A discussion arose around looking for a new doctor and what it meant for a doctor to be “Board-certified”. We called a friend who is an M.D. She explained that this was an exam administered by an organization of specialists. “A lot of the questions aren’t very relevant to practice and there are plenty of people who are good at taking tests who can pass the Boards without being good physicians.” What if someone didn’t pass the Boards? Could they still practice as a specialist? “Absolutely.”
How about looking at where a doctor trained? A doctor can’t graduate from residency without having achieved a certain level of proficiency at least certified by the hospital where he or she trained, right? At least a few of the doctors at the hospital have to agree to sign his or her diploma? “Wrong. Finishing residency means that you spent three years in residency. If it was a very competitive residency, it means that the doctor looked good when graduating from medical school and getting matched. But if he or she slacked off during residency, you have no way to know.”
I was beginning to get worried. In aviation you don’t get a pilot’s certificate based on having taken a minimum number of hours of lessons, though there are minimum hour requirements. You get a certificate when an independent FAA-designated examiner (or the FAA itself) flies with you and compares your skills to a published standard. Was there nothing like that in medicine? “There used to be for surgeons, but it was too hard to administer so they got rid of it.”
Just when I thought that it couldn’t get any worse, I reflected that hospitals were non-profit organizations. The typical non-profit is focused on its staff, avoiding employee lawsuits, and growing its cash hoard. There is little interest in the customer or the quality of services delivered. If a resident was doing a bad job, maybe there was no way to fire the guy. “Your fears are justified,” my doctor friend responded. “I trained with one guy who was spectacularly incompetent. He came close to killing a few patients. Everyone knew that he was incompetent. We were all dragged into a room by the head of the program who explained that this guy might sue if we continued to give him negative peer evaluations. Thus we were not allowed to say anything bad about him in the future. He finished his training.”
So… in a world where people who plug computers together get certified by Microsoft, it seems that there is some check on a doctor’s quality when he or she finishes medical school and virtually none after that. How could a patient find a good doctor then? “The only way is through personal recommendations from other physicians.”
I remember hearing about some online service billed as an analogue to CraigsList, but for sharing information about doctors, dentists, plumbers, etc, etc. Can’t seem to track it down now, though…
Ah, the medical expert as the prime example of the successful test taker. Love it.
Seriously, though, there is always the problem of finding a new doctor.Some web-based methods evaluate doctors; can these be trustesome feel that these may not allow proper judgment since they are so open to mis-use. One can go to a bunch of doctors and attempt to settle on someone good. But, the patient also hopes that the peers and the process allowed only the competent to get to the level of regular practice.
Having lived in several cities, I can attest to the issues of trying to find medical care since viewpoints (and, training) seem almost to be an issue of localization (is science missing something here?). Some feel that evidence-based medicine might help establish more standard care; will that help with the problems of competence?
For those who can, the solution may be to travel to where you were before in order to have some type of continuation with people that you know. Then, believe it or not, you can get referrals by various means. However, these do need to be followed by personal visits and trial appointments.
Oh, by the way, talking to the family of doctors can help, too. Could there be an anonymous scheme based upon collecting information from people who supposedly know doctors, and some aspect of medical issues, directly?
I don’t think the boards are useless. You can in fact not pass them. I don’t that studying to take a test is completely orthogonal to developing the skills you need to be a good doctor. There’s at least some relationship.
And your idea that someone who is good in medical school suddenly becomes completely incompetent over the years of their residency is also flawed. I guess it could happen, but a good residency location is not a useless data point.
Nothing’s perfect. “Yet another certification,” whatever it is that you’re proposing (it isn’t clear, perhaps you want your friend the M.D. to administer some sort of test?), would still have its own flaws.
By the way, who’s dying?
And if you think that a for-profit hospital means better quality, think again. I worked a a for-profit and it meant slashing staffing ratios to the bone and spending a lot of money to attract rain-makers, in this case, cardiac surgeons, to the staff. Quality was only paid lip service.
There’s a company called Checkbook, subscription, where subscribers rate, among other services, doctors. I’ve had very mixed luck. Some of the worst end up there, and the service itself has antiquated technology that makes me wonder who uses it. It also seems like the doctors who graduated in like, 1962 get overall more votes, a certain bias happening. Also there’s some “best doctors” organizations, where they supposedly ask doctors who they would go to. Again, it seems like a name recognition game. One (of many) flaws with unanimous recommendations is you don’t know who the source is, what they expect from a doctor — often at best a very basic anatomy lesson and a amiable demeanor. Doctors often refer to the same clinic, regardless of ability. The best luck I ever had was when I worked with all doctors whose opinions I respected.
I recommend reading books by Atul Gawande which offer a good insiders view of the medical system. One example was a case of a medical student who received bad medical treatment and was made by the institution to sue them (ie they asked him to) because that is the only way they had to deal with this kind of issue (ie expensive and time consuming). He also has a chapter on doctors that had addiction issues (drugs, alcohol etc) and treating them and the issues behind it. (They are people after all so as in the general population that sort of thing will happen.) Perhaps the best food for thought is that half of doctors, nurses, hospitals, treatment programmes etc are below average. (Ok below median, but median and mean are close enough for large samples.) Who wants to be treated by the below average? Who wants to admit and seek improvement. and hence welcome lawsuits etc. Atul Gawande’s books also give you a good idea of just how little medical science knows about the human body. Much of it may as well work by magic!
I also listened to a good EconTalk podcast about the whole malpractise industry. Of note is that in some juridisctions awards can be 3 – 6 times those of others, even their immediate neighbours. It turned out that the single biggest predictor of these larger awards is if judges are elected. ~95% of the judge campaign funding comes from lawyers in the area not constituents so it is isn’t a direct pandering to the electorate.
“How could a patient find a good doctor then? “The only way is through personal recommendations from other physicians.” ”
Exactly right! Or a recommendation by a trusted RN. This has been the surest method for me over the years.
Doctors recommending other doctors is also suspect. One doctor we knew gave a recommendation to go to a certain doctor because he knew him from the elevator in his building. Another doctor was recommended because of the hospital affiliation that came with that doctor without any knowledge of how good she was. Then there was the time mom got a doctor from a published “top doctor” book which should have been the field recommending this doctor. The janitor in the hospital we went to (who looked and talked exactly like actor Morgan Freeman) laughed his ass off when we said how we came by this doctor. He said doctors pay to be in those books and advised my mom never to do that again. Another doctor who was on the faculty of a med school got extra reputation by publishing journal papers which of course does not attest to what kind of doctor he was. So, the moral of the story is,
you can only trust the janitor.
Yes, there are now websites where patients are rating the doctors.
(vitals.com; healthgrades.com) At least on those sites you might be able to
get a consensus from patients. Although on one rating the patient said, this
doctor doesn’t take insurance but they are well worth it. What kind of a moron
goes to a doctor who doesn’t take insurance?
In my case, the best recommendations have been from close MD friends of mine whom I trust, not a doctor whose only relationship with me is professional. Also, when I lived in Manhattan for a while, the doctors with the very best reputations never took insurance since there was enough demand from fat cats who could afford to pay for all their health care out of petty cash.
A few months ago, I had an accident and ended up in ER. Had a major surgery and many post-op complications. During this time, I had an “Aha!” moment. There is so much information on things that don’t matter as much as our health care. We can get excellent referrals on a text book, automobiles, tools or a roofing contractor. When it comes to our health, there is nothing we can find about the doctors in whose care we are. Either we end up in the care of whoever was available that day in the ER or go with questionable references.
I made peace with this state of affairs by rationalizing that doctors are watched over by all these boards and that board certified doctors stood for something. Now, you have shattered that comforting notion as well!
Needless to say, this sucks. I have seen my fair share of doctors and it hasn’t always been a positive experience and access to proper information would have been helpful.
As a member of the secretive MD society I will try to outline my own path and the steps involved in obtaining current Board Certification. Primarily I am outlining the path as medical education is a bit of an unknown to anyone outside of medicine.
1) 4 years of med school following undergrad. Includes written testing, oral quizzing in lectures or at patient bedside, videotaped interactions/exams with patient actors. Written tests called Step I,II, and III USMLE (United States Medical Licensing Examination) given at different points in the training, which each involve a 2 day written test.
2) Residency “rotations” through different areas of medical care with daily “rounds” made famous by just about any TV medicodrama with Attending physicians drilling residents at bedside or in small conference rooms. At the end of each rotation the Attending writes up an evaluation of each resident physician and medical student. It can be difficult to fail a student but my teaching team has recommended failure for an intern (1st year resident) just this last December. Formal conferences and lectures are sprinkled through residency as well.
Residency lasts 3 years to more than 10 years depending on specialty.
3) Fellowship (optional) variable number of years after finishing residency to concentrate on even more specific skills- i.e. orthopedic surgeon taking a Hand Fellowship to further subspecialize.
4) Post Residency Take board certification exam for your specialty. Generally involves 1-2 days of written examinations and may involve some oral exam as well. Each year a certain number of Certified Medical Education hours are required which may or may not be very educational but involves some form of continued learning. Younger physicians are required to undergo recertification examinations every 7-10 years which do vary by specialty but again involves 1-2 days of written exams. My specialty recertification exam fails about 10-15% of takers.
My opinion of my own recently recertified Board status? Crap. Few of the questions in the exam addressed my own practice. Unfortunately I don’t have the answers on how to address competence in a field in which only a small fraction of the possible knowledge has yet been explained by science. Even so, this small understood fraction of the possible knowledge regarding human existence so completely dwarfs our capacity we must break the information into ever smaller subspecialities in an attempt to master even a small area of the human body. Run quickly away from any doctor who claims to know it all. I’m as arrogant as the next doc yet I seem to feel a need to fess up on an annoyingly common basis and say “I don’t know the answer”.
Personally I don’t believe more testing/certification is the answer. Using your aviation argument regarding certification and testing I would pose this question. Do you care which certified A&P mechanic works on your aircraft or is it all the same to you once they have the rating? I imagine you choose a mechanic based on the same word of mouth recommendations I use when trying to find a good house painter.
Patient based web site?
Patients are able to gauge my compassion but may be no better than a jet passenger rating the pilot who just made a heroic landing in horrific conditions but that jarring landing is all that gets judged.
“Best Doctor” publications
Strangely becomes a listing of all local department chairman or other politically connected docs with some truly outstanding docs included – or left out. Don’t let my bitterness at my doc wife beating me out every year bias you.
Malpractice suit rates?
The most sued docs are the best and the worst ones. The worst for obvious reasons but Susie Super Surgeon may take on extremely high risk surgeries as no lesser doc will touch that tumor but Susie knows she is the only chance Grammaw has.
Insurance plan rankings.
Even if you can suspend your sketicism regarding their need to protect their bottom line there are a huge number of confounding variables but perhaps the future will provide some utility.
So why bother being certified? Most doctors require a speciality board certification in order to be on an insurance plan. No insurance plan means no patients coming in your door. As a bonus, insurance plans now use office electronic medical records to data mine for quality care and report cards are regularly issued. Again, the ability to measure quality is extremely difficult.
As an aside the reasons some doctors don’t take insurance
1) In a field not really covered by insurance – such as cosmetic boob jobs etc.
2) The growing field of “boutique” medicine –
http://en.wikipedia.org/wiki/Boutique_medicine
3) Exasperation with billing attempts. Even a small medical practice requires several full time billers/coders to fill out insurance paperwork (and you thought the forms you fill out in the waiting room were bad). Some practices are experimenting with a simple pay me 20 bucks every time you come in concept.
Having gone through both sets of certifications, (aviation through CFII, and medicine through subspecialty boards) I can tell you it’s much easier to become a commercial pilot then a board certified doc. There’s no guarantee that having either certification ensures competency, but at least it’s something. A pilot may be competent on the day of the check, but that commercial license is good forever – never to be checked again essentially (a ride with an instructor every two years barely counts…). On the MD side I have to jump through a long series of hoops to maintain my status.
32 Papa: Of course it is tougher on average to become a doc than a pilot. My point was that independent judges at many stages must say “I’d be willing to put my kids on the plane with this guy” for the pilot, whereas for medical doctors the last checkride is apparently the match (about halfway through training).
You’re right that the Commercial certificate is good forever, but that’s of no practical significance. A charter or airline pilot is taking line checks and instrument proficiency checks roughly once every 6 months. Many of these checks are either with the FAA or a designated examiner and those folks have no qualms about grounding a rusty pilot (at most airlines the guy or girl will be sent back for retraining and given an opportunity to take a new checkride, usually in a simulator, with the FAA or its designee).
A story about using aviation standards in medicine:
http://www.independent.co.uk/life-style/health-and-wellbeing/health-news/right-patient-right-limb-two-questions-that-have-almost-halved-death-rate-at-one-hospital-1366705.html
Does any doctor have advice for a doctor who is practicing in his EP cardiology subspecialty but cannot pass the EP boards (although did pass the cardiology boards)…have taken EP boards three times and not passed after much studying and preparation. Is there a way to find a coach ? tutor ? advisor to help figure out what I’m doing wrong in my studying and test taking ??
Another doctor ratings site: http://www.ratemds.com/
Phil:
These days, it is pretty much impossible to practice medicine without being board-certified in a specialty recognized by the American Board of Medical Specialties. As another poster noted, insurance companies frequently require specialty certification and so do hospitals. It is possible to practice independent of a hospital if you don’t have a need for their operating room facilities or a need for staff affiliation as a condition for working at an outpatient surgery center. So non-certified physician might work in a doc-in-the box office where insurance was not accepted (really not a bad idea, just for business reasons). But these opportunities are scant.
Board certification anymore isn’t just a matter of passing a test (or series of tests) after being signed off as eligible by your residency program director. (Yes, someone actually does have to sign their name to a document saying you have fulfilled the training requirements established by the American Council on Graduate Medical Education for training in that specialty; you can’t sit for your specialty board exams until they do.) Once passed, you enter a cycle of “maintenance of certification” which is a series of requirements, some proctored tests, some patient chart reviews, some self-administered open-book tests, and documented accumulation of continuing education hours and good standing on hospital staff and before your licensing authorities, all of which repeats itself every 7-10 years. There are older doctors whose requirements on becoming board certified came with no time limitations, this done before re-certification requirements were established. Those individuals are not required to re-certify as the changes cannot legally be made retroactive to apply to those receiving the “lifetime” certificates. They are allowed to voluntarily re-certify, but few do because of the cost and inconvenience. The exception is for those seeking positions as officials of the specialty board organizations, where there is usually a requirement to meet the re-certification requirements by the current standard.
From what i have seen of the online “ratings”, I wouldn’t trust them. They mostly seem to be unmonitored for abuse or manipulation. There is no way to determine whether a poster actually was a patient or a practitioner or anyone else, and since they are anonymous, there is no accountability. They seem equally open to libel as well as fraudulent self-promotion. Someone who is angry about a bill or some non-care-related matter could use these sites to impugn a doctor’s reputation out of spite with little recourse by the practitiioner, not even a reasoned rebuttal. I would not trust anything written anonymously, ever. If a poster won’t list a full name and contact information, you have to wonder why.