I would never get on an airplane if I didn't feel highly confident that the pilot was fully competent. In order to fly a commercial airplane a pilot has to undergo rigorous and continuous training and testing. I'd walk before flying with a pilot whose only credential was his assurance that he'd been diligently "keeping up with his field" and that he was extremely confident in his abilities. I'm glad to know that the FAA and the airlines have extremely demanding programs to ensure the competency of pilots.
I would trust 99% of pilots to remain competent on their own. But when it comes to flying 99%" isn't good enough. We need to know, within the bounds of what is reasonable, that all pilots are competent. Unfortunately, because of the few bad ones, the remaining 99% have to undergo all the rigorous training and tests.
Doctors are like pilots: what they do is far too important to let them individually decide for themselves whether they are competent, or how they should demonstrate their competency. Just because the vast majority of pilots and doctors are competent doesn't mean that we should loosen our standards.
This topic is important now because of a current red-hot debate over what physicians have to do during their career to maintain their certification– called maintenance of certification, or MOC. A short while back I posted my thoughts about this topic, in response to the growing and highly emotional rebellion within the medical community against a new MOC scheme. (To be clear: as I wrote earlier, I’m not a doctor and I don’t have strong opinions about the specific details of this controversy. I am writing only to object to some of the more general arguments and ideas that have been put forward by the MOC rebels. I am certainly not defending the new MOC scheme.)
There was a fair amount of pushback to my earlier piece, though unfortunately my critics didn't respond to my specific ideas. So let me be very clear: A major function of any MOC program is to help protect patients from being treated by doctors who are no longer competent. Unless, of course, you believe that there are no incompetent doctors. It is therefore completely illogical to maintain that the MOC program should allow physicians to attain MOC without some sort of rigorous, objectively determined MOC. One of my critics proposed that "it is the individual physicians who should be mainly responsible for their own learning needs, not some group of outsiders." I wouldn't get on a plane flown by a pilot who was "mainly responsible" for his or her own learning needs. The same logic is even more true for doctors.
So when doctors say that they want to revise MOC, I think they need to take into account that MOC must help protect patients from incompetent doctors. I realize that this means that this process may not be pleasant for some doctors. But some degree of discomfort is probably inevitable if the process is to have any meaning. (And, again, let me restate that I am not defending the specific details of the current process.)
The second point I want to discuss concerns the role of continuing medical education (CME) in this debate. Many of the MOC rebels have stated that they think CME has a large role to play in MOC. I pointed out that the current CME system is largely funded and controlled by industry and that, partly for this reason, CME in its current form should not play a significant role in MOC.
I haven't seen a cogent response to my criticism of CME. The same critic mischaracterized my position. "If industry funding is involved there can be no educational value," was the way he stated my position. But of course I did not say that industry-funded CME has "no educational value." But because much CME has some value doesn't mean that it has enough value for this important purpose. More importantly, the main purpose of industry-supported CME is not to educate doctors, it is to further the interests of industry. More broadly, as I wrote in my earlier post, even if the content is factually correct, the overwhelming presence of industry-funded CME distorts the overall medical agenda and curriculum. Quite simply, most physicians don't need hundreds (and I am not exaggerating) of choices in free CME program to help them choose new oral anticoagulants. But there is an enormous need for programs on a vast array of noncommercial topics that are less likely to gain financial support from industry. As I wrote before, I’m sure industry would just love to replace the current MOC content with content funded by themselves. But I don’t think this would be a good idea for anyone else.
The aviation field has created a remarkable culture of safety over the decades. Unfortunately the same cannot be said for medicine. Now of course it is true that the analogy between the two fields can be stretched only so far. Pilots have a difficult job that requires intense training, but medicine is more complex by several orders of magnitude. What works for aviation won't necessarily work for medicine in exactly the same way. But for medicine to begin to implement a similar culture of safety a necessary first step will be the acceptance by physicians that a lifelong commitment to learning and training can not be left simply in the hands of the physicians themselves.
