THCB

On the origins of Maintenance of Certification in the National Health Service: A Serial Killer

Screen Shot 2014-09-10 at 6.22.08 AMBritain’s most prolific serial killer was a General Practitioner (GP), Dr. Harold Shipman. He wasn’t England’s most famous murderer. That accolade goes to Jack the Ripper. The Ripper killed five women in the streets of Whitechapel. Shipman might have been responsible for over 200 deaths.

Shipman’s legacy to the medical profession was not just a permanent simmering of mistrust. He triggered the introduction of revalidation, Britain’s version of maintenance of certification (MOC).

During Shipman’s prosecution the media scrutiny on physicians was intense. It’s both a beauty of and curse on our profession that we’re assumed to have such high code of ethics yet not spared the foibles of human nature.

“Homo homini lupus” doesn’t spare physicians. Bashar al-Assad was an ophthalmologist. Ayman al-Zawahiri once had taken the Hippocratic Oath.

This means that outliers, inevitable products of a Gaussian distribution, also get past the gates of medical school.

The government set up an inquiry headed by Dame Janet Smith. How could Shipman have gotten away with murder for so long? What were the systemic failures?

The Shipman Inquiry is 5000 pages long, compiled after interviewing 2500 witnesses. It cost the tax payer nearly 21 million pounds. Its conclusion was stunningly bland even if of military precision: doctors need more policing. This is like concluding that the First World War happened because people aren’t always nice to one another; a truism so uniformly true that it ceases to inform policy.

The report called for the General Medical Council (GMC), the prime regulatory agency for physicians, to work for patients, not physicians.

The solution: Revalidation.

Ambrose Bierce said of reflection “an action of the mind whereby we obtain a clearer view of our relation to the things of yesterday and are able to avoid the perils that we shall not again encounter.”

But we’re in a rational age of managerialism. Every rare event is dissected to the hilt for the root cause and the world changed to make sure the event doesn’t repeat.

The politicians promised no more Shipmans. The media wondered what Shipman’s colleagues were doing whilst he was going around overdosing people on diamorphine.

Some physician leaders, for whom vicarious acceptance of guilt on behalf of their colleagues knows no bounds, particularly if that acceptance opens doors to Whitehall (Britain’s equivalent of the Beltway), asserted that physicians must deeply introspect how a Shipman arose in their midst.

If you’d asked GPs then to spend time in the Gulag in repentance for Shipman, they might have agreed. So strong was the shame of Shipman.

Let’s pause momentarily and reflect. Revalidation (MOC) was instituted to catch serial killers.

Time-limited medical license, continued medical education, 360-degree evaluations, maintaining portfolios with goals and objectives and demonstrating that one is up to date with the PARADIGM-HF trial, would have caught Shipman (and might even have nudged Bashar in to dealing more equitably with the rebels).

Shipman was loved by his patients. He was a charmer. Psychopaths often are. He once was interviewed for TV. Shipman would have aced Press Ganey. His Yelp reviews, assuming he didn’t kill his victims before they wrote a review, would have been a near perfect five. He would have been on the speaker circuit for patient-centeredness.

How about making GPs demonstrate they’ve kept in touch with evidence-based medicine? That would have caught Shipman, surely?

Rhetorical questions, as I am sure you’ve guessed. Professional competence and murderousness are conditionally independent. But I’d conjecture that a physician who decides to embark upon a killing spree is more likely to get away if intelligent and professionally competent.

That Shipman knew the lethal dose of diamorphine meant he was aware of the non-lethal dose, and probably the dose that’s just lethal but not incriminating. The problem certainly wasn’t his lack of knowledge.

What if Shipman received a 360-degree review by his peers? That would’ve picked up his murderous intent?

Peer reviewer: “Dr. Shipman, I see you’re up to date with CME. Just one last question. Do you plan on murdering someone?”

Shipman: “Only the Secretary of State for Health.”

Peer reviewer: “Ha, ha! So do I!”

The readers of the Daily Mail wondered why his colleagues failed to detect his psychopathic tendencies. Even if there was an inflection in Shipman’s affect after he killed, does anyone seriously believe this should have lead his colleagues to suspect murder?

Perhaps the ethics classes in his medical school should have emphasized that killing patients is against the Hippocratic Oath. That might have stopped Shipman.

Maybe doctors should be have a regular test which, amongst other things, asks “do you think it is fine for physicians to kill their patients with lethal doses of diamorphine?”

Perhaps Shipman would have been nudged to the “somewhat agree” box from “always agree.”

It needn’t be emphasized further that revalidation (MOC) would singularly have failed to stop the event in response to which it was instituted. Shipman, that scourge of society, was clinically competent. Evil, yes. Incompetent, no.

This means that the prescription of The Shipman Inquiry was parody. It may as well have been written by John Gresham, certainly would have been less excruciating to read.

But here’s the important point: it wasn’t parody. It was politics.

Shipman presented a perfect opportunity, the long awaited straw wolf, for regulators to gain control of the “too big for their boots” doctors, through a sleight of hand that few would notice: conflating the morally dangerous with the clinically incompetent physician.

It gave the GMC boundless power, power that continues to grow under the pretext of protecting patients, and power they seem little inclined in relinquishing.

The physician leaders had loftier ambitions whilst the medical profession was too paralyzed with shame to point out what was blitheringly obvious: nothing can catch a physician serial killer before he embarks on a killing spree if he chooses to deceive.

The only way to prevent a Shipman is by the bokanovsky process in Huxley’s dystopia; i.e. factory production of embryos, tailor-made to become physicians with the right blend of empathy, compliance, and attentiveness to evidence-based medicine.

But, as we find out in the Brave New World, despite a quality assurance program more rigorous than Toyota’s six sigma, sooner or later someone falls through the stochastic cracks.

Revalidation is the dialectic between randomness and democracy’s desire for perfect security. It’s also a product of the constant battle between regulators and managers on one side and the physicians on the other. This is not quite the tension between workers and capitalists that Marx envisaged. It’s a white collar war. Between the importance of regulators and autonomy of physicians only one can survive.

Needless to say, revalidation has not been useless when one acknowledges the real motivations behind its introduction.

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26 replies »

  1. As a criticism of using MOC to prevent murderous physicians, this article obviously makes sense. But as a criticism of MOC in general, it’s pretty damn silly. Why should doctors ever have to prove their competency, even at the beginning of their professional careers? But if they do have to prove their competency, why should be only once, at the very beginning of a multi-decade long career, and never again? What if a physician experiences brain damage from accident or stroke or other disease? Should this person be legally able to practice as long as they are inhabiting the same body as the person who once proved themselves competent many decades earlier? Why should we have out there physicians practicing who have proven their competency at very different times, decades apart, and using very different standards and levels of knowledge in the field of medicine? Criticizing the ridiculous process of legislative sausage making does not really answer those questions. What the content of the initial requirements for certification or for later maintenance of certification is of course open to very legitimate debate.

  2. You’d have to explain your use of “dubious”??

    “For doctor run amok there are 10 nurses who have done equal or worse things.”

    Then they are unemployed. They have much more oversight and each bad event is investigated and appropriate action taken. Nurses loose license easier than doc.

    “Nurses dont have to get credentialed at hospitals.”

    They have to apply for jobs and if hired have abundant oversight. Every day is a “credential” day.

    ” Nurses dont have their errors tracked in a nationwide database.”

    State tracking not enough? How about previous job reference. The usual question from new employer to old employer is, “Would you hire this nurse again.”

  3. Your statements are dubious at best. For doctor run amok there are 10 nurses who have done equal or worse things.

    Nurses dont have to get credentialed at hospitals. Nurses dont have their errors tracked in a nationwide database.

  4. Yes, I see your point in FFS. They want these people alive as long as possible and as long as the money keeps flowing in. That is generally why people request medical care, to remain alive and comfortable. But, what if the insurer is an HMO where denial of treatment means profit?

    What would happen if the HMO owned the hospice center and refused to adequately treat those in pain or with expensive chronic illness? Could they induce the unknowing patient into hospice by offering more comfort and then potentially provide benign neglect or even a bit of assistance?

  5. Technically speaking they would gain by keeping the patient alive for as long as possible to keep billing them for non-lethal doses of diamorphine.

    Home visits used to be very commonly done by GPs particularly in small, towns with small communities in the North of England, where Shipman practiced.

  6. Two wrongs don’t make a right. Politicians have killed far more innocents than Shipman.

  7. “Home visits and death.” You are sparking my “paranoia”.

    How could that happen in this country? Vertical integration? A large company that insures a large number of people that are treated by the company’s own doctors in the company’s own hospital where all stand to make a profit on cost savings.

    What would happen if that large company were to include hospice care? Could there be an early shift in the direction of hospice care where diamorphine becomes a money maker (or in reality a cost saver)?

  8. “One problem with enforcement in this space, however, is that health professionals of all stripes are often very reluctant to speak against physicians, and prosecutorial reticence to pursue them is well known unless the circumstances are egregious.”

    My wife nurse of 40 years has seen a lot of this. Nurses usually get full critical examination of errors, docs however tend to get the country club gent scrutiny.

    I think with docs it’s the, “There by the grace of God go I” approach.

    When she was a head nurse she could not get fellow OB/GYNs to launch an investigation on one of their own. She was sure he’d killed a baby and his care was frequently reckless – believe me, nurses know. But many of his patients loved him as he had a knack of exaggerated eloquent flair telling them how he saved their babies.

    He finally left over a too long to explain incident with my wife (involving criminal charges) with a carefully written letter of recommendation just to get him out of the hospital. Following his career was easy as he continued to make the newspapers but never had to give up his license.

  9. The very first enforcement action I took was against the milk industry. Their promotion board in our jurisdiction was marketing to consumers that whole milk was a low-fat food. The basis for their claim was that milk was, by volume, mostly water and since fat made up a small proportion of the overall volume, they were safe to make the claim. And so began the fun of chasing healthcare liars and cheaters. No killers, though. The statute I enforced was commercial law, not criminal law.

  10. Thanks allan.

    We may not agree who runs to government but we do agree that more regulations will not provide the citizens the security that they sometimes desire, after a catastrophic event such as this.

  11. Yes, but he committed a lot of murders in their homes, as part of the home visits.

    That’d take surveillance state to a whole new level of definition.

  12. Ha! Ha!

    BTW, Paul Krugman doesn’t seem to think that independence is a good idea, economically.

    I’d agree.

  13. “Revalidation is the dialectic between randomness and democracy’s desire for perfect security. It’s also a product of the constant battle between regulators and managers on one side and the physicians on the other. This is not quite the tension between workers and capitalists that Marx envisaged. It’s a white collar war. Between the importance of regulators and autonomy of physicians only one can survive.” Brilliant paragraph, Saurabh.

    Only a government commission could issue a 5,000 page report and concluded that the solution to the psychopathology of one man is to hyper-regulate a profession in a manner that is completely lacking in evidence of safety or efficacy, during a time when safety and efficacy are supposed to be the new coins of the realm.

    I have worked in law enforcement, and my reaction to this was visceral: How is it possible that no one saw or suspected anything? And, if people did sense things were awry, why didn’t they speak up? One problem with enforcement in this space, however, is that health professionals of all stripes are often very reluctant to speak against physicians, and prosecutorial reticence to pursue them is well known unless the circumstances are egregious. Maybe that’s the wall of protection that needs to be rebuilt, so that bad actors can be pursued vigorously.

  14. With all the closed circuit TVs abounding in the UK, surely they could put them in the GPs’ offices? Not like the UK isn’t already a police state!

  15. Saurabh, a very proficient job that I intend to use in reference. Government apparently doesn’t have all the answers.

  16. What does it say when a guy like me who practices Occupational Medicine manages to pass the Family Practice Boards every 7-10 years? (Hint, I’m not that smart). Oddly, the first recert exam I took after practicing Industrial Medicine for about 5 years, I did decent on the OB/Gyn part and worst on the Occupational Med part. I have a friend who is a smart and good physician who has also been doing mostly Occ Med. He was unable to pass his recert and now practices without it. While it may not hurt him in his current employment, if he goes elsewhere, he may have trouble finding a job if not Board Certified.
    Talos has a good point as well, while certification is universally required, does it make a doc any more qualified or “special” in his/her given field?

  17. “He seemed like the Doogie Howser of India, able to crack the country’s best medical school, and work there as a 21-year-old doctor. Anoop Shankar later claimed to add a Ph.D. in epidemiology and treat patients even as he researched population-wide diseases. He won a “genius” visa to America, shared millions in grants, and boasted of membership in the prestigious Royal College of Physicians…”

    http://www.nbcnews.com/news/us-news/ivory-tower-phony-sex-lies-fraud-alleged-w-va-university-n199491

  18. Within the American Board of Family Medicine, the first Board to require recertification, there is a small yet significant faction against the idea of recertification starting to rise, to the point that the Board President issued an email to all diplomates regarding the value of Board certification, including the “evidence” that Board recertification and MOC is good for everyone. It made me laugh and cringe at the same time.

    After reviewing the data presented regarding MOC and board recertification, I found the studies to be self-serving and weak in their correlations. I believe in continuing education, though the Board exams rarely correlate to real life. I will continue to be forced to participate since its required for my job to be board-certified and most insurance companies demand it.

    As consolidation continues in the healthcare field, my work in a large healthcare organization is constantly monitored for quality and outcomes, including narcotic use, thanks to Big Data. If I stray to far from target guidelines, I will be visited by the Elders of Medicine regarding my practice habits and asked to change my sinful ways. So why do I need MOC?

    In the past, with mostly individual providers practicing in the field, Board certification meant something. In this new space, Board recertification becomes redundant as the healthcare organizations start using the EHR to monitors employee physicians much closer than any Board, since there is real money on the line in real time, not every 7-10 years.

    From my perspective, given the lack of clear data after years of certifying and recertifying doctors, the change to more recertification testing and the ongoing MOC is a move by the Boards to reclaim authority and power that they lost years ago, along with developing an ongoing cash flow revenue stream. Doctors have gone along as long as it had value, and now, in the changing world, doctors are discovering the only value of Board certification (and MOC) is that allows them to keep their jobs and is not viewed as enhancement since everyone now is “required” to be Boarded to work in most organization.

    “It ain’t special if everyone got’s one.”

  19. The tension between regulators and physicians is very similar in the NHS.

    The farcical thing is that there is no reason why Shipman would not have passed revalidation (MOC).

    So despite the regulatory overhaul society is still at thread from random evil outliers.

  20. No killers prompted this process in the States, it was our “own” Crtification Boards that started this. Most states I am aware of already have requirements for CME to renew a medical license. This, apparently is not enough, we have to expend time, energy and money to recertify every 7-10 years with MOC in addition to taking a test.
    Our vaunted Board leaders assure us that this really shouldn’t be that time consuming or financially draining, however, I’m not sure how many of them are in full-time private practice, and their salaries are in the mid-high six figures.
    Because my practice is not exceptionally demanding, I will readily admit I don’t find the process daunting, but imagine a private practitioner working 10 or so hours a day plus rounds, call, etc. and it makes it very hard. Meanwhile they are still keeping up with the routine CME requirements.
    What is even more alarming is that because of the lack of available primary care physicians, NPs are being put forth to work independently. While I have nothing against NPs and believe they can well be part of a national provider solution, it seems contradictory that physicians with 4 years of med school and 3-4 years of residency are still required to take tests to prove they are capable, while NPs with less training, are not.
    So, who is the serial killer here?

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