who can you trust

Monday, June 24, 2013

Dr. David Chao’s recent fall from grace is a reminder that it is hard to decide who might be trusted to provide medical care and who should be avoided. Dr. Chao had been team physician and orthopedic surgeon for the San Diego Chargers, until he resigned this week, ostensibly because of a back injury and to spend more time with his family. Then the news broke that his privileges had been suspended and he was no longer allowed to operate at two hospitals. This came after the National Football League Players Association had questioned his competence because of two malpractice lawsuits and a letter of reprimand from the California Medical Licensing Board. However, the NFL had three independent physicians review his medical care and found it to be satisfactory. Plus, there were the testimonials of the Charger players, including Philip Rivers and Nick Harwick, supporting Dr. Chao.

There is a difference between the ability for a doctor to practice medicine and the ability to practice well. The presumption is that there safeguards on place to keep the public safe and informed about physicians who hand out their shingle. But that information is not readily available; the journey from medical school to looking after patients is not necessarily a line easily followed.

The first step is the easiest. Go to medical school (also appreciate that this timeline may also apply to doctors of osteopathy or DOs) and get an MD. Then it’s time for postgraduate training. Complete an internship year and pass the national medical board exam and you can apply for a license to practice in most states in the US. Each state has its own rules and regulations and medical licenses don’t cross borders. Some states require two years of extra training while Maine requires three. Some states have no limits as to how often the new MD can fail the board exam, just as long as there is an eventual passing grade. Other states may allow only two failed attempts. There are different requirements for graduates of foreign medical schools that are somewhat more stringent.

This first step allows the doctor to open a practice and see patients. The state medical licensing board has little continuing oversight, except for the yearly medical license renewal, where the physician attests that they have completed continuing medical education, have not been convicted of a crime and have not been sued for malpractice. While most doctors practice in their field of training, there is little to stop a doctor from opening a weight loss or cosmetic surgery clinic or any other area of practice.

Most doctors take step two and continue residency training to become a specialist. Primary care takes three to four years, while surgeons and subspecialists may spend the better part of a decade developing their skills. To qualify as a specialist, the doctor is required to pass an exam given by their specialty board; some are written, some are oral and many have both. The certificate is often time limited and the specialist has to pass exams every 7-10 years.

Finally, there is step three. Many physicians care for patients in a hospital and need privileges to do so. These are granted by the hospital medical staff through the credentialing committee and allow the doctor to work in the areas where they are qualified. An internal medicine specialist would not be given obstetric privileges to deliver a baby and a pediatrician would not likely practice in an adult ICU. Hospital credentials are a big deal because each doctor is his or her brother’s keeper. The background of each doctor is scrutinized including medical school, residency training, licensing, disciplinary actions and malpractice lawsuits. An information clearing house allows information to be shared nationwide, and most hospitals require privileges to be renewed every couple of years. It is a big deal for a hospital to limit or remove privileges. Most doctors are held to minimal standards of performance and skill and it takes great effort to fall below that low bar. Insurance companies may also screen doctors and HMOs, PPOs and the other alphabets of managed care may also set practice standards.

How to choose a doctor remains a difficult problem. Some pro sports teams have made that decision based on money; what doctor or hospital will pay the most to advertise themselves as doctors to the stars. The rest of the world often relies on word of mouth and referral from family or friend. This may be problematic because most patients love their doctor but are less than aware of training, credentials or practice issues. This is where the internet comes in handy and here are a couple of places to check:

The saga of Dr. Chao seems more than a little contentious and his story will fade. The San Diego Chargers and Scripps Hospital will continue on. The NFL Players Association will fight to provide their members with the best doctors available. And fans will appreciate that it’s hard to decide whether a doctor is a star, a benchwarmer or shouldn’t even be in the league.

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