Bureaucracy is Killing Medicine

I received a phone call the other evening from a colleague who was asking for my advice about how to deal with hospital credentialing. He wanted to hire an intelligent, gifted, and well experienced interventional cardiologist for his practice, but he was not able to extend a job offer because he was not able to make things work out at his hospital. Because I had been in similar circumstances he wanted my help in finding a way to make this work.

The man he wanted to hire has worked as an interventional cardiologist for over twenty years. He has been in the trenches through many of the advances in interventional cardiology and understands the ins-and-outs of stents, how to place them, potential problems that may arise in during cases, and how to handle all sorts of emergencies when dealing with a patient whose life literally is in his hands. He is the kind of person who I want to take care of me should I ever have a heart attack.

So what is the problem? Why can this man not go to work at this new hospital? Has he had a stroke? Has he suffered some sort of mental breakdown that has made him unable to practice? No. The only reason he is not able to do his job is because he decided to do something else for a while and has not been in the cath lab for two years. Now the hospital is not willing to credential him unless he first performs seventy-five cases. But he is not allowed to do the cases in the hospital, unless he is first credentialed. So he has to find another hospital in which to do the cases, but then he will likely find the same problem there. The only easy way for him to get the cases needed would be for him to do fellowship training over again, which is ridiculous.

He has found himself in the modern day version of Catch-22. Insane bureaucracy. Why do hospitals require these cases? Well, a group of people at some time sat in a room and said that someone who was working as an interventional cardiologist should have done at least seventy five cases over the past two years.

Where did that number come from? There may be an actuary that at one time may have calculated the actual risk of a bad outcome based upon the numbers of procedures that an interventional cardiologist had performed in the previous two years. Thus a threshold can be found. But does that number actually mean anything? These numbers often appear arbitrarily based on some risk assessment and benefit model, but to the physicians involved the numbers used often appear to be pulled out of thin air, and my gut tells me that these numbers just get passed around between hospitals as some sort of a consensus figure, not necessarily derived from any specific empiric knowledge.

That is what the hospital by-laws state. And why do the by-laws state that a person who everyone agrees is fully qualified to practice, and could step into the cath lab with minimal problem, needs to go back to square one? Lawyers.

This is all about lawyers. I live in Alabama. In pretty much any ranking of the states we are near the bottom, but most of the time we can at least say ‘Thank God for Mississippi!’ for keeping us out of last place. If you were to assemble a ranking of the most vile and disgusting members of our society, the most repugnant reprobates, sociopaths, and pedophiles would at least be able to say ‘Thank God for lawyers!’.

Why have lawyers ruined medicine? Because of their own incompetence. Lawyers generally do not want tort reform because they want to be able to make a quick buck by suing doctors because they were able to find something that went wrong during granny’s boat ride down the river Styx. Ambulance chasing lawyers and their better domesticated and fumigated compatriots have kept a horrendous medical malpractice system in place in this country in order to make money. And the lawyers do make out like bandits in this system while any victims of real malpractice hardly get any compensation. With the explosion in hospital administration and insurance company bureaucracy, lawyers have come to have even more say in the way that medicine is practiced in this country.

The measure that all doctors must now conform to is the ‘I cannot defend that’ standard. If a doctor wants to do something that a hospital lawyer somehow thinks that he cannot defend in court, then that thing is not allowed. Given the incompetence of many of our lawyers, this sets the bar quite low. And because doctors are now considered interchangeable widgets in the system, the same low standards must be set for everyone.

So due to the incompetence, or at least lack of confidence, of the lawyers who might have to defend someone, somewhere, in some theoretical case we have actually debased medicine, and made the total care delivered by the health care system decline. Because some unqualified idiot somewhere might screw up while putting in a coronary stent, we now have to say that all doctors must have at least have done seventy-five cases in the past two years and not screwed those up, so that in the case that something ever does goes wrong, some hospital and their lawyers will feel more comfortable defending that doctor by being able to say that he or she fit the ‘standard of practice’.

These same lawyers have also made it impossible for a doctor to go to another hospital and act as an ‘observer’ or a ‘trainee’ in order to get cases for credentialing. Lawyers have convinced everyone that ‘observers’ are not allowed due to the Health Information Portability and Accountability Act (HIPAA) – which most lawyers (and doctors) have not even read because it is another stinking pile of unreadable garbage which comes out of Congress disguised as ‘law’. The only way to get into the cath lab of a hospital and do cases is to be an employee of that hospital or be in a fellowship program with that hospital.

Never mind individual skill. Never mind competence. Never mind that someone may be an expert. What drives fear into the hearts of lawyers everywhere is the thought that they may have to defend someone against an ambulance chaser who asks the doctor on the stand “You mean to tell me, doctor (with all sarcasm and derision said lawyer can bring into his voice), that you had not done the requisite number of cases leading up to your hospital credentialing that we ask of the lowest of new trainees?”

So common sense flies out the window. Forget doctors policing their own. Forget about the old practice of ‘proctoring’ where the doctor can come and do some cases under supervision to make sure that his or her skills have not degraded. Now we have to listen to hospital and insurance company bean-counters who wouldn’t know their left anterior descending coronary artery from their inferior rectal artery how to practice medicine. This is the fall-out of Obamacare, and more generally the fall-out of an out-of-control bureaucracy put in place by both political parties over the past twenty five years.

Who watches the watchers? We must be vigilant in determining the best way to protect patients from potential fraudsters, but at the same time we must protect ourselves from the same menace. In exactly the same way as the credentialing system has been tainted, the Maintenance of Certification (MOC) system had been corrupted. MOC should ideally be a place where doctors can obtain knowledge without the threat of losing hospital privileges or insurance company compensation. But where the corruption of the credentialing system has been to reduce risk for the hospitals and insurance companies, the corruption of MOC has been for the financial benefit of the people who are running the system.

Unfortunately, our masters at the American Board of Medical Specialties (ABMS) and all of their counterparts, which in my case includes the American Board of Internal Medicine (ABIM) and the American College of Cardiology (ACC), just do not get it. Like the sea change in presidential politics we are undergoing a transformation of the willingness of fellow physicians to blithely follow along with the MOC program.

Yes, there are valuable bits of knowledge in the program, and this type of learning can be an important part of medicine. But the current establishment in place is deeply corrupt. Just as the poisoned well taints all of the fruits of the orchard, just as water contaminated with bacteria can result in entire batches or product lines being recalled, the valuable parts of the MOC program have been spoilt. These products are polluted, infected, rotten, and diseased, and we must be done with them completely to rid ourselves of their putrid stench.

We may build some new system in place of MOC, but until we have a full house-cleaning at the ABMS and the ABIM we will not be rid of the smell. It is time to fumigate and eject this redolent fetor which fills the ranks of our ‘leadership’. End MOC now. End MOC today. And end the silly requirements for credentialing and use common sense in deciding who can practice medicine. Rid medicine of this fraud, this embarrassment, this menace of bureaucracy!