Archive | March 2012

How Stronger Residency Directors and Board Certification Can Work Together

Residency directors have a challenging job.  They are entrusted with selecting young doctors and training them over the course of several years.  Newly graduated medical students are thereby turned into internists, surgeons, radiologists, pathologists and the like.  Fellowship directors build upon this foundation with extra training, setting the stage for these graduates to become clinical experts in their respective fields.

The Maintenance of Certification (MOC) process adds an additional and continued requirement once doctors achieve their initial board certification, but the entire process has come under unified, multispecialty criticism.

Another article critical of the certification process noted that program directors already know plenty about the qualifications of their trainees, and seemed to suggest that program directors’ power to hold back or terminate trainees could reduce the need for the post-residency certification (and recertification) process.

It can be said that the ability to pass tests does not equate with the ability to practice ethical, high-quality medicine.  People who are good at passing tests (i.e. the majority of people who get into medical school) can keep doing it right through board certification.  But is that a good use of time and resources?  Likely not, and this is one reason why MOC has been criticized as little more than a Trojan Horse to maintain certifying board revenue.

However, there is a question whether residency directors can effectively manage their trainees, as they once did.  In past decades, residency directors’ power was near absolute, and many programs (especially surgical fields) ran pyramid structures that only graduated a few of the trainees each year.  Residents knew they were under the microscope every day, and continued progress in the program was not assured.  The old pyramids have been eliminated, although that is not the key problem.  The evidence shows that few residents are ever actually dismissed from training.  Even problem residents – as many who have been in a residency can anecdotally support – are often nudged along and graduated.  This is easier than firing them, which is often a costly and difficult endeavor.

This is not an easy topic to get data on, but the 2009-10 annual report of the Accreditation Council for Graduate Medical Education (ACGME) suggests that firings are in fact rare.

Of 111,140 full-time residents, 261 (0.2%) were dismissed.  Even counting the 112 (0.1%) who Unsuccessfully Completed Program (seems an odd word choice), the 96 (0.09%) who went on Leave of Absence, and the 943 (0.8%) who Withdrew, only 1.3% of all residents were somehow taken out of programs every year.  That seems like a small number, and perhaps represents directors’ aversion to taking hard action against sub-par trainees.

Certifying boards may say this is why post-residency evaluation is essential.  But failure in (or noncompliance with) certifying exams cannot keep sub-par physicians from practicing, though it can reduce their options.

The MOC process is imperfect, and stands to be simplified, improved, and made less expensive. Concurrently, the discretion of program directors to remove sub-par trainees should be increased.   They should also be empowered to direct a simplified initial certification process culminating in the final month of residency.

This can ensure that well-qualified people complete residencies with their initial certification, and can later maintain their qualifications with a sensible and cost-effective MOC process.


The Real Lesson from the Health Reform Contraception Battle

The recent battle over Catholic institutions being required to provide contraceptives and abortion services over their objections is illustrative of what is coming as various aspects of the law come into effect.  Nobody is really sure about what the effects will be, and we should not forget that we were told, “We have to pass the bill so that you can find out what is in it.”

The takeaway point from the contraception conflict may not be about religious freedom, constitutional protections, or women’s rights of self-determination over their own bodies.   What the contraceptive fight shows us is this:  with health reform, people will be told one thing, and they are going to get another.  As Rob Halford noted, “You’ve got another thing comin’!”.[1]

To enlist their support for health reform, Catholic leaders were assured that their beliefs on contraception and abortion would be respected.  And then they were ordered to do something quite the opposite.

In order to forcibly reorganize one-sixth of the economy, some tough tactics will be required, and that is exactly what was attempted in this case.  The ultimate success or failure of the reform effort will be influenced by the responses from the various industry segments as they get targeted by the law.

Doctors, healthcare executives, insurers and state governments have some idea what the changes will mean, but most of this experiment will be subject to improvisation as various consequences – intended and otherwise, come to light.

Patients may be less aware of the implications, because only the positive elements have been emphasized; no lifetime insurance limits, no pre-existing condition exclusions, and so forth.  But they will be the last of the stakeholders to realize the likely downsides of reform; less physician-provided care, long waits for appointments, difficulty accessing specialized services, and much higher cost-sharing.

The decision to tackle the health care problem with greater expansion of government-control rather than seeking market-determined solutions will lead to many interesting days ahead.  One positive element of the law is that it runs a number of experiments, and in theory this will lead to a trial-and-error process of coming up with workable solutions for the various problems.

Another positive is that more and more physicians are realizing that in order to best serve patients, they need to take control of their businesses and work on creating real value for consumers, both in quality and cost.  In some way, the great expansion of a non-market derived reorganization of the system may be the spark that leads to the creation of a more transparent,  private system emerging parallel to the current one (as has been seen in countries with national health systems).  This may be the most lasting legacy of the reform law.

[1] The author apologizes to readers unfamiliar with the work of the Judas Priest vocalist.