October 26, 2015
Medical Idolatry And Healthcare Outcomes
By Michael D. Shaw
Many articles have appeared in this column questioning the conventional wisdom on matters ranging from infection control practices; to the validity of established (yet oft-changing) guidelines on diet, and “healthy” blood titers for a host of substances; to suitable blood pressure numbers. The implication is that such wisdom is subject to influence by sundry commercial and political forces.
While most people are familiar with the CDC, FDA, and NIH, in many cases, so-called non-governmental organizations (NGOs) are involved. These can be trade associations such as the American Heart Association and American Medical Association, as well as consensus standard groups such as the Association for the Advancement of Medical Instrumentation. And then, there are the certification bodies, such as the American Board of Internal Medicine (ABIM).
In a sense, the prestige and very existence of these institutions is a form of idolatry, which—like it or not—is part of human nature. Less dramatically, we restless humans are searching for answers, and some sort of higher authority to assure us. However, we ignore the factors that may tempt such authority at our peril.
It isn’t revolutionary to point out the unseemly alliance between those bodies that set “healthy” blood values, and the very pharmaceutical companies that sell products to adjust these values. In one of many examples that could be cited, there is essentially no hard science behind the draconian reductions in the blood glucose level defining type 2 diabetes—from 160 mg/dL, to 140 mg/dL, to 125 mg/dL (8.9, 7.8, 6.9 mmol/L). Nonetheless, there are plenty of hard sales numbers for all the drugs thus prescribed.
As to ABIM—according to its website—it is one of 24 medical specialty boards that make up the American Board of Medical Specialties. The associated boards work together to establish common standards for physicians to achieve and maintain board certification. The boards were founded by their respective specialties to protect the public by assessing and certifying doctors who meet specific educational, training, and professional requirements.
Notably, board certification is optional, although it is quite difficult to practice in most settings without it. After all, it’s about protecting the public, right? Surely then, with all the certifying that has gone on since 1936, ABIM would have reams of data showing that board-certified doctors are so much better than their loser non-certified counterparts. Alas, ABIM’s website cites but three studies, and the findings are not exactly robust in their defense of certification.
The oldest study (2006), that focused on elderly patients with acute myocardial infarction (AMI), concluded: “Treatment by a board-certified physician was associated with modestly higher quality of care for AMI, but not differences in mortality.”
A study from 2009 examined outcomes in patients receiving an implantable cardioverter-defibrillator, but confused the issue in that all participants were board-certified, but only 61% of them were certified in the “appropriate” field of electrophysiology. Even so, there were only very small differences in outcomes.
A study from 2010 entitled “Associations between Physician Characteristics and Quality of Care” looked at degree obtained (MD or DO), Gender, Board Certification, Years in Practice, Medical School (foreign or domestic), Malpractice, Disciplinary Action, US News Research Rank, and US News Primary Care Rank—as they related to various measures of quality of care. 10,408 Massachusetts physicians were included in the study, and 92.8% were board-certified.
The best we can glean from the 2010 study is:
“Board certification was associated with high performance scores at the overall level and with both acute and preventive care. We recognize this is an association and does not imply that board certification itself drives the difference between higher and lower quality physicians. However, this association does provide preliminary evidence suggesting that there may be some quality of care benefit to be derived from maintenance of certification programs or the inclusion of board certification activities as a requirement for maintenance of licensure.”
Inasmuch as there were so few non-certified docs in the study, one wonders why this paper was even cited by ABIM.
That the certification exams are expensive and difficult is onerous enough, but does ABIM really have to engage in grotesque activities evocative of a cartel to support its brand? Its website sternly warns:
“All ABIM materials are protected by the federal Copyright Act, 17 U.S.C. § 101, et seq. Access to all such materials, as further detailed below, is strictly conditioned upon agreement to abide by ABIM’s rights under the Copyright Act and to maintain examination confidentiality.”
“ABIM examinations are confidential, in addition to being protected by federal copyright and trade secret laws. Candidates and diplomates who undertake examinations agree that they will not copy, reproduce, adapt, disclose, or transmit examinations, in whole or in part, before or after taking an examination, by any means now known or hereafter invented. They further agree that they will not reconstruct examination content from memory, by dictation, or by any other means or otherwise discuss examination content with others.”
Such copyright infringement litigation has occurred and is ongoing, even though the notion that repeating something from memory violates a copyright is absurd on its face. By that logic, if I relate the plot of a movie to a friend, I have violated the copyright of the studio.
Beyond that, if everyone is board certified, then this status is no longer special, is it? What’s next? Platinum-level certification?
Meanwhile, we lucky Americans still pay way too much for mediocre healthcare outcomes.