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!


Certification Culture


Clear evidence of our government bureaucracy run amok is found in the rapidly growing area of certification. Years ago people would get hired for a job, perhaps, but not necessarily after specific training in a vocational school, college, or university, and would then proceed to learn the trade through years of applied work. Trainees or apprentices early in their careers may have been designated as such, but the general public had enough common sense to determine whether someone seemed to know what they were doing and were worth employing for some specific task.

Through the ages systems have developed for the certification of people as experts in their particular trades. Early on these were guilds of successful tradesmen. Later various boards arose to certify and license doctors, pharmacists, and veterinarians. Attorneys are certified as fit to practice through their Bar Associations. There have been a number of factors which have contributed to the development of these certification systems including 1) a rapidly expanding knowledge base in society which has made it impossible for people to know enough to judge for themselves whether the people they want to employ actually know what they claim to know; 2) experts in various fields wanting to preserve the integrity of their profession from people who may try to claim expertise that they do not possess; and 3) governments wanting to protect citizens by providing a mechanism for determining whether people are the experts they claim to be.

In recent years, however, the certification system has become a behemoth with such complexity and momentum that attempting to even slow this monster, let alone begin to reign it in, is becoming a nearly impossible task. A quick search begins to reveal the size of the problem. In any given state the number of certified occupations runs into the hundreds: the state of Washington lists almost five hundred. Certifications run the gamut from accountants to zoologists, and just listing all of these along with their basic requirements could easily fill a book. You can become a certified aircraft fuel distributor, a certified tattoo or body piercing artist, a certified snowmobile dealer, a certified egg dealer, a certified East Asian medicine practitioner, or a certified fur dealer. There are certifications for firearms, fireworks, fire sprinklers, you you can even become a certified fire protection engineer. You even need certifications for your leisure activities: certified martial arts participants, wrestlers, kick boxers, and whitewater river outfitters. You can be a licensed seed dealer, shellfish harvester, waste tire carrier, or taxidermist. And lets only hope that Anthony Weiner found himself a licensed sex offender treatment provider.

“So why has this system gotten so out of control?” You may ask “Each of the factors driving these certifications that you listed before appear to be noble goals. Isn’t the whole certification system a good thing?” To answer these questions, we must reexamine the factors driving the system and explore their ‘dark side’. Each of these has what we could generously call a contraposition, or more cynically call their seamy underbelly or ‘dirty little secret’.

Let us start with #1 above. The human knowledge base is rapidly expanding to such an extent that even for your exceptional ‘Renaissance man’ or polymath cannot know everything. Theoretically, it may at one time have been possible for someone to know the sum of human knowledge, and over the years there have been a number of claims of people who in fact did so. These range from Aristotle in ancient Greece to Leonardo da Vinci, Athanasius Kircher, Gottfried Leibniz, Thomas Young, and Max Weber. Of course it is impossible for any of these men to have known everything known to humans in their time, but these well read individuals of high IQ and high capability at least could hold their own on just about any conceivable topic. No one in the last hundred years could make such a claim, and in recent decades just knowing the index has become a challenge. The extent of human knowledge continues to expand at exponential rates. In the future it may be possible for an artificial intelligence to once again know everything, but that is a discussion is for another time.

The problem is that knowledge is expanding at a rate that any system that tries to certify someone as an expert is out of date by the time it is established. Just as software standards run years behind the cutting edge of innovation, and are often useless by the time a standards organization can put them together, the certification tests in rapidly growing fields are hopelessly outdated. In my occupation, cardiology, the science has advanced very rapidly, and old standards of care are often being revised and retooled, if not overturned entirely.

This creates a huge quandary for the people who are making and taking the certification tests. If a newly published study overturns an old way of thinking, and a question about this particular topic appears on the recertification boards, how is a knowledgeable expert to answer? Do you answer the question with the knowledge as it was at the time the board question was likely written, or do you answer with the newer, and (presumably) more correct information in mind? This becomes even more of a conundrum for people who are performing research. These people may have knowledge that is not yet available to the general public, and so they may be forced to answer questions with information they know to be wrong. And the more cutting-edge an expert is, the more difficult this task becomes, and the more that expert may get ‘wrong’ on an outdated recertification board test.

An entire industry has now arisen in order to prepare people for the certification tests. A common theme of these board preparation courses is knowing what the proper ‘board answer’ is, regardless of the state of knowledge in that given field. So we have essentially built a surrealistic alternate reality of ‘meta-truth’ that needs to be studied and mastered in order to pass the board certification tests. And the saddest reality of this alternate universe is that the true experts – the people with the best, actual, cutting edge knowledge – are the ones who have the hardest time with it. The average schmoe who doesn’t keep up with what is really going on in any given field will probably do just fine on the test.

“So if it is so hard to figure out who really is an expert in any given field, why do we do it?” you may ask. Well now we get to the dark side of #2 above. Attaining a level of expertise in any field is difficult. It takes time, dedication, and will to become a master of a craft. People who have dedicated their lives to any particular trade tend to become very fond of the art of their work, and they want to defend that trade from outsiders who have not worked as hard as they have. This is a very natural human instinct, and there is not necessarily anything wrong with it.

However, it is not the master of any given profession who feels threatened by interlopers, it is the novice. The person who is least sure of their own ability will feel the most threatened by someone else’s ability to outperform them. And so the certification system tends not to be built by the best people in any given trade, but the worst, because they want to create a back-stop to prevent any others from overtaking their ‘turf’. It is these people who are so uncertain of their own skills that they must find some way, some badge, some stamp-of-approval from above to prove to people that they are worthy of their title. So they create a certification system that gives the illusion of expertise for all of the people who pass the bar. But we know that not all ‘experts’ are equal, and we should not pretend that it is so.

There is an old joke in medicine: What do you call the guy who came last in his class at medical school? Answer: Doctor. Part of the problem with branding everyone who passes the board exam as an ‘expert’ is that now the system can treat all of the doctors as interchangeable widgets. In our current system no doctor is allowed to charge any more for his or her services than anyone else, and the insurance industry and government can choose to pay whatever they like for those services. The doctors just have to shut up to get paid. In a just system, skilled doctors would be able to charge more than unskilled doctors. (Yes, this happens in some very small slivers of the industry such as dermatology and cosmetic surgery where society has determined that it is OK for ‘optional’ medical procedures to be paid for out of the system, but for most of medicine doctors are paid whatever the Medicare system determines to be enough.) If you want to see the best cardiologist in the world, shouldn’t you have to pay a premium? Or do you just want to leave it to chance as to whether you will get to see a top notch doctor versus the latest foreign medical graduate?

The Maintenance of Certification system (MOC), the Patient Protection and Affordable Care Act of 2010 (PPACA, or ‘Obamacare’), and the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), all treat doctors as interchangeable widgets. You cannot charge more or less than anyone else, regardless of your level of service or expertise. The foreign medical graduate who assessed you from the doorway saying something you didn’t understand is paid the same as your best hands-on, attentive, caring, and emotive doctor. And the sad fact is that the doctors who really care and want to spend the time with you get paid the least, because they have put your care first, and are not in it for the numbers. The cold, quick, calculating doctor who works as a machine and never makes an emotional connection to any patient will get paid the best. Because time and thinking are not rewarded, but getting people through the door is.

This brings us to the dark side of #3 above, which is government enriching itself in the process of all of this certification. Each of these certifications requires a fee which must be paid to cover the costs of the test. But is that all it covers? Recent investigations of the depths of corruption in the American Board of Medical Specialties (ABMS) and their underlying partners in crime – in my case the American Board of Internal Medicine (ABIM) – have found that the people making these systems, who we have already determined are the least capable in their milieu, have been enriching themselves on the backs of the hard working doctors in the field. Not only do these ‘doctors’ (I use quotes because for the most part these people do not actually see patients) pay themselves high six-figure salaries, higher than most of their actually working counterparts, they lavish upon themselves benefits such as paid spousal travel, chauffeur driven town-cars, and condominiums. These governing bodies which must make up reasons for their own existence are just another manifestation of the bubble inhabitants who have controlled the system for their own gain. We are talking about millions, if not billions, of dollars that are at play and the sucking sound keeps coming from Washington, and in this case Chicago.

It is time to put a stop to this entire culture. We need to return to our roots and abolish the entire certification system. “What?” you ask “you mean even doctors and lawyers?” Yes, and Indian chiefs as well. Let us build a new system where people can be knowledgeable about and thus feel comfortable with the level of expertise of their brethren. But let us also build a system where the true expert can be paid his or her worth.