Out Of The Old Black Bag



Maintenance of Certification: The Eternal Medical Student


By Anthony Kovatch, M.D.

AHN Pediatrics — Pediatric Alliance Arcadia


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“Cowards die many times before their deaths; the valiant never taste of death but once.”

“Julius Caesar” by William Shakespeare


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Musical Accompaniment: “Teach Your Children” by Crosby, Stills, Nash, and Young.


I thought that I was very fortunate indeed when I learned that physicians of my age and experience with grey hair had “grandfathered” out of the controversial, even contentious maintenance of certification (MOC). This requirement provides practitioners with a pathway to stay current in the fund of knowledge germane to their specialty. Detractors of the requirement claim it is too time-intensive and expensive, and irrelevant to everyday practice. I have no opinion; I have ongoing problems of my own as described below!

Replica portrait of my grandfather: From whence it all began


I never met my maternal grandfather, Michael Bonacci, since he died long before I was born. Neither did I even see photographs of the ambitious man whose legacy (unlike that of the matriarch of the Bonacci family, his benevolent wife, Marietta) seemed to be suppressed or forgotten by the descendants of his 13 children. However, when I first beheld the portrait of an esteemed surgical department chair in the gallery of past dignitaries lining the corridor of the local teaching hospital, I was convinced that it was a replica of my Italian immigrant grandfather — sternly looking into my eyes and questioning my worthiness as his heir.


Leonardo Bonacci (1170 to 1240-50), known historically as Fibonacci (son of Bonacci), was the second most famous native of Pisa, Italy after the Leaning Tower. His mathematical concept, the Fibonacci sequence, has influenced the scientific field to this very day, earning him the title, “The most talented Western mathematician of the Middle Ages.”


There was a conviction in the Bonacci family that they were descendants of the groundbreaking mathematician Fibonacci. Although Michael was simply a grocer/banker by trade, his sons were all expected to be professionals, preferably in the scientific field; the four daughters were commanded to marry prudently and bear sons who would be even higher level professionals. The crowned jewel of the sons, Riccardo, became the local celebrity of Hazleton, PA — the family physician who was “everybody’s everything” and had a wide reputation of extraordinary kindness and compassion until his death. (When my parents died prematurely he anonymously paid my way through medical school.) The crowned jewel of the daughters, the beautiful but headstrong Virginia, repudiated Michael’s wishes, married for love rather than status, and consequently became the “black sheep” of the family. However, she was equally as ambitious as the father she defied and solemnly promised on his deathbed that her firstborn son would follow in Doctor Riccardo’s footsteps.

And so I was groomed from birth by subliminal tactics of which I was not aware to emulate “Uncle Rick”; I somehow attended the same college and medical school that he attended decades before and developed an “imposter complex” that I harbor to this day. I angered and broke the hearts of Michael and Riccardo in the long run by declining to be “everybody’s everything” as a family practitioner in Hazleton, opting instead for pediatrics — again it was love rather than status! I imagine that Michael Bonacci’s stern glare of remonstration was directed solely at me. At that time of my decision, I knew nothing of the legacy of kindness and compassion to which I was heir.

The heirs of compassion:  Indoctrination must start early!


As I have claimed for years, medicine is a “blood sport,” a battle within one’s self. This did not discourage my two younger sons from following in Riccardo and Tony’s humble footsteps. The bloody challenges start in medical school, peak in residency, and endure until the last syllable of our recorded time in practice. It is true what our professors declare:  When you’re in practice, every day is like final exams. This is particularly true of pediatrics where the essential body of knowledge can be mastered in three years, but the intuition, intestinal fortitude, and compassion needed to function every day is an eternal learning curve.

I think maintenance of certification (MOC) should be rewarded by a diploma from the respective academy of medicine; maintenance of compassion must be a grueling daily obsession and must be self-imposed; it involves overcoming “compassion fatigue” and the abject cynicism encroaching on our noble profession. I was fortunate that I had superlative taskmasters in Michael and Riccardo, and even Virginia, although her modus operandi was usually hidden beneath the surface!

I have been privileged to pass on the torch to Michael’s great grandsons, Kevin and Joey (both pictured above). Therefore, I have experienced the stress and gruel of medical school not only once personally, but vicariously times two. In the second (Kevin) and third (Joey) episodes, the old man moonlighted at a psychiatric institution to pay tuitions, helped them prepare for national board exams and shelf exams, educated them in the culture of “rounds” via the Socratic method, and, most crucially, provided palliative counseling when frustration and exhaustion threatened their aspirations. It was the latter that produced most of the grey hairs and sleep-deprived nights and removed any personal guilt over my MOC exemption. I earned the right to counteract the imagined threatening glare of my grandfather with a smile of smug satisfaction (alas, with overriding reverence):  “Cool it, grandfather Bonacci, I did you right! Although I did not, your great-grandsons exceeded your expectations!”

As residents say after a busy night on call: It was scut x 3! (scut being tedious, mindless physical tasks that nobody else wants to do). I realize even now in the twilight of my career that I have been a medical student three times — at least in spirit. Sometimes I accuse myself of self-pity and the cowardice of the striver who anticipates failure many times, but I think this has been necessary for my maintenance of compassion. I think in my mind I will forever be the eternal medical student, the eternal resident, the eternal doctor-on-call. Michael Bonacci would have had it no other way! And maybe Fibonacci too!


Dedicated to Doctor “Uncle Rick,” my anonymous benefactor and beacon of kindness. I hope I did you right by providing medical care to your grandsons, Jack and Nick, and cheering them on at an occasional lacrosse game!