licensed for life

Monday, August 27, 2012

The NFL preseason is almost over and this is the week where mandatory cuts are made and coaches decide who will play when the games really count. Veterans cannot count on experience to keep their job and rookies who were college stars just a few months ago cannot be guaranteed that their skills will translate to the pro level. Veteran players have a knowledge advantage but need to train harder each year to compensate for their gradually aging bodies. New players have to rely on athletic ability to overcome lack of experience. Performance on the field and in the locker room needs to impress the head coach enough to make the team.

The road to practicing medicine and looking after patients independently takes time, effort and commitment. There is a four year undergraduate degree followed by four years of medical school. That gets you an MD (piece of paper number 1), but most states require at least one year of post graduate training before granting a license to practice medicine (piece of paper number 2). Once upon a time, most newly minted doctors spent their first year in a rotating internship, working a month at a time in different medical specialties like obstetrics, pediatrics, anesthesia, surgery and internal medicine. Afterwards, they hung up a shingle and became a general practitioner. Now, family medicine, internal medicine and pediatrics are considered primary care and require a minimum of three years of graduate training. Other specialties can take years longer. Still, it only takes one post graduate year to qualify for a license and hang up that same shingle.

After finishing residency, the next hoop is passing a specialty board examination and being called a specialist (piece of paper number 3). This recognition has an expiry date and requires the doctor to retake and pass another exam every few years. Finally, there is piece of paper number 4, acquiring hospital privileges. The medical staff credentialing committee reviews the doctor’s training, licensing and experience and grants the privilege to care for patients in the hospital setting, based upon their skill set. A neurosurgeon is not allowed to deliver babies and an anesthesiologist can’t repair broken bones. Federal rules require credentials to be reviewed and reapproved every two years.

While the specialty certificate and hospital privileges need to be renewed, the medical license granted by the state is forever. The license is renewed every couple of years and only requires that the doctor fill out a form, pay a registration fee and attest that they completed a few hours of continuing medical education.

Time and age erode the physical skills of athletes but they can compensate somewhat with experience. The same is true in medicine. As physicians age, the wisdom gained from seeing thousands of patients helps as physical and mental capacity slow somewhat. In the United States, the physician population is aging along with the general population and more than 20% of doctors are now older than 65. Professional pilots have a forced retirement age, which may not be appropriate for senior physicians, but there is no testing mandated to see if the doctor you are scheduled to see, is up to the task. There is no physical or cognitive exam required. In fact, a senior citizen runs through more tests to get a driver’s license than a senior physician does to keep his office open.

In medicine, the expectation is that a doctor will recognize his own skill deterioration and retire gently into the night. Sometimes, colleagues will nudge them in that direction, but there is no summer training camp to test skill and competence. There is no coach who decides that a doctor is not going to make the roster and has to be cut. A state license to practice medicine confers a lifetime pass to a doctor who looks after patients. For all the government rules and regulations, the patient can only rely on caveat emptor…let the buyer beware.

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