Quis custodiet ipsos custodes?

by Kim Bellard, February 1, 2011

Don’t worry if your Latin is as rusty as mine; I’ll provide a translation of the title a little later on in case its meaning has not become clear by then.

The New York Times recently got a lot of attention for their story about older physicians, reporting that one-third of U.S. physicians are over 65, and that proportion was expected to rise as baby boomer docs increasingly begin to hit 65.  The Times pointed out that, while many of these older physicians provide excellent care, there are not strong mechanisms in place to assure continued competence of the aging physicians, and, in fact, many older physicians are “grandfathered” (pun unintended, one hopes) from efforts intended to help demonstrate physicians’ continued expertise, like tougher board certification standards.  They contrast the situation for physicians with that of pilots, who not only face mandatory retirement at age 65 but also are required to begin periodic physical and mental tests at the tender young age of forty. 

With all due respect to the Times, the issue is not age (and, by the way, their estimate of one-third of physicians over 65 appears overstated – as best I can tell, one third of physicians are 55 and older, but slightly less than twenty percent are currently over 65).  The issue is competence and demonstration of that competence, regardless of age. 

In 2009 Sidney Wolfe and Kate Resnevic of Public Citizen analyzed data from the Federation of State Medical Boards (FSMB), and found that disciplinary rates per 1000 physicians ranged from .95 in Minnesota to 6.54 in Alaska, with the overall U.S. average at 2.92.  According to their analysis, that latter number has actually been dropping in recent years, over 20% lower than the peak in 2004.  Maybe physicians are getting better, and maybe the doctors are that much worse in Alaska (or in Kentucky or Ohio, the next highest states), but one has to worry about how well problems are being reported. 

Indeed, last year Catherine DesRoches and her colleagues published an article that reported survey results about physicians’ attitudes towards peer reporting.  Only 64% felt a professional obligation to report fellow physicians who were significantly impaired or otherwise incompetent to practice.  Seventeen percent of the surveyed physicians had direct personal knowledge of a physician colleague who was incompetent to practice, although only 67% of those admitted they actually reported that colleague.

The disciplinary actions and the survey results don’t measure quite the same thing, but one has to worry that there is too big a gap between 17% of physicians knowing an incompetent colleague and yet, on average, only 0.3% of physicians with disciplinary actions.   Even if the latter number was the “right” number, the variation of the disciplinary rates between states would still be troubling.

Economist Mark Perry, of the University of Michigan and a visiting scholar at the American Enterprise Institute, has some strong views about the medical profession.  Not pulling any punches, he likens the medical profession to a cartel (see, for example, this blog entry).  He contrasts the number of law schools versus medical schools over the past 100 years.  The former has grown sharply (much to many people’s dismay!), while the latter has dropped even in the face of predictions of looming physician shortages due to population growth and aging of the population (all those baby boomers hitting 65!).  The number of schools is perhaps not the best measure, but the number of students graduating from medical school each year has not changed substantially over the past 30 years (something some blame on federal policies on residency training funding).  The number of physicians per 1000 residents has been increasing over the past several decades, but this is due in large part due to importing physicians from other countries rather than graduating more in the U.S.  Despite this increase, the U.S. still ranks well below the OECD average for practicing physicians per 1000 population.  We just pay physicians much more than other countries (as reported by the Congressional Research Service and others.  But that’s a topic for another blog.

It has always been difficult for consumers to get information on physician performance.  Sites such as Healthgrades or WebMD have some information on physicians, but to date they have still been largely demographic in nature.  The FSMB allows consumers to get some information on individual physician disciplinary actions, at $9.95 per result.  Some specialty associations are developing quality measures aimed at consumer reporting, as are NCQA and others.  Various health plans have been trying to publish data on physician quality, although not without controversy.  Most recently, Medicare launched its Physician Compare site, as it had done some time ago with Hospital Compare; the launch has its critics (see Michael Millenson’s view).  All of this is good – and none of it is enough.

The medical profession takes great pride in its work, and since the medical school scandals of the early 20^th century has fiercely kept control over medical training and oversight.  In medieval days guilds served the purpose of ensuring that trade secrets and practices in specific areas stayed within the members of those guilds.  Both the legal and the medical professions retain many characteristics of those guilds, including having de facto monopolies for their field of expertise.   Whether that is good or bad can be debated, as could how much of a monopoly either actually enjoys, but as consumers we should be able to expect demonstration of that expertise, not just have to take it on faith.   And we should be able to assume that the profession will do a good job of policing its own members and standards.

As can be inferred from my prior blog entries, I am a big believer in the importance of transparency of information and of consumers’ right to get – and obligation to use – information on the services they may receive and the practitioners from whom they may receive them.  We need our health care professionals focusing on improving the quality of care, which already is neither as high nor as uniform as it should be (see, for example, my previous entry “Gambling on Health Care”).  We shouldn’t also need to wonder if the medical profession is properly ensuring that their brethren are adhering to the adage in the Hippocratic oath -- “first, do no harm.” 

Sad to say, one only has to pick up a newspaper to realize these concerns are very real.  It certainly wasn’t the sole responsibility of local physicians to report or of the state Board of Medicine to put a stop to the recently discovered events at the abortion clinic in Philadelphia – some physicians did try, and the city and Health Departments also didn’t do their parts -- but the local medical community and the Board both evidently had some knowledge of the horrors and must bear some of the blame for not doing more to protect those patients.  Who was watching out for them?

About that title.  It has been more decades than I care to admit since I took Latin, but fortunately Wikipedia helped me find the right quotation.  For those of you similarly not fluent, it means “Who will watch the watchers?”