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The Not So Skinny on Exercise Associated Muscle Cramps

I’m just about fully recovered by a sudden case of shin splints and calf cramps in both legs this past Monday. I did no running, just walked for a little over 4 miles between our house and the shopping mall.

I thought I was doing pretty well until I got about a half mile from home. I had to cross a relatively busy street that doesn’t have a traffic light control, just a sign that suggests drivers slow down and stop for pedestrians in the crosswalk. Many drivers breeze through at around 30 mph and so I generally wait until there’s no traffic or when cars slow down enough that I can’t see the driver’s maniacal grin.

As a few cars waited, I began to cross the street and about halfway over, I started to trot and immediately both my calves cramped up. It was painful and I just managed to limp over to the sidewalk. As I leaned over and tried to ease the cramps by grabbing my toes and bending them toward my shins, I wondered why that happened.

Part of the reason was this was the first long walk of the spring after a winter of being relatively sedentary, other than some routine exercises including stationary bicycle, step box, and stretching routines.

I’m used to shin splints, which I noticed before the leg cramps. But I’ve never had both calves cramp like that. I’d gotten enough fluids, I wasn’t dehydrated, and I wasn’t low on electrolytes. Then, I got curious about the interplay of all those and found out there’s a fair amount of controversy about the causes of what I found out was called exercise-associated muscle cramps (EAMC)

Shin splints are a minor annoyance and could be due to me just being an old guy overdoing it and wearing not the greatest shoes on a concrete trail. Resting a while is the main way to get past it. But because of the double whammy of bilateral shin splints and calf cramps, I hunted on the internet for studies of the causes of EAMC, specifically calf cramps.

I’m sure most readers are familiar with web resources like the Cleveland clinic, which provide general guidance. They usually recommend avoiding dehydration and staying up to speed on electrolytes. Rest is the main suggestion. Meditating over an oleomargarine figurine of Elvis Presley is not recommended but has not been sufficiently studied.

Anyway, I found an interesting web site which challenges the usual guidance about the causes of EAMC. One of the authors of an article (“What Are the True Causes of Cramps While Running?” by Phattarapon Atimetin, MD; published May 15, 2019 on the website samitivejhospitals.com website) disputing the cause of EAMC being dehydration or mineral deficits pointed out that these are less likely than something called “altered neuromuscular control,” which appears to be advanced by a scientist named M.P. Schwellnus. However, the author didn’t cite any references, so I had to hunt them down. I think I found the right articles.

I found one the author didn’t mention, which was a comprehensive review (note the publication date, a few months after Dr. Atimen’s article):

Maughan RJ, Shirreffs SM. Muscle Cramping During Exercise: Causes, Solutions, and Questions Remaining. Sports Med. 2019 Dec;49(Suppl 2):115-124. doi: 10.1007/s40279-019-01162-1. PMID: 31696455; PMCID: PMC6901412.

The authors’ bottom line is:

Exercise-associated muscle cramp is a relatively common occurrence in a range of sport and exercise activities. Onset is generally unpredictable, and the intensity and duration of muscle spasms are highly variable. Spontaneous muscle cramping in occupational settings involving hard physical effort suggests that high ambient temperature and large sweat losses accompanied by the ingestion of large volumes of plain water may be risk factors, and there is some evidence that the risk is reduced by the addition of salt to ingested fluids. Laboratory models of cramp involve either voluntary or electrically-evoked activation of muscle held in a shortened position. These studies have produced mixed results regarding the effects of disturbances of water and salt balance on the risk of cramping; however, they do suggest that, at least in this model, sensory organs in the muscle invoke abnormal reflex activity that results in sustained motor drive to the afflicted muscles. There may be different mechanisms at work in different situations, and there is no conclusive support for any of the proposed mechanisms. Preventive and treatment strategies are not uniformly effective.

They mention M.P. Schewllnus, but they don’t endorse the altered neuromuscular control theory or any other as being explanatory in every case of EAMC. The review was supported by the Gatorade Sports Science Institute (GSSI), which makes me wonder about it a little.

I’m not certain but I think the references for the studies Dr. Atimen mentioned are below:

Schwellnus MP. Cause of exercise associated muscle cramps (EAMC)–altered neuromuscular control, dehydration or electrolyte depletion? Br J Sports Med. 2009 Jun;43(6):401-8. doi: 10.1136/bjsm.2008.050401. Epub 2008 Nov 3. PMID: 18981039.

Braulick, K. W., Miller, K. C., Albrecht, J. M., Tucker, J. M., & Deal, J. E. (2013). Significant and serious dehydration does not affect skeletal muscle cramp threshold frequency. British Journal of Sports Medicine, 47(11), 710-714.

Hoffman MD, Stuempfle KJ. Muscle Cramping During a 161-km Ultramarathon: Comparison of Characteristics of Those With and Without Cramping. Sports Med Open. 2015;1(1):24. doi: 10.1186/s40798-015-0019-7. Epub 2015 May 21. PMID: 26284165; PMCID: PMC4532703.

The reference below is more recent and the authors’ bottom line is below:

Kevin C. Miller, Brendon P. McDermott, Susan W. Yeargin, Aidan Fiol, Martin P. Schwellnus; An Evidence-Based Review of the Pathophysiology, Treatment, and Prevention of Exercise-Associated Muscle Cramps. J Athl Train 1 January 2022; 57 (1): 5–15. doi: https://doi.org/10.4085/1062-6050-0696.20

Advances in our understanding of EAMC pathogenesis have emerged in the last 100 years and suggested that alterations in neuromuscular excitability and, to a much lesser extent, dehydration and electrolyte losses are the predominant factors in their pathogenesis. Strong evidence supports EAMC treatments that include exercise cessation (rest) and gentle stretching until abatement, followed by techniques to address the underlying precipitating factors. However, little patient-oriented evidence exists regarding the best methods for EAMC prevention. Therefore, rather than providing generalized advice, we recommend clinicians take a multifaceted and targeted approach that incorporates an individual’s unique EAMC risk factors when trying to prevent EAMCs.

The review was not supported by Gatorade. It turns out the best management is rest and gentle stretching. If that doesn’t work, the advice is to seek advanced medical care. There is no evidence that meditating over an oleomargarine figurine of Elvis Presley is effective in any way—although, again, it has not been studied that I know of.

Rounding@Iowa Podcast: “Advances in the Treatment of Pancreatic Cancer”

This episode of Rounding@Iowa is about important medical advances in the treatment of pancreatic cancer. As you listen to Dr. Clancy interview Dr. Joseph Cullen about what’s new, you’ll hear a lot about high-dose intravenous Vitamin C. This can enhance treatment and improve response to chemotherapy and radiation therapy. Dr. Cullen’s most recent study about this technique showed the overall survival of patients with late-stage pancreatic cancer increased from 8 months to 16 months.

86: Cancer Rates in Iowa – Rounding@IOWA

Iowa's cancer rates are among the highest in the country, and they are rising. In this episode of Rounding@Iowa, Dr. Gerry Clancy and guest experts Dr. Mary Charlton and Dr. Mark Burkard discuss the data, risk factors, and prevention strategies clinicians can use to make a difference. CME Credit Available: https://uiowa.cloud-cme.com/course/courseoverview?P=0&EID=81274 Host: Gerard Clancy, MD Senior Associate Dean for External Affairs Professor of Psychiatry and Emergency Medicine University of Iowa Carver College of Medicine Guests: Mark E. Burkard, MD, PhD Professor of Internal Medicine-Hematology, Oncology, and Blood and Marrow Transplantation University of Iowa Carver College of Medicine Director, University of Iowa Health Care Holden Comprehensive Cancer Center Mary Charlton, PhD Professor of Epidemiology Director, Iowa Cancer Registry Iowa College of Public Health Financial Disclosures: Dr. Clancy, Dr. Burkard, Dr. Charlton, and Rounding@IOWA planning committee members have disclosed no relevant financial relationships. Nurse: The University of Iowa Roy J. and Lucille A. Carver College of Medicine designates this activity for a maximum of 0.75 ANCC contact hour. Pharmacist and Pharmacy Tech: The University of Iowa Roy J. and Lucille A. Carver College of Medicine designates this knowledge-based activity for a maximum of 0.75 ACPE contact hours. Credit will be uploaded to the NABP CPE Monitor within 60 days after the activity completion. Pharmacists must provide their NABP ID and DOB (MMDD) to receive credit. UAN: JA0000310-0000-25-090-H99 Physician: The University of Iowa Roy J. and Lucille A. Carver College of Medicine designates this enduring material for a maximum of 0.75 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Other Health Care Providers: A certificate of completion will be available after successful completion of the course. (It is the responsibility of licensees to determine if this continuing education activity meets the requirements of their professional licensure board.) References/Resources: Iowa Cancer Plan

Reference:

Kellie L. Bodeker, Brian J. Smith, Daniel J. Berg, Chandrikha Chandrasekharan, Saima Sharif, Naomi Fei, Sandy Vollstedt, Heather Brown, Meghan Chandler, Amanda Lorack, Stacy McMichael, Jared Wulfekuhle, Brett A. Wagner, Garry R. Buettner, Bryan G. Allen, Joseph M. Caster, Barbara Dion, Mandana Kamgar, John M. Buatti, Joseph J. Cullen,

A randomized trial of pharmacological ascorbate, gemcitabine, and nab-paclitaxel for metastatic pancreatic cancer,

Redox Biology,

Volume 77,

2024,

103375,

ISSN 2213-2317,

(https://www.sciencedirect.com/science/article/pii/S2213231724003537)

Abstract: Background

Patients with metastatic pancreatic ductal adenocarcinoma (PDAC) have poor 5-year survival. Pharmacological ascorbate (P-AscH-, high dose, intravenous, vitamin C) has shown promise as an adjunct to chemotherapy. We hypothesized adding P-AscH- to gemcitabine and nab-paclitaxel would increase survival in patients with metastatic PDAC.

Methods

Patients diagnosed with stage IV pancreatic cancer randomized 1:1 to gemcitabine and nab-paclitaxel only (SOC, control) or to SOC with concomitant P-AscH−, 75 g three times weekly (ASC, investigational). The primary outcome was overall survival with secondary objectives of determining progression-free survival and adverse event incidence. Quality of life and patient reported outcomes for common oncologic symptoms were captured as an exploratory objective. Thirty-six participants were randomized; of this 34 received their assigned study treatment. All analyses were based on data frozen on December 11, 2023.

Results

Intravenous P-AscH- increased serum ascorbate levels from micromolar to millimolar levels. P-AscH- added to the gemcitabine + nab-paclitaxel (ASC) increased overall survival to 16 months compared to 8.3 months with gemcitabine + nab-paclitaxel (SOC) (HR = 0.46; 90 % CI 0.23, 0.92; p = 0.030). Median progression free survival was 6.2 (ASC) vs. 3.9 months (SOC) (HR = 0.43; 90 % CI 0.20, 0.92; p = 0.029). Adding P-AscH- did not negatively impact quality of life or increase the frequency or severity of adverse events.

Conclusions

P-AscH− infusions of 75 g three times weekly in patients with metastatic pancreatic cancer prolongs overall and progression free survival without detriment to quality of life or added toxicity (ClinicalTrials.gov number NCT02905578).

Keywords: Pancreatic neoplasms; Ascorbic acid; Controlled clinical trial; Gemcitabine; Nab-paclitaxel

Dr. Cullen mentions that patients contact him not infrequently to ask if taking high-dose oral Vitamin C will help them achieve similar results. Unfortunately, it will not. Giving it intravenously facilitates giving much higher doses. The study had a relatively small number of participants, which limited ascertainment of quality of life.

On the psychological side, there are ways to bolster the mental health challenges of those with pancreatic cancer, which typically has a grim outcome in terms of survival:

Spiegel D. Mind matters in cancer survival. Psychooncology. 2012 Jun;21(6):588-93. doi: 10.1002/pon.3067. Epub 2012 Mar 21. PMID: 22438289; PMCID: PMC3370072.

Further, Dr. William Breitbart, MD, Chair of the Department of Psychiatry and Behavioral Sciences at Memorial Sloan Kettering Cancer Center was interviewed in 2021 and emphasized the need for bolstering mental health for those diagnosed with pancreatic cancer. According to Breitbart, “Pancreatic cancer triggers an inflammatory response in the body, which can lead to mood disorders,” Breitbart explains. Psychiatrists can prescribe certain antidepressant medications that directly target that inflammatory response.”

The Zamboni Effect

I was walking around the mall today doing ordinary old guy things: watching the Zamboni machine resurface the ice rink, which I’ve never seen before, by the way. The surface was pretty dull before the Zamboni team started. There were two kids in the seat, one young lady driving and the other young man pointing out spots she missed. They went around and around getting the thin layer of water on the whole rink while eager skaters waited to get out there. They rejuvenated the rink, got it shining like crystal and skaters spun, twirled, and had a great time. It was the Zamboni Effect.

After that, I got up and did my usual thing, looked at books in Barnes & Noble, got a bite to eat, wondered why the mall security guy was walking by the bench so often where I was sitting. After his third pass, I got up and did my best to look like a solid citizen who is aware that loitering might look sinister to some mall security guys.

And when I wandered back to the tables next to the ice rink, I sat down again because the mall security guy was nowhere in sight. While I was just zoning out watching people pass by, one of them stopped and made a funny face at me. For a half-second, he didn’t register in my memory and then he called me by name. I suddenly recognized him as a former resident in the Medical-Psychiatry training program at University of Iowa Health Care (UIHC). It was Ravneet, one of the best trainees I have ever had the pleasure to work with.

It was kind of a shock. He had left for a great position with a health care organization out in Arizona many years ago and is very successful. He and his wife and daughter were on vacation and were walking through the mall. His son is also a high-level performer in science but he was not with them today. Ravneet takes time out every so often to travel like that. I’m sure it helps rejuvenate him—kind of like how the Zamboni machine rejuvenates the ice rink–the Zamboni Effect.

We exchanged pleasantries, he took a selfie with me, and I forgot to ask him to send me a copy, probably because I was so flabbergasted at running into him at the mall. It really brightened my day. Again—the Zamboni Effect. I really felt rejuvenated.

Every now and then, we all need the Zamboni Effect. Maybe it could even help the mall security guy.

Iowa Bills to Ban Vaccines and Require Vaccine Manufacturers to Waive Immunity Die

This week was what the Iowa Legislature calls funnel week. Today determined what bills stay alive and which one die.

The bills opposing vaccines died for this legislative session:

“mRNA vaccines: Senate File 360 proposed a ban on health care providers administering gene-based vaccines, like the COVID-19 vaccines developed by Pfizer and Moderna. Under the proposal, health care providers who administered vaccines that use nucleic acids like messenger RNA (mRNA) would face punishments of a misdemeanor charge and a fine of $500 for each violation.”

“Vaccine manufacturer immunity: House File 712 proposed requiring vaccine manufacturers waive their immunity from lawsuits over injuries that result from a “design defect” in a vaccine in order to distribute or administer the vaccine in Iowa. Under the 1986 National Childhood Vaccine Injury Act, there is a National Vaccine Injury Compensation Program providing no-fault compensation to individuals and families injured by childhood vaccines. While supporters of the bill said the current compensation program has problems, medical practitioners and advocates said allowing for lawsuits to be filed against manufacturers would prevent vaccines from being available in Iowa.”

Story published in Iowa Capital Dispatch, “Funnel week 2025: What bills are alive, dead at Iowa Statehouse after first deadline” by Robin Opsahl. March 7, 2025.

What Does “Design Defect” of a Vaccine Mean In the Iowa Bill to Require Vaccine Manufacturers to Waive Immunity from Lawsuits?

Beats me. Sorry, just kidding. I’m just a little bleary from looking at the web sites about the definition of “design defect” related to vaccines as it applies to the Iowa bill to make vaccine manufacturers waive their immunity from lawsuits about vaccine related injuries.

I am sympathetic to anyone who in fact has suffered a vaccine related injury.

That term “design defect” has been bugging me for days now and I just found out that this has been the subject of states vs federal legal wrangling for years. I’m not up to explaining all the legalese but there is a really tangled trail of cases in Georgia and Pennsylvania roughly around 15 years ago that ultimately led to a U.S. Supreme Court decision saying, essentially, the Vaccine Injury Compensation Program and the federal Childhood Vaccine Injury Act of the 1980s preempts all state level vaccine design defect claims.

I think that explains why the Iowa bill says that vaccine manufacturers have to waive their immunity from suits if they want Iowans to get their vaccines.

I can hear the groans and shouts of dissent even as I write this. Hey, you can’t make this up. Talk to your legislator or lawyer about it.

I’m not sure why Iowa would want to repeat the grind that Georgia and Pennsylvania went through which led to the conclusion that you can file vaccine design defect claims at the state level and not have to repeat history which would likely lead to any decisions made there being reversed in federal court.

And I’m not sure why any vaccine manufacturer would want to fight that battle in Iowa either. They might just steer around us and take their vaccines elsewhere.

The beginning of the Georgia story.

The end of the Georgia story.

The beginning and the end of the Pennsylvania story.

Vaccines aren’t perfect. They are neither 100% safe nor 100% effective. However, I support having vaccines available to help keep us healthy and the right to choose getting a vaccine. That’s why I don’t support a bill that I believe would make them less accessible.

New Wrinkle on Iowa Bill to Oppose mRNA Vaccines in Iowa

This is a follow up to yesterday’s post about the Iowa legislature’s proposition of a new law that would essentially ban mRNA vaccines in Iowa. I don’t understand the numbers and codes on the new sections, but the new one proposes that manufacturers of vaccines would have to waive immunity from lawsuits arising from “a design defect of the vaccine.”

I’m not sure if that’s addition to being charged with a simple misdemeanor, subject to a $500 fine for administering the vaccine. I oppose this one too because I think it would essentially make vaccines difficult to access and harder to persuade new medical staff to come to Iowa.

There’s going to be a meeting about the bill at 4:30 PM CST. I can’t remember if it’s at the state house or at the Exile Brewing Co. for sandwiches and Ruthie’s beer.

In any case, the comment section is overwhelmingly in opposition to the bill. I saw several comments mentioning that we already have the National Vaccine Injury Compensation Program (NVIP), which is designed to field requests for compensation to those who believe they’ve been injured by certain vaccines. I had not heard of it before. It’s administered by the federal government, Health Resources & Services Administration, which is under the Health and Human Resources department.

There is a nice easy to read summary about the complicated story of vaccine safety and liability at the Children’s Hospital of Philadelphia website. It was reviewed by Dr. Paul A. Offit, MD last year. He attends meeting of the Centers for Disease Control and Prevention, although I think he missed the one last month about the flu vaccine because it was cancelled.

If I see anything earth shaking about the meeting this afternoon on HF712, I’ll make an addendum to this post.

Proposed Bill Would Ban mRNA Vaccines in Iowa

Sena just alerted me to a bill in the Iowa legislature right now that proposes mRNA vaccines (like the Covid vaccine for example) be banned in Iowa. Part of it says that any person who provides or administers such a vaccine would be guilty of a simple misdemeanor and subject to a $500 fine. I do not support it although I also support the right of others to disagree.

The bill advanced out of subcommittee yesterday and I’m not sure how although, admittedly, I don’t know what exactly that means about its chance of being ultimately passed into law. There were hundreds of comments against it. It moves for further consideration to the Iowa Senate Health and Human Services Committee according to a story in the Daily Iowan.

This sent me to the web to find out what other silly laws Iowa has passed. A few of them are below:

“Any person who attempts to pass off margarine, oleo, or oleomargarine as real butter is guilty of a simple misdemeanor in Iowa. This one originated in 1943, but is still in force today.”

“In Marshalltown, horses are forbidden to eat fire hydrants.”

“It is illegal for a mustached man to kiss a woman in public.”

All of the above are on this Iowa State University web page.

The Connection Between Vitamin A and Measles Is Not Just About Carrots

The measles outbreak is big in the news and the issue of the role of Vitamin A in measles reminded me of something I saw back in the 1970s. I was working as a drafter and survey crew assistant for WHKS & Co (consulting engineers in Mason City, Iowa) at the time. As I was working on a drawing, a co-worker walked by my desk and I noticed her skin was the color of a carrot. She was orange. She explained that she and her husband had been taking high doses of beta-carotene, which is a precursor for Vitamin A. She and her husband both worked at WHKS & Co but I think he was home sick that day, from taking too much beta carotene.

So that segues into what I found out about the connection between measles and Vitamin A. The Centers for Disease Control and Prevention (CDC) has a web page on it and cites references for the role of Vitamin A. Vitamin A does not prevent measles. But in children who are severely ill and hospitalized from measles and under a physician’s supervision, age-specific doses of Vitamin A can be given for a limited period of time.

There are two references for the administration of Vitamin A in the context of kids with measles, available through weblinks from the CDC. One of them is the World Health Organization (WHO), which recommends Vitamin A for vitamin deficient children and because measles infection by itself can cause acute Vitamin A deficiency, resulting in xerophthalmia (severe dry eyes). This can lead to blindness.

Usually this is more of a problem in developing countries, but the WHO recommends it even for children in the US.

The other reference is Red Book. This is not the magazine for American women looking for tips on beauty. The Red Book is from the American Academy of Pediatrics and it notes the WHO recommendation to administer Vitamin A to patients “…regardless of their country of residence.”

The caveat is that you can get either not enough or too much of a good thing. Beta-carotene is a precursor to Vitamin A. Vitamin A toxicity is bad.

And you could avoid all this because there is an effective vaccine for measles. Don’t take my word for it. Talk to your pediatrician.

More on the Focused Practice Designation in Emergency Psychiatry

This post just provides further information (in addition to what was in yesterday’s post) on the evolution of the Focused Practice Designation (FPD) for consultation-liaison psychiatrists who might be interested in certifying to work in emergency departments. I use the word “certifying” because it seems clear that the FPD pathway has been intended to follow the board certification pathway, which I wondered about.

There’s a little background on the progress to the FPD path (established by ABMS in 2017) that began a few years ago in the article below:

Simpson S, Brooks V, DeMoss D, Lawrence R. The Case for Fellowship Training in Emergency Psychiatry. MedEdPublish (2016). 2020 Nov 11;9:252. doi: 10.15694/mep.2020.000252.1. PMID: 38058898; PMCID: PMC10697437.

The take home message is quoted below:

“-Over 10 million emergency department encounters a year in the United States are for behavioral health concerns, but quality emergency psychiatric care remains inconsistently available.

-New emergency psychiatry fellowship programs are being developed to train expert clinicians and prepare leaders in the subspecialty.

-These efforts will improve access to high quality mental health treatment for all patients regardless of treatment setting.”

And there is a 55-page form on the web from the American Board of Medical Specialties (ABMS) Committee on Certification (COCERT). There are several endorsements from various stakeholders including but not limited to the Academy of Consultation-Liaison Psychiatry (ACLP) and the American Board of Psychiatry & Neurology (ABPN) which make it clear there is a consensus about the value of “board certification” because most of the endorsement letters specify that. These letters are dated from just last year.

The University of Iowa Health Care system, based on the website does not (yet) offer an emergency psychiatry fellowship. They do offer a consultation-liaison psychiatry fellowship, which the ABMS supports as contributing to the attainment of the FPD credential.

However, I’m unclear if the FPD pathway won’t soon become yet another ongoing certification challenge for clinicians, many of whom find it more of an interference to their practice than a benefit. Although I believe that appropriately trained psychiatrists are helpful in the emergency room (after all, I did that for a long time), I have a nagging doubt that it will unclog the overcrowding there. Dr. George Dawson pointed that out yesterday in his comment to my post.

In the Purpose, Status, and Need section of the ABMS 55-page application form, starting on p.2 of the pdf, the American Board of Emergency Medicine (ABEM) specifies that the PFD would not be yet another subspecialty. The proposed 12-month fellowship in Emergency Behavioral Health (EBH) “…would not be ACGME-accredited training…” which distinguishes it from a subspecialty—yet they would be “recognized” for having the FPD.

Further, the application asserts that the EBH would “…address the mental health crisis in the US.” The reference to the “moral injury” that our colleagues suffer in the emergency room is not lost on me. I believe in the all for one and one for all concept. However, I’m less confident that this would lead to fewer patients boarding in emergency rooms. These days, entire hospitals often have no or too few beds available for either psychiatric or non-psychiatric patients.

Under the “Eligibility and Assessment” section, the emergency room psychiatrist seeking FPD status must hold ABEM or ABPN primary psychiatry certification. They would also be required to meet continuing certification requirements in EBH to maintain active FPD status. There is presently a “Practice Pathway” to the FPD, but that would eventually close. After that, the psychiatrist would need to complete a 12-month ABEM-approved EBH fellowship. The cycle length for the FPD in EBH would be 5 years, beyond which the applicant would be subject to re-verification of ongoing EBH practice experience “…to meet continuing certification requirements.”

You can learn more about FPD (including frequently asked questions) at this ABMS web site.

It sounds like board mandated MOC to me, and I don’t know how many clinicians will choose that route. It could discourage some psychiatrists from pursuing the FPD pathway. I’m also unsure how this will address the practical issue of emergency room boarding of patients with psychiatric illness, since doctors ultimately don’t control hospital bed capacity.

New Consultation-Liaison Psychiatry Focused Practice Designation in Emergency Behavioral Certification in Emergency Rooms

I just found out about the American Board of Medical Specialties (ABMS) announcement of a new addition to the Consultation-Liaison Psychiatry subspecialty: Focused Practice Designation. It looks like it’s going to be administered by the American Board of Emergency Medicine (ABEM), possibly in collaboration with the American Board of Psychiatry & Neurology (ABPN).

I’m unsure of the nuts and bolts, but on the surface, it looks like it might be a promising way to address meeting the needs of the many patients who appear in hospital emergency rooms.

On the other hand, I’m unclear on whether this might also lead to the addition of yet another layer of medical and psychiatry board maintenance of certification exams and fees. It looks like some boards of medicine and surgery require those who want to pursue the Focused Practice Designation (FPD) specialization route sit for an initial certification exam which would be time-limited followed by something called “continuous certification” which is a form of maintenance of certification (MOC). This often entails periodic exams and fees which many physicians find burdensome and expensive, leading to petitions opposing MOC and finding alternatives to fulfill the continuing education needs in less costly and time-consuming ways. One notable alternative is the National Board of Physicians and Surgeons (NBAS).

I’m not sure why another layer of bureaucracy needs to be added to achieve the goal of ensuring that emergency room patients with mental health challenges have access to mental health professionals. In fact, there is an American Association for Emergency Psychiatry open to membership which includes psychiatrists, physician assistants, psychologists, nurses, social workers and other professionals. However, the goal behind the FPD route is to increase the presence of physicians in the emergency room. This creates a specific and arguably needed role for consultation-liaison (C-L) psychiatrists.

I get the impression the exact way this will be rolled out is under construction, so to speak. Although I can’t find language in the announcements for the new FPD specifically saying that there’s going to be another MOC for C-L psychiatrists, there doesn’t seem to be any language assuring there won’t be. The FPD web page for the American Board of Obstetrics & Gynecology (ABOG) makes it pretty clear—there’s a MOC for that.

Just because you don’t see anything currently on the ABEM and ABPN web sites about MOC being required for the FPD doesn’t mean that it won’t appear in the near future. For now, the ABMS table outlining the differences between the certification requirements for specialty/subspecialty designation and the FDP doesn’t specify extra certification for the FDP for C-L psychiatrists per se.

I’m hoping for the best for patients and doctors.