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[Aug. 16th, 2012|02:30 am]
Scott
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A patient I saw recently (note) thinks snakes will eat him if he sleeps; he intends to solve this problem by never sleeping. This is the second most questionable plan I heard today.
We recently had the "special treat" of hearing a lecture by the head of the American College of Prestigious Bigshot Doctors Who Control Everything (I can't remember the actual name) on "maintenance of certification". Doctors who finished all their training twenty years ago risk falling out of date with the latest medical knowledge. "Maintenance of certification" means you've got to prove you still know what you're doing every so often if you wan to keep your accreditation.
The ACPBDCE gives four requirements to keep your accreditation. First, you've got to be in good standing with the licensing board, which I assume means no malpractice or anything like that. Second, you've got to pass a test every so often. Third, you have to do Continuing Medical Education. And fourth, you need to do surveys of your patients and the other doctors you work with and see what they think of you.
Although I admire the idea, I couldn't help picking up a security theater vibe from the whole thing.
For example, continuing Medical Education is monitored by self-report. That is, when you're applying to keep your accreditation, they have a little check-box: "Did you get continuing medical education?" and you tick "Yes". Then you get re-accredited.
But, the head of the ACPBDCE explained, you can't just tick the checkbox willy-nilly, because some doctors get audited. To keep them honest, you know.
The auditing process consists of the doctor writing down what kind of continuing medical education she received, and the auditors believing it. It seems pretty foolproof, unless of course the doctors lie in which case the whole system collapses. The ACPBDCE official specifically mentioned that you don't have to save any documentation proving you really took the continuing medical education, because that would be unnecessarily inconvenient.
But there's still the survey of patients and co-workers, right? Yes there is. So get busy choosing which patients and co-workers will be taking it. Because that's something doctors totally decide. You are free to give the patient survey only to the borderline personality disorder patients who have decided that you are literally the best doctor ever and can do no wrong, and you are free to give the doctor survey only to your golf buddies.
This may be unfair to the ACPBDCE. I'm oversimplifying the survey, for one thing. You actually have to do a survey, discuss what changes you should make based on the results, then do another survey to assess your changes (although the key point - that it's all self-reported and bad results on both surveys don't disqualify you from anything - remains sound). And they do have the exam you have to take. And I think their philosophy is that doctors are generally honest people and they just need to keep being reminded what they have to do, rather than actually monitored for compliance.
And I agree that it's pretty rare that a doctor will outright lie about having taken a course. And I think it's pretty rare that a doctor will outright be so callous not to care that her patients hate her on a survey. But first, I thought part of the justification of all these certification requirements is that occasionally there will be some really horrible doctors, and you've got to catch that person. And second, I have seen the way that even good, honest doctors do Continuing Medical Education:
"Hmm, my patient is a few minutes late...what to do? Ah, I've got a medical journal here on the desk. There's a Continuing Medical Education supplement in the back. I'll just take a look at...what's that? Patient's car is in the parking lot? Okay, I'll just skim this part...and this part...okay, I can't read all of this but I can just take the test at the end...oh, that's not a very good score...but I checked the answer key at the bottom and now I know why I got that one wrong, so I'm going to count this as a success. That's five Continuing Medical Education credits right there."
It's hard for me to condemn them - this was how I did almost all my homework from elementary school to college - but it does seem worryingly common. The only person I know who doesn't do this even a little is my father, who true to form reads the entire medical journal cover to cover and brings up the more interesting articles as dinner conversation. I have yet to reach the stage where I have my own medical journal subscription, but if I have inherited the ability to make myself do that, I will totally forgive Gregor Mendel for my premature baldness.
I intend to do everything I can to cultivate the personal virtue required to make myself stay educated, and you should feel free to harass me about this if I don't. But should I fail, I can rest assured that the ACPBDCE isn't going to twist my arms about it. They seem pretty happy to trust me - as long as I pay them their mandatory $175 fee per year. After all, this level of eagle-eyed policing of the medical profession doesn't come cheap. |
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Apropos of improving medicine, have you read Atul Gawande's _The Checklist Manifesto_? I did yesterday, it was pretty neat. Beyond the straightforward checklist stuff, he talks about how big-building construction is so complex that it killed off the "master Builder" decades ago. It's all about detailed team plans now, including plans to communicate about unexpected stuff. But medicine's, especially surgery, is still into a "master Doctor" idea, even with all the specialization.
This may interest you:
www.newyorker.com/reporting/2012/08/13/120813fa_fact_gawande#ixzz238ySbiTo
It's about doctors and the Cheesecake Factory.
Heh. The previous book I read was _The American Way of Eating_. Applebee's, at least, does not make things from scratch. They do have a System, though compliance is another matter. ("Corporate's coming to inspect! Remember to tell them you had food safety training!")
It's on my list of things to read, which is itself a short book at this point.
Let me suggest this as well:
well.blogs.nytimes.com/2012/01/06/think-like-a-doctor-ice-pick-pain-solved/
Which is an account of the bright side of continuing education. | |
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