Aimee Lutkin writes: The Difficulty of Completing Medical Residencies While Starting Families Is Holding Women Back In Medicine. In her piece she cites a Bloomberg article: Why Having a Baby Pushes Women Out of Medicine.

Both articles acknowledge medical training is hard. Yet both suffer from a fundamental flaw- students and physicians make choices. I’ll use one of the Bloomberg examples:

Like many medical residents, O’Brien forwent maternity leave, against the advice of her doctor. She’d already been accepted to a fellowship with a strict start date; she couldn’t extend her training any further. Instead, she used up all her days off, sent her newborn to day care, and returned to work, often ducking into a shower stall mid-surgery to pump breast milk.

Readers should understand that FMLA (Family Medical Leave Act) applies to residents. So O’Brien was eligible for up to 12 weeks of leave. Let’s look-

forwent maternity leave- choice

accepted fellowship- choice

newborn to daycare- choice

Don’t get me wrong, I have enormous respect for anyone brave enough to have kids while in training. I think it’s admirable for someone to put they’re family’s actual needs ahead of other personal goals such as long-term revenue and professional advancement. But it’s at least disingenuous to expect that you can “have it all.” O’Brien made her choices. Everyone of them. Oh, one other choice not included in the Bloomberg article- why didn’t the father of the baby stay home and provide care?

Children change everything. I got married as a resident and my wife (also a resident- surgeon no less) made the specific choice to delay kids until we finished and got new jobs started. Are we “older” parents, yes. But our kids had the benefit of a stable home and income and we were able to have control over our lives that would have been impossible while in training.

O’Brien and her ilk want the world to bend to her needs. It won’t. The O’Briens in medicine need to learn to accept their consequences of actions and live with them. I admire the women and men who can manage families while in training. The behaviours of “O’Briens” make all of us look like whiners.



Just when you thought it might be safe to return to the waiting room. It’s not.

GOOP the pure junk science website offers a wide array of not-medically-valid-possibly dangerous pseudo-treatments for non-diseases. It has been widely derided for the sheer magnitude of the absurd claims. Entirely on the defensive. some of the GOOP “doctors” decided to speak out trying to resurrect their credibility. They failed, in my book. They failed for three reasons:

1) Who they are, what they’ve done, and what they’re credentials are is unrelated to their scientific and medical credibility on any given topic. It’s a common logical fallacy know as “appeal to authority.”

2) They have conflated absence of evidence with evidence of absence. Whether such  junk devices and science are actually dangerous takes only a single reported occurrence. Proof of safety is, in contrast, elusive.

3) These sites are cluttered with endless “testimonials.” While these may make entertaining reading it’s important to remember that non-randomized, non-blinded, uncontrolled, combined anecdotal experience is not data, no matter how much of it you get.

Scientifically implausible medical “therapy” needs credible evidence not simply testimonials.

But how does this persist? Basically, mainstream medicine allows it. Even large, well-known institutional providers are getting into the “alternative and complementary medicine” act. This occurs at a time when physicians themselves acknowledge that 20% of “mainstream” healthcare is without meaningful patient benefit. Since this study involves AMA members (members of a protectionist trade guild) one might expect the 20% figure to represent a floor rather than a ceiling on the amount of unnecessary care delivered.

But it’s not just the trade guilds. State medical boards also implicitly promote charlatanry. Looking just at Mississippi (the recognized worst medical board in the country see also here and here) we find such things as “low pressure hyperbaric oxygen” therapy- which despite the testimonials lacks any scientific basis and stem cell “research”– another “therapy” lacking in meaningful scientific basis and foisted on the public as “research.” Yet, in the case of stem cells it lacks any of the traditional characteristics of medical research- no real theory (unless let me have you money is a scientific theory). No real systematic collection of analysis of data. No real selection of patients in a manner that might permit reasonable stratification to determine if anyone actually benefited. In the case of the cited stem cell “clinic” the physician is a non-board certified former surgeon.

The bottom line- you can’t depend on other doctors. You can’t depend on medical boards. You simply need to be diligent, ask questions, and realize that you- the patient- are little more than a revenue center to most doctors.



Aiming for the bottom

Maybe you’re tired of hearing about whiny doctors and recertification. OK, I’m almost done with this but there’s one more item that’s worth noting. In the last post I mentioned that non-certified, minimally competent doctors should go to Mississippi since the standards are very low there. In fact Mississippi consistently ranks 51st in healthcare.  The Medical Board is little more than an extension of the state medical association.

The Mississippi State Medical Association has developed a “Maintenance of Certification Playbook.” This fascinating document is little more than a concerted effort to assure that Mississippi’s minimally competent physicians are never required to meet standards used in the remainder of the free world. It’s a fundamentally pro-physician and anti-quality document. It addresses only physician needs. Take these excerpts from the president’s message:

Despite MSMA policy opposing mandatory MOC and use of board certification as a credentialing criteria, the problems persist and continue to vex Mississippi physicians. To help physicians combat burdensome MOC requirements MSMA staff initiated a plan which began with a review of efforts already in place across the country.

MSMA staff shares the legal opinion with other policy experts that these laws are not sufficient and will not provide the protection physicians want. More importantly, a legislative fix isn’t realistic.

A collective voice will leverage influence to change the root of the problem. The playbook also contains model medical staff bylaws and other bylaw changes you can use to ensure your hospital medical staff bylaws protect physicians from the growing concern with MOC.

Aside from being a rambling, incoherent diatribe it’s filled with misconceptions, misinformation, and outright fabrications. More important, why would anyone charged with assuring the licensure on minimally qualified physicians care whether non-certified physicians are protected?

Among the materials cited in MSMA’s “playbook” is a link to “The National Board of Physicians and Surgeons (NBPS).” This appears to be a like-minded group of similarly whiny physicians who wish to systematically “dumb down” modern medicine. The only thing that’s missing is Rand Paul’s “National Board of Ophthalmology.” Make no mistake the same doctors who claim maintenance of certification is too expensive can pay dues and make donations to NBPS. The technical term for that is hypocrisy.

It’s no mistake that one of the most public attempts to minimize “physician burden” comes from the state with the worst healthcare. It’s little more than Mississippi’s ongoing effort to assure maximum revenue for minimum effort from minimally qualified physicians. Read the MSMA “Playbook.” If your state state takes the Mississippi path fight it. Your life may depend on it.

Why not re-cert?

Physicians think that once they know something they know everything, forever. The claims they make about MOC (maintenance of certification) are completely BOGUS. As I’ve noted previously, board certification is the lowest rung on the ladder of professional achievement.

Let’s look at the arguments (see also here, here, here, here, here, and here):

This one’s particularly interesting. The American Osteopathic Association ties membership to certification. In other words the association wanted to ensure a minimum standard of knowledge. But some osteopathic physicians decided to sue to prevent this. You read that right- physicians sued their own organization so they wouldn’t have to demonstrate ongoing minimum levels of knowledge.


1)It’s too expensive- this one’s laughable. These are the same folks who regularly overspend on everything. They own boats, airplanes, second homes, girlfriends and wives. The idea that demonstrating their continued minimal competence is too expensive is simply a nauseating lie. It’s priorities. Patient care and professionalism isn’t a priority.

Just so we can put this into perspective (these are NOT poor people) let’s looks at physician compensation. Here’s the lowest offered base salary, NOT including bonus and benefits by specialty for 2017:

Anesthesiologists: N/A
Cardiologists (noninvasive): $250,000
Dermatologists: $250,000
Endocrinologists: N/A
Emergency room physicians: $280,000
Family medicine physicians: $135,000
Gastroenterologists: $300,000
General Surgeons: $275,000
Internal medicine physicians: $195,000
Neurologists: $220,000
OB-GYN: $210,000
Oncologists: N/A
Orthopedic surgeons: $350,000
Pediatricians: $165,000
Psychiatrists: $195,000
Pulmonologists: $275,000
Rheumatologists: N/A
Urologists: $325,000

definitely  think we should all shed a tear for those poor under-paid doctors.

2) It’s time consuming- true. But everyone has time constraints. Even elementary school teachers have continuing education requirements. They have less flexibility in their schedules, equally long hours and less money. This , again, is code for “I don’t want to do that because I’m an important doctor.”

3) It’s not relevant to the daily practice of medicine- really? The continuing education requirements and possibly testing establish a minimum standard. It’s not even good medicine just barely OK. Recall my previous post where I noted the pass rate for the ABIM exam. You have to be an idiot not to pass. Certification only matters if you’re not certified. You have to be too stupid, too lazy, or too incompetent to fail.

4) It may trigger licensure concerns. This may be valid. Maybe. But in most sates failing a certification exam should trigger competence concerns. Anyone who fails though can always go to Mississippi where the bar is set really low and anyone can get a license. Mississippi is 51st in healthcare for a reason. So fail the exam and move there.

5) Colleagues are uniting in opposition. I have to rely on my mother here. “If all your friends jumped off a bridge would you do that too?” There’s an enormous number of healthcare concerns doctors could unite over. Instead, doctors are rallying around a silly protest about demonstrating their competence.

Every doctor knows about certification and recertification. Once they get through the door though they get “into the dance” they think they can “make the band play whatever they want.” They’re wrong. It’s time doctors stop whining and start acting like professionals. We, consumers, have a say in this. If your doctor is not board certified, find a new one.




Smoking and Child Abuse

A recent discussion on Medscape posed the question “Is parental smoking child abuse?” Art Caplan makes some important points but he also misses some more important points:

  • second hand smoke is nowhere near as dangerous to children as obesity.
    • it’s a genuine irony that if a parent brings a child to the  doctor and the child is <5th percentile in weight and the parent admits to “underfeeding” the child there’s a good chance the parent will be talking to a child welfare agency.
    • In contrast if a child is seen and the child if 3 time the upper limits of normal for his/her weight- the doctor will just shrug.
    • <fill in favorite fast-food burger> is more hazardous to children than second hand smoke.
  • second hand smoke has nowhere near the risk to children as riding in the back of an open pickup truck or riding without a seat belt.
  • second hand smoke is nowhere near as dangerous as riding in a vehicle with an intoxicated parent.

It’s hard to “bite off” just one of these issues and not address the others. It’s very hard to legislate good parenting or common sense. In most of these cases there is a strong correlation with socioeconomic status. It’s even harder to legislate against being poor, or stupid.

Doctors are situated to help intervene but they rarely do.





Single Payer?

Should you care how many health care payers there are? There’s a lot of talk about “single-payer” systems for health care (see here, here, here, and here). The problem is not the payer. The problem is mis-aligned incentives. The problem is what your doctor is allowed to do. Some authors pose the possibility that the single-;payer system is bad. It’s not. Many states/nations have better healthcare at lower cost with a single-payer system. It’s more an issue of administration and aligned incentives.

Let’s back up for a second. The doctor-patient relationship originates in principles of contract law. But the maintenance rests squarely in the principles of agency law. By that, I mean your doctor must act only in your best interest. A single-payer system may be able to align physician interests with patient interests in a way not possible otherwise.

It’s time to put patient care first and physician self-enrichment second. Patients are not revenue vehicles for physicians.


‘Useless’ Surgery Is Still Popular

Not all treatments your doctor offers are actually therapeutic. In fact there’s an astounding quantity of sanctioned quackery available to individuals who are willing to purchase “non-therapies.”

There are few requirements that your doctor tell you that your surgery may not be helpful. Most states expect basic disclosure. Basic medical ethics and informed consent generally will require that your doctor explain risks of the procedure.

But your doctor may not know anything about the effectiveness of the procedure (beyond the personal enrichment associated with performing the procedure). You should question every procedure extensively. You should be comfortable that there is genuine possibility of improvement.

After all, you’re the patient. The procedure should be performed for your benefit not for the financial enrichment of your doctor.