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Tag: Maintenance of Certification

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.

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Google Glass: A Paradigm Shift in Assessing Procedure Competency?

I recently had the privilege of becoming a Google Glass Explorer.  Basically, this means I walk around with a funky pair of glass frames and look strange – even for an urban hospital setting.

The Glass has a built in camera, and a small display that you can see with numerous apps ranging from GPS navigation to searching the Web.  As cool as this the technology is – is there any utility in the healthcare setting?

There is the capability of video chat, where a consulting physician can see what I would be seeing in the operating room, and tell me what I may be looking at and what to do next. Pristine Eyesight, based in Austin Texas, is trialing this use of  Glass in University of California, Irvine. Applications for nursing are being developed as well.  Yet will this truly impact quality? I am not sure.

Yet one thing that intrigues me about the Glass is the perspective given when using the video function.  I recorded some small surgical procedures and reviewed the video afterwards. I watched where I placed my hands, how I held the needle driver, where I took my bites, and in general – what I looked at during the case.

I felt like an NFL Coach reviewing game tape.  For the first time in my surgical career, I was able to really see what I did, a perspective that I had never before experienced. This lightweight device with built in eye protection was far more comfortable than any helmet-cam I had used, and the line of sight was right in tune with my visual field. So I began thinking – is there a way this tool can improve outcomes in healthcare?

According to the American College of Surgeons, almost 5,000,000 central venous catheters are placed annually in this country.  Complications including placement failure, arterial puncture and pneumothorax range from 15-33% in numerous studies.  So how is this common procedure taught?

The classic “watch one, do one, teach one” methodology has been modified over the years.  Now, after watching a few lines placed, house staff must perform a certain number of central line placements (usually 5) under the supervision of a senior resident, fellow or attending.  Once the appropriate number is reached, the trainee is “competent” to perform the procedure on his or her own.   Yet are they truly competent? Perhaps the high complication rates result from a flaw in this classic teaching methodology?

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