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    Sunday, October 06, 2002

    Bloviator Response Part II: I’ve been considering Ross’s challenge regarding the issue of physician self-regulation. He’s wrong that we make no effort to regulate ourselves, but he’s right that it could be a lot better. Something’s wrong with a system when a doctor who loses his license in one state resurfaces in another without even taking the effort to change his name.

    Self-regulation within medicine varies greatly from state to state and from specialty to specialty. State’s have different requirements for continuing medical education to maintain licensing, and specialties have different requirements to maintain board certification. A physician doesn’t have to be board certified to practice medicine, or even to be a member of a specialty. To be a “general practioner” he need only complete one year of internship and pass the national medical boards, the licensing exam we all take during medical school and again at the end of our internships (or first year of residency.) There was talk some years ago of changing this, of requiring that everyone be certified by a specialty board to practice, but at that time it would have left a lot of very competent, experienced older physicians out in the cold. They entered the field before the dawn of specialty training. So, the measure wasn’t adopted. As time goes on, that objection becomes less and less compelling, so in a few more years we may see certification become necessary to practice.

    To be board certified, a physician has to complete a residency in his field and then pass an exam. For family physicians, the residency is three years, for surgeons it can be as long as six years. Some specialties (family practice, pediatrics, emergency medicine, and internal medicine as far as I know. There could be more), require members to take re-certifying exams every seven years to remain board certified. Failure to pass the exams doesn’t limit the ability of a physician to practice medicine, but it does make it harder to stay credentialed by insurance companies and to remain on hospital staffs (unless they’re hard up for staff), as well as to get good malpractice insurance. Many would argue that passing an exam is no indication of one’s worth as a doctor, in some cases they’re right. How can you assess a surgeon’s skill with a written exam? He could have all the smarts in the world and pass a test with flying colors but be a total klutz in the operating room. But still, the tests at least provide a basis for judging basic medical knowledge.

    Most states require doctors to attend a certain number of hours of continuing medical education (CME) programs each year to maintain their licenses. Specialty boards also require this to maintain certification, at least the ones with re-certification programs do. All CME programs are not created equally, however. Some are little more than drug company junkets, and the states often make no distinction between those and the more reliable programs sponsored by the national professional societies, or at least accredited by them. The certifying boards, however, do make a distinction, and they require that the majority of CME hours come from accredited programs.

    I think what really bothers Ross, however, is our failure to come down hard on physicians who practice outside the pale of what most of us consider good medical practice. He was very upset about the over-sympathetic physicians described in my post and in the New York Times last week. This is always a very difficult issue, because a good deal of medical practice is more art than science, and our responses to our individual patients can’t be made in cook-book fashion. Sometimes, our colleagues don’t do things the same way we would, but our way isn’t necessarily the only way, or the infallibly right way to do things. Case in point is the issue of pain treatment. As recently as five years ago, the standard of care was to move with caution when treating chronic benign pain because it is so often complicated by emotional factors. Now, the standard of care has become to treat pain as the “fifth vital sign” (that’s a topic for a whole ‘nother rant) and to use narctotics liberally to alleviate it. I happen to think that approach does more harm than good, as do a lot of other physicians, so I continue to take the cautious approach and avoid addiction and dependence in my chronic benign pain patients. But, someone who believes strongly that all pain must be completely alleviated could accuse me of practicing bad medicine. Whether their accusation sticks or not would just depend on the political environment at the time. Personally, I’d rather not go about censuring physicians based on so-called “quality of care standards” because the standards themselves are always changing, even when they aren’t adopted under the influence of lobbyists.

    In the absence of harm, it’s also difficult to restrict a physician’s ability to practice without violating their civil rights; especially if that restriction is based only on style. A surgeon in my hospital had his privileges suspended because of quality concerns a few years ago. He sued both the hospital and the chief of surgery, winning over a million dollars in damages. That sort of judgement makes everyone wary of pointing fingers.

    posted by Sydney on 10/06/2002 10:28:00 AM 0 comments


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