Still Qualified?

Your doctor has some qualification. Your doctor graduated from medical school, probably. Your doctor has some training after medical school, probably. But what about after that?

There are several things to consider here:

  1. Does your doctor still possess the specialty skills for which she was originally certified?
    • How would you know?
    • Should you care?
  2. How up-to-date is your doctor’s skill or knowledge?

Almost every medical board in the US requires some “continuing education.” Historically this was the chance for a physician to go off to a resort and drink and hang out with old friends and colleagues while his/her spouse wandered around the resort or town and squandered money. It was just something you did because the state medical board said you had to.

Now the certification boards have gotten in on the action. The American Board of Medical Specialties

works in collaboration with 24 specialty Member Boards to maintain the standards for physician certification. Our focus is on improving the quality of health care to patients, families, and communities by supporting the continuous professional development of physician specialists. We achieve our mission as an organization by helping physicians achieve their potential as providers of quality health care.

The ABMS website further notes:

ABMS Mission Statement

The mission of the American Board of Medical Specialties (ABMS) is to serve the public and the medical profession by improving the quality of health care through setting professional standards for lifelong certification in partnership with Member Boards.

Higher Standards Drive Lifelong Assessment and Learning

For more than 80 years, we’ve evolved the standards for medical specialty practice and certification to support advancements in medicine, science, and technology. As a community of learners and leaders, we periodically evaluate and update our professional and educational standards to reflect the changes in medical specialty practice and health care delivery processes.

Physicians meet these standards in order to become Board Certified. Maintaining the following competencies keeps their certification active throughout their career and forms the foundation of the ABMS Program for Maintenance of Certification (ABMS MOC®):

  • Professionalism
  • Patient care and procedural skills
  • Medical knowledge
  • Practice-based learning
  • Interpersonal and communication skills
  • Systems-based resources

The standards guiding the ABMS Program for MOC are patient-centric with a greater emphasis on professionalism, patient safety, and performance improvement. They help physicians become active participants in the evaluation of their own practices. Physicians can see how their practice compares to those of their peers, how it differs from published best practices, and how their own practice evolves over time, progressing toward the ideal practice.

The standards also include guidelines which help the ABMS boards select learning programs and improvement activities, create assessment and evaluation systems, and pioneer effective new pathways for physicians to learn the latest innovations in their specialty.

Lifelong Assessment and Learning Inspires Quality Improvement

Quality improvement is vitally important to our nation’s health care. Patients place an unprecedented level of trust in their physicians. They expect that the certifications held by their physicians represent a current demonstration of their knowledge and skills. The ongoing process of MOC assures that level of quality and trust.

The ABMS Program for MOC has grown to respond to the needs of patients by tapping into and extending the deep reservoir of duty and compassion of our physician specialists. Both patients and the profession benefit as the MOC competencies become deep-rooted into medical practices as well as our nation’s educational, accrediting and certifying activities.

All  that sounds pretty good. In fact how could any reasonable physician argue with something like “improving the quality of health care.” But lately physicians have begun pushing back against “re-certification” programs. One physician resented re-certification so much that he invented a certification board and certified himself! You know him as Senator Rand Paul (see here, here, here, here, here, and here). His “certification” is 100% bogus. His “certification” board appears, at this time to be 100% non-existent.

But the boards (all of the ABMS member boards) are in trouble. They need to find a reason for their existence. If we look at just Internal Medicine (ABIM). The exact number of graduates of American IM residencies who pass the ABIM certification exam is not widely distributed information. But generally the 5-year “conversion rate” to certification is in excess of 95%. (First-time taker pass rate here. Program pass rates generally exceed exceed 90% and almost universally exceed 80%.) The real question is if “Certification by the American Board of Internal Medicine (ABIM) has stood for the highest standard in internal medicine and its 20 subspecialties” How can pass rates be that high? Seriously- Navy SEAL training has an 80% attrition rate. The navy can recruit from the very best fighters from the navy and marines and still there’s an 80% attrition. Internal medicine residencies draw from American and international grads (some of whom barely speak and understand English) and 80% pass the exam! How does an 80% pass rate comport with a claim of “the highest standard?” In fact, ABIM barely establishes a minimum acceptable command of basic medical knowledge.

Bearing that in mind, why would anyone care about re-certification? Let’s turn this around. Since certification really sets a minimum standard (yes these physicians are limbo-ing under the bar of “minimal knowledge”) then certification only matters if a physician does not have it.

No, you should not trust your health to any physician who cannot pass his/her certification exam. It does not matter why he/she can’t pass. That physician has not demonstrated  a minimal command of basic knowledge.

Soon, we’ll look at the myriad reasons, almost all vacuous, why physicians don’t want to re-certify.





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.




Real medicine is better

By now everyone knows that I have a fairly low opinion of doctors and most modern medicine. But, I have to note that there are worse things- the alternative “therapies” that are, in fact, entirely non-therapeutic. These “therapies” rely on you, the general public, to be gullible enough or desperate enough to hand over money in exchange for, well, nothing.

One of the best documented cases is an Australian woman named Carissa Gleeson. Gleeson had a cancer, sarcoma actually, a fairly nasty tumor. Initially she embarked on some seriously foolish naturopathic treatments. Eventually she came around to the realization that chemo and living might be a better idea than dying broke from a potentially curable cancer.

But naturopathic quackery is not the only type for gullible patient. Another of my favorites is Anthony William  who calls himself the Medical Medium. The breadth of his quackery- and outright fabrications seems endless. Some of his advice is quasi-useful. He encourages consumption of fruits and vegetables- hardly a bad idea. But he encourages it because:

Because they grow from the earth and are showered by the sun and sky, enduring out in the elements day after day as they form, they are intimately connected to the holy forces of nature. They don’t just contain the building-block nutrients we need to function. They contain intelligence from the Earthly Mother and the heavens that we desperately need about how to adapt.

Perhaps the best reason to accept William as a full-fledged quack is that Gwyneth Paltrow likes him! Yes, that Paltrow- the purveyor and peddler of unscientific, potentially lethal items and devices and other gunk (ironically sold at It’s not terribly dissimilar different from two Klansmen  endorsing each other.

Others that make my “favorites” list:

Geoffrey Ames whose license was appropriately revoked after he was finally found responsible for the death of a patient. But theWashington Department of Health Medical Quality Assurance Commission. Ames initially came to attention because of his use of something called The Life Information System Tens, or LISTEN. The device allegedly tested the patient’s muscle resistance using low-voltage electricity. Eventually Ames abandoned the device because he could obtain the same information “simply by touching the patient.” This form of hoax electrodiagnostics is fairly common.

Clare O’Nan an acupuncturist in Mississippi. Her website claims:

Clare’s focus is primarily on pain and ophthalmologic conditions, including macular degeneration, retinitis pigmentosa, dry eyes, and more. She is the only licensed acupuncturist in Mississippi who specializes in vision treatment and one of a few in the country.

She has a new website now. Her claim to be able to “treat” macular degeneration caught the eye of the Mississippi State Board of Medical Licensure (MSBML), which licenses acupuncturists. O’Nan noted that she doesn’t treat macular degeneration (for which there is no recognized effective, scientifically valid treatment). She treats the “symptoms.” MSBML took no action.

State medical boards will not reliably protect you from bad care or quacks. You must take an active role in your care and be cautious. Unscrupulous “practitioners” will gladly separate you from your money.

Opioid Epidemic

Every one’s excited about the “epidemic.” Recently I posed the question, “who cares?” As it turns out not very many people.

Let’s look first at the epidemic. Using CDC data we can see the rise in deaths from opiates:

opiate deaths

Wow, it seems that no one thought this was a problem until WHITE PEOPLE started dying. People of color either no how to use recreational drugs or simply don’t. The epidemic is a problem because it’s affecting the white middle class. Gosh, no we gotta do something. The death from opiates is widely expected to top 55,000 for 2016. That’s the equivalent of SIX people every hour, every day. What did the Federal government do? The CDC issued “guidelines” for prescribing. Many states have issued similar guidance- but it’s mostly voluntary. Prosecutions are rare and the penalties vary widely. State medical boards routinely fail to take meaningful actions.

The bottom line- doctors continue to be treated “special.”  They’re subjected to some additional scrutiny and “guidance” now that their actions have begun killing white people but they’re largely immune to discipline.


Who cares about opiates?

There’s an opioid epidemic. Oops. Maybe that should be a question. There’s an opioid epidemic?

Even if there is, who cares?

Doctors care. Not because of patients but because addiction pays. I can say with complete certainty that without payment no physician would be offering addiction treatment. The newest rage is Suboxone for “medication assisted treatment (“MAT”).” Suboxone, like methadone before it, is not a cure for addiction- no matter what The American Society for Addiction Medicine may say. These addicts are not recovering they are exchanging one addictive narcotic drug for another one. A different drug for which they need a prescription which can only be obtained by a licensed provider (physician, physician-assistant, or nurse practitioner).  The idea behind MAT is substituting one addiction for another. To put it in perspective it’s like treating an alcoholic with limited supplies of prescription beer. It’s like treating crack addicts with methamphetamine.

Doctors also care because they make money from each and every visit at which they write prescriptions. The price for a “suboxone visit” may be as high $500 and some providers only take cash. The rise of “pill mills” has occurred, not because doctors altruistically want to ease the suffering of people but because it pays. In short, cutting back prescribing cuts into business. Medical boards are hesitant to intervene because they are frequently run by doctors- the same doctors who make money prescribing. For example, Mississippi, with great fanfare announced the “Governor’s task force” on opioids in December 2016. Eight months later the task force has 41 recommendations. The few recommendation that have been released so far are similar to what other jurisdictions already have in place. It’s worth noting that the Governor specifically indicated that “here have been 95 overdoses to date this year in Mississipp.”

“Pain doctors” frequently run cash-only businesses with waiting rooms and parking lots filled to capacity with “unsavory” individuals. Pill mills are enough of a problem that there are instructions for how to recognize them. It’s not hard. See here, here, here, and here.  Some of my favorites:



Recent occurrences may cause doctors to re-think whether the income from opiate prescriptions is really worth it. South Bend, IN now has “groups working together to fight the local opioid epidemic.” It remains to be seen what “working together” will actually mean. It is, after all, only the providers (mostly doctors) who can stop the flow of unnecessary prescriptions.

More on the “opioid epidemic” later.