Considering Maintenance of Certification
Physicians benefit from having a near monopoly on caring for patients. We benefit from the high bars that have been set to become a physician; we benefit from the limits on the number of available providers; and we benefit from the resulting high fees we get paid. The public is thought to benefit from the resulting assurance of high quality care.
This is not the way a libertarian would organize the provision of medicine. The provision of medical care is highly regulated. Not all the regulations are to physicians’ liking. Along with our monopoly power, comes controls that are designed to assure the quality of the care we provide. Our education has been regulated, getting licensed has been regulated, and getting certified has been regulated. Now, maintaining that certification has been regulated, too.
One-time certification is not good enough for drivers or for pilots. Why should it be good enough for doctors? Medicine is a field that changes. When I trained and when I received certification, few of the medications I prescribe today were even available. Can the certification I received so many years ago guarantee that the quality of service I offer today meets the high standards?
On the one hand, I hope so. The certification showed that I was sufficiently smart, capable of learning and regurgitating lots of information, and that I could recognize skin diseases when shown pictures of them. With recommendations that I was of sufficient moral character to continue learning, my certification by my residency and my board offered some assurance that I would stick with training and stay abreast of new developments for my patients.
But that does not totally assure that I do. Is continued testing at intervals a reasonable thing? At its face, it seems so to many lay people, even though additional testing has not been demonstrated to prove competence. I hear from physicians complaining about requirements for maintenance of certification (MOC). Some of the complaints resonate with me, particularly the view that there is no proof that current MOC requirements actually assure quality. Other complaints, like that the certifying boards are corrupt cartels that extort doctors, do not resonate with me, no more than the suggestion that doctors are corrupt cartels that extort patients. I am quite sure that the members of our certifying boards are devoted to seeing that patients receive great medical care and to helping physicians achieve that aim.
Rather than complain about MOC, I would love to hear detractors offer a better solution. I am quite sure the American Board of Dermatology would love to recommend a low cost, nononerous effective quality assurance program. If you do not like MOC and have a better approach, let them know. Is the CME we are required to do to maintain our licenses enough assurance of quality? If the argument that MOC has not been shown to improve quality, claiming a CME requirement assures quality seems suspect at best. What would a serious solution look like? It would have quantitative, representative measures. Perhaps, it could include random independent evaluation of videotaped patient encounters, supplemented by review of treatment decisions made of lesions and rashes based on photographs or on “secret shoppers.” All the really serious means to document and assure quality would be far more heinous than anything being considered now. Maybe we should count our blessings, enjoy our eroding monopoly for as long as it lasts, and not complain quite so much.
Steven R. Feldman, MD, PhD
Chief Medical Editor
Dr Feldman is with the Center for Dermatology Research and the Departments of Dermatology, Pathology, and Public Health Sciences at Wake Forest University School of Medicine in Winston-Salem, NC.