metastatic disease and never considered osteonecrosis.

Palliative medicine physicians should not be required to certify in their primary specialty


1. Specialty certification is not useful clinically.  For those of us who only practice palliative medicine, there is little need for learning the vast majority of stuff required for core specialty certification.

2. Taking the time to re-certify, including board prep and maintenance of certification, comes at a cost.  There is a limited amount of space in our brains.  As I’m stuffing internal medicine knowledge back in my brain, I worry that I may be excreting important palliative care knowledge.  (This may not be true – I may be excreting unimportant fantasy basketball knowledge).  In any case, time spent studying for core certification is time not spent learning and practicing palliative medicine.

3. It also comes at a monetary cost.  Board certification is expensive!  I just dropped several Benjamin Franklins on board prep material alone.  Total cost is easily over a thousand, and that money comes out of my salary, not grant funding.  In 5 years, I’ll be paying and going through the studying again for palliative medicine.  More people might certify in palliative medicine if they didn’t have to ALSO maintain certification in their primary specialty.

4. Palliative medicine is its own specialty.  We are as deserving of being a stand alone specialty in our own right as any other field (oncology, geriatrics, etc).  Why should we be held to a different standard?  It demeans the field.

If I was not required to maintain certification in my primary area of internal medicine, would I do it?  I’m not sure, though I think the answer would be no.  It’s just not worth it to me to go through the process.

What do you think? What would you do if not maintaining your certification was an option?

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