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.





Certification Scams?

Physicians complain. About everything.

As a physician who has passed five separate certification exams in three different disciplines I can attest to the fact that I hated every second of the process. It didn’t make me better, or stronger, or smarter (with all due respect to Nietzsche). As I noted previously certification doesn’t really matter- unless you don’t have it. My most recent certification exam had a 95%+ pass rate. Exactly what does that mean? Quite possibly it means that the board set the bar so low that anyone- except a few morons- could pass. In this case it’s only relevant if someone isn’t certified.

The high costs of certification has recently come under intense scrutiny, especially by the physicians taking the exam. Dr. Brian Drolet was recently quoted whining about the cost

Let’s say you finished journalism school, went through another five years of training, and had to pay over $5,000 to take tests to be a certified journalist. You’d be curious why it was necessary at the end of all that training.

It should not be a surprise to Dr. Drolet. He’s had 4 years of medical school and 5 years of post-graduate training. At some point I’ll be here referred pejoratively to someone who was not certified. Non-board certified physicians are routinely thought of as second-class citizens by those of us who are certified. Those of use who are certified have a hard time understanding why the non-certified cannot pass or won’t take the exam. Indeed, regular consumers should be equally suspicious of non-certified physicians.

Drolet’s complaints regarding cost are valid though. The boards are large, in most cases “non-for-profit”, organizations. But they’re extraordinarily wealthy organizations. And their purpose is to certify physicians but also to perpetuate their own existence. An creating legacy is expensive.

Certification is an entirely voluntary action. Physicians have the option of not taking the exams. There are consequences of not being certified:

  • the non-certified physician will frequently be thought of as “second class” (and they often are)
  • non-certified physicians have failed (for some reason) to demonstrate command of a minimum body of knowledge and skill (makes it clear why they might actually be second-class)
  • non-certified physicians may not get contracts with insurance companies
  • non-certified physicians may not get hospital privileges or employment opportunities
  • should I repeat the part about second class again?
  • but strictly speaking, it is voluntary.


Patients shouldn’t worry about the cost of certification for doctors only whether a doctor is certified. Patients definitely should be concerned about the cost. Few doctors in the US make less than $100K annually. The cost of certification is frankly trivial compared to revenue. In fact, it’s trivial compared to the $50K the doctor paid for his car or the $750K he paid for his house. Or the upkeep on his pane or boat.

Check to make sure your doctor is certified. Steer clear if (s)he’s not.


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.