From Arthur Silk, MD--

Conscientious doctors realize that the half-life of a medical education is about 10 years. If you were Robinson Crusoe, MD, class of 1990, and just returned from isolation, you could not--in good conscience--practice good 21st century medicine.

The remedy, of course, is continuing medical education. Doctors may not remember that until the latter years of the 20th century, CME was an ethical, but not a legal requirement. After a few well-publicized medical gaffes, newspapers and influential politicians called for mandatory medical re-licensing every five years. Although many cooler heads realized that this was unworkable and even a disaster, it might have happened under further political pressure.

After a doctor is licensed, his or her interests and practices almost always vary widely as they pursue a variety of specialties. So what would a one-size-fits-all re-licensing exam look like? What would happen to the doctors who failed it? The ability to forestall this Armageddon was one of organized medicine's triumphs. The alternative to unwieldy re-licensure proceedings was to make CME mandatory instead of optional. And it has worked.

Whether we like it or not, most of us are contracted with insurance plans. Blue Cross, Aetna and others have many faults, but one of their strengths has been that they at least attempt to measure the quality of the medicine practiced by their contractees. They do this by using hospital-based patient encounters and outcomes as a measure of competence. To a great degree, this has worked--until recently. Many primary care doctors, internists and family practitioners have chosen to skip hospital medicine and entrust their sicker patients to hospitalists or intensivists. Many primary care doctors now never go near the hospital except for periodic mandatory staff or committee meetings. All this is preamble to what I see as a need for a new way of measuring medical skills and expertise.

To date I have not heard any call for change. But it would take only one or two overzealous reporters getting their teeth into what they perceive as a poorly managed case until the all-too-sensitive insurance overlords felt they had to find a public remedy. What might that be? Mandating pay-for-performance programs seems something they might recommend.

But if they judge me by the number of my diabetic patients I have persuaded to get to goal weight you might as well count me out right now. Or if they count the number of patients gasping with COPD I have convinced to permanently stop smoking, I might have to look for different work. And I don't like the idea of patient satisfaction questionnaires measuring my clinical skills. Satisfaction dips if patients have to wait for appointments, but how can patients really know if I deliver high-quality care or just have bad scheduling skills?

I wish I had as easy an answer about how to monitor what every doctor does in her or his office as the state did when it satisfied our critics by making CME the law. But I firmly believe that organized medicine had better find an answer about how to monitor medical skills or rest assured that our corporate paymasters or the state will.

Arthur Silk, MD, practices internal medicine in Garden Grove. He can be reached at adsilk@pacbell.net.


From Emile Wakim, MD--

Monitoring of clinical quality and competence is, indeed, quite important to our patients, the insurance companies and even ourselves. Recently, pay-for-performance models have been suggested as the means to accomplish more standardized care and higher-quality outcomes. However, many in our community see this as another way that insurers can continue to "downcode" for our services and preferentially rank healthcare providers on the basis of cost instead of quality. All around the country and at the recent California Medical Association House of Delegates, P4P programs are recognized as a tool of the detested health insurance companies.

What alternatives currently exist?

Having a national patient registry, generated through a national electronic health record, would allow physicians to generate substantial research on outcome measures, provide more accurate standards of care and assess their practice outcomes compared with national standards without feeling unjustly scrutinized by insurance companies. Such a system could automatically provide comparisons for the physician's personal use to optimize patient care. The government could subsidize this technology so there would not be a significant outlay of capital by individual physicians or groups. Payers would not be allowed to access specific physician or group information, but would only be able to access the results of studies generated by this data, just like any other organization could. This system would set appropriate expectations among the public and provide valuable, validated information for patients.

The current laws requiring CME credits are substantiated and do provide a means of updating the knowledge of the physician community. It seems reasonable to me that this system should be maintained in its present form.

The larger issue that Dr. Silk alludes to is who will drive the future direction of healthcare delivery in the United States. We can ensure that the future of medicine is safeguarded by having physicians direct medicine's evolution in the years to come. This can be accomplished by speaking collectively, with one voice, and "coming to the table" as the most important member of the healthcare delivery system.

We should actively support all efforts to reverse the application of antitrust measures at the state and national level. With healthcare delivery and access becoming more important in the political arena, we can capitalize on the opportunity to push legislation that allows physicians to collectively negotiate healthcare policy and reimbursement with public and private health insurers. Removing antitrust measures would provide greater strength for all physicians, correct many physicians' complaints, and dramatically improve outcomes at the local, state and national levels. We could win back the right to treat patients in their best interest, without excessive, uneducated or inappropriately applied oversight.

The biggest winners in this endeavor would be our patients, who could enjoy the improved patient-physician relationship that would be the result of our efforts. I agree with Dr. Silk. Organized medicine has to aggressively support our core needs. However, we must remember that all of us need to actively participate in these processes to provide organized medicine with the strength to win battles.

Emile Wakim, MD, practices orthopedic surgery in Huntington Beach.