Medscape's Best and Worst

As each calendar year reaches its conclusion, many organizations attempt to compile best and worst lists, be it TV shows, movies, cars, people of prominence or infamy that bring character and maybe immortality to the year that will soon fade into history

Medicine like any other pursuit has its heroes and its scoundrels.  I would take a safe guess that all physicians can name in an instant the five teachers who shaped them and the five guys they thought should be reported to the state board, if not the FBI.   For the bad apples, we contented ourselves as residents to mostly scoring them with a lot of zeroes on our attending physician evaluation form but never pursued anything seriously punitive.  For the benefactors, we not only gave them higher scores but assimilated some elements of their revered practices into what became of us professionally forever.  We know who they are and what they did on our behalf, even if nobody else does.

We also come across medical colleagues who we do not know but find their way into the medical and secular news for their exceptional deeds that reach beyond our personal experience.  Some win Nobel Prizes, some swindle Medicare.  In recent years we have passively received enough lurid news in print or electronically that it registers as our daily expected dose of world affairs.  Some respond, most don't but file some imprint deep into the cerebrum where it might be retrieved if ever needed but does not stay with our awareness for very long.  At the other pole, when we attend our annual meetings, some physicians get awards while we sit in the audience and clap.  Professional achievement always gets our admiration.  We see the news of physicians gunned down, including a personal college friend killed in the Pittsburgh synagogue massacre or by a disgruntled patient, usually not the superstars of medicine but professional colleagues who get some combination of sympathy and honor for the dignity that their abruptly halted careers brought to the medical profession.

While our recognition of these physicians tends to have the trajectory of a funnel where stuff goes in the big end, gets concentrated and disappears in a moment out the small end, we are fortunate to have an organization like Medscape that identifies, catalogs, and retains these positive and negative outliers each year in an easily searchable way.  The list comes out in mid-December and is traceable at least back to 2011.  Being something of a news voyeur, I scrolled through the current roster as it came passively to my email inbox.  What makes physicians, and sometimes scientists, heroes or villains can be hard to tease out on one year's list, but by searching back about five years, laudatory and despicable themes emerge with some consistency, which may not be all that different than how we each individually assigned the best and worst physicians who we personally encountered between medical school and retirement.

The rascals have a lot more consistency, and most years larger numbers, than the exemplars.  With rare exceptions they have traded in their white coats for orange jumpsuits.  Some are outright predators, engaging in assaults on mostly female or pediatric patients.  Others engage in various forms of lucrative unconscionable care.  The scientists among us might call them errors of the First Kind, assigning significance to diseases that were not present.  The intent takes it outside the realm of error.  Patients without cancer received chemotherapy, normal coronary arteries got stented, inappropriate but systematic retinal photocoagulation, and any variety of excessive bodily invasions from sinus surgeries to repetitive skin biopsies.  While these docs seem more profiteers than predators, there is something inherently evil about intentional unneeded care.  Over the few years of my review, there were few overtly incompentents, other than a few surgeons functioning above their level of training, but generally medical schools and residencies produce capable people, though not always ethical people.  The next common category are the profiteers.  There are a lot of these.  They probably caused little bodily harm to vulnerable people so, in my mind at least, would fall one level less on my personal evil-meter.  They are more financial cheats than medical ones, though a few cut corners by obtaining less expensive medicines from authorized sources then billing for the real thing.  But mostly these doctors arranged for others to due financial processing of bogus services for financial gain but not medical harm.  There were a lot of these on each annual list.  And finally we have a handful of unfortunate people who offered suitable care but got videotaped engaging in mockery of patient or staff or fulfilling a dream of being a rapper while removing a body part.  Poor judgment probably, worthy of a worst of doctors list, probably not.

Medscape's best of doctors each year fall into more categories with too few to make generalizations of how the majority of practitioners can upgrade themselves to be more like them.  One common category of people worthy of admiring though not emulating are those whose recognition that year was brought about by their untimely death.  They did good work, for sure, but it was the car accident or plane crash while on a mercy mission that caused Medscape to include those physicians that year.  About an equal number also arrived on the annual recognition list by appearing in obituaries first.  These people had lifetime achievements, mostly in advancing the science of medicine.  Their CV's no doubt had a few awards while still functioning well enough to appreciate the adulation their work had earned.

There is another very large category of praiseworthy doctors whose medical knowledge and skill does not tower any higher than the rest of us, though their dedication and tenacity might.  Each list has physicians, mostly still alive and working, who enabled people at the margins of medical care to have better access.  Some travel into the Third World to bring this about.  Some set up rural clinics, some make a career of treating medical pariahs, the modern version of lepers perhaps, people who a lot of us would groan if we saw those patients on our schedule.

One final category that appears on every list, probably no more skilled medically than anyone else, but who endured unusual challenges to complete their medical degree.  These include professional and Olympic athletes, refugees from war zones partly completed with their education who had to flee and reapply with some difficulty in an unfamiliar country with a new language.  One started as a patient, a teenage surgical ICU alumnus with life threatening gunshot injuries who became captivated by what the surgeons were doing for him and then pursued his education under burdensome conditions but prevailed.  One does not need to be the most prodigious clinical or science maven to excel.  Pursuing a dream relentlessly is an option available to most of us in some form.

So what becomes of these people?  The medical scoundrels amass quite a lot of prison time.  Do they remain bottom feeders in custody, or might there still be some spark of benevolence that once got the favor of the Admissions Committee?  Do they sit in their cells and mope or do they impart the literacy skills and science aptitude that they have to be of benefit to other inmates who had less going for them at the time of their arrests than the doctors did?  There are medical reporters for Medscape and elsewhere that could pursue that direction.

And the Top Docs who are active, do they continue to inspire colleagues and patients with that same persistence they used to excel so that others might be more dedicated to self-management and responsibility for the diseases that they have?  Appearance on the Medscape exceptional list should have an enduring presence beyond the 15 minutes of fame or infamy that Andy Warhol thought all people are entitled to have.

License Renewal

Every two years, the state has an obligation to its inhabitants, or not even inhabitants but also those who traverse borders to get their care, that the people offering that care in exchange for their livelihood have a threshold of training and character that justifies this.  It's a little harder to certify skill, but education makes a reasonable surrogate, or at least one that is easy to document, not very different than quality measures imposed on us in practice that give the illusion of quality in lieu of the real thing.

My three licenses have come from my state of residency training, lapsed many years ago as the maintenance requirements became increasingly onerous and expensive, justifiable only for those still hostage to that Board for their livelihood.  I have maintained one in my state of residence, where I also maintained a solo practice for 20 years and in the state where I practiced for my final eight years, retiring a few months ago.  On the off chance that I might want to do some locums tenens in one of those states, and the fee not being too exorbitant, I opted to maintain them one more time.  One comes due in a few weeks, renewal submitted electronically with MasterCard authorization, with a prompt email notice of approval.  Pennsylvania has a retired physician option which waives the educational requirements but not the fee so it pays to just do the Continuing Medical Education for now.

Unless one has been accused of activity unbecoming of a physician, which is not a lot of people other than maybe malpractice accusations which need to be acknowledged but do not disqualify, the barrier to renewal rests with the CME needs.  Like my other states, and a fair number of my insurance credentialing criteria, Pennsylvania requires 100 hours of CME spread over two years.  Category 1, the type that gets certificates of completion is usually the most difficult to obtain and sometimes requires a fee, only has to be 40 of those hours.  Much more, and the Commonwealth might have to deal with de-licensing their rural physicians who either do not have access readily or would need too much time away from  the practice to accumulate that much, which would run counter to the mission of making competent medical care available.  City slickers, which is me, just pick from the Grand Rounds or online options.  And since Category 2 can be interpreted loosely, medical writing in my case, consultation, lectures, mentoring medical students, it is readily available to rural physicians and accumulates in the course of ordinary physician activities. 

But there is always fine print.  Twelve of those hours need to be in risk management education, which can be interpreted rather broadly.  Medpage Today used to have an agreement with the University of Pennsylvania to certify what qualifies as risk management and offer a UPenn certificate of completion.  The University dropped their participation but Medscape Today kept the same classification, so when in doubt it is safe to assume that qualifies.  It comes in quarter hour increments so you could be doing dozens of those articles and questions to come to 12 hours.  Grand Rounds with appropriate titles do not require a learning exam, so that's probably the fastest way to accumulate these over two years.  I got six that way, the rest online.

My home state of Delaware found itself in a pickle a decade or so back when a pediatrician turned out to be a sexual abuse predator.  As unusual as this is, Delaware followed by many other states including Pennsylvania, enacted a series of child protective laws and require all licensees who might have occupational contact with children to take a course in what those laws are and answer some questions to make sure they are understood.  It's fairly easy, but takes a full three hours, for physicians who are highly literate and used to taking reading comprehension tests to do this.  The requirement may be more difficult for some of the holders of other occupational licenses or others without a state license but occupational contact with children who have little formal education or familiarity negotiating a computer course.  Printed certificate in CME folder.

Finally Pennsylvania officials are still uncertain whether their docs are the cause of a dangerous expansion of opiate use among the state's citizens, or maybe the best resource for its resolution.  A two hour CME module on opiate prescribing was added to module, probably irking the pathologists and radiologists whose patients are beyond pain. 

Done.  $360 added to my next credit card bill.  Maybe an audit somewhere in the next year or two to see if I am more truthful than our current President, which I perceive myself to be.

Those fees are a big windfall for  the Commonwealth of Pennsylvania, which has a lot of doctors.  There are disciplinary proceedings that the Board reports from time to time but I do not think I have ever personally known a doctor cited.  Level of skill varies, but I think everyone exceeds its threshold.  While I am technically permitted to do brain surgery but don't know how, some self-screening occurs and for those who really want to practice above their level of skill, there are other credentialing mechanisms of hospital staff membership that keep the medical Walter Mitty's in check.  And when all is said and done, those 140 hours of CME category 1 that finally accrued probably added less to my skill than the board might have hoped, except for the 22 obtained at my national specialty meeting.  But pursuing medical knowledge for the sake of mastering it has its psychic dollars, so I really didn't mind the effort.  And it's likely the last time except for a minor provision I will need to satisfy for Delaware in the coming months.

Almost Like It Was

It had been my intent to sign back into Sermo the first day of Hanukkah, leaving me with an absence of a few months.  It's the longest I've been away, not even a lurker, and had no interest in being a lurker on return.  At one time Sermo absorbed a lot of my free moments, and even my productive ones.  I would engage in discussions, make fast quips, use the Endocrinology cases that people posted and commented upon to teach my residents on elective with an analysis of the various comments that individual respondents would make, some expert, some less familiar.  Like much social interaction and media, an element of echo chamber became increasingly apparent.  The best scholars both in clinical medicine and in general erudition had moved on.  In retirement I could have depleted all day there, but as my electronic colleagues became less endearing, I gave myself a limited hiatus which concluded yesterday.

My time back was intentionally brief.  Much like you cannot tell the difference in your kids from one month to the next but their aunt who has been in the hospital can, that's what I found.  Scrolling back about 5 days, the subjects and posters had changed, mostly for the better.  Libtard this and libtard  or related sloganeering that so dominated titles of recent years, did not appear in any meaningful volume.  At my exit there were a handful of folks who I thought might be trolls, probably not paid to pitch the political hardball five times a day but self-motivated to see how much of an electronic gathering they might generate.  The physicians I would walk across the electronic street to avoid had disappeared.  A few frequent flyers remained, a fellow who was still between jobs when I left, a fair number of physicians still moping about administrators and insurance companies who'd done 'em wrong, a lot of stuff that might come out verbally at a Medical Staff Christmas party.  I engaged in a few of the conversations, one by a lady who had taught herself to read.  I was taught to read in two different alphabets but would have failed if I had to do it on my own.  One conversation involved the demise of the prestige that once accompanied the MD or DO degree.  True enough, but I decided a long time ago that my self-esteem did not depend on my possessions and my diplomas are my possessions.  My knowledge and skill are shared, and seem to have been appreciated right through retirement.

There were people creating threads who I did not recall from months past.  One had the nom du plume tushi, a fellow from a developing country.  The censors are apparently more tolerant than the state motor vehicle divisions who might have censored that from their vanity plate roster.

Being there had very little emotional impact.  Not offensive.  Not an echo chamber.  Better than when I had left but without the return of the dozen sharp minds of years back whose comments I made a point to read.

An obscure but important book about recapturing a waning Jewish organizational culture in America came out about ten years ago, Getting our Groove Back by Scott Shay, a rather well-to-do NYC banker of Orthodox background.  He devoted a chapter to the attrition of Conservative Jewish affiliation, regarding the loss of the middle as one of the great American Jewish disasters, which it probably is, no matter how self-inflicted.  I think the departure of the best and the brightest who contributed their articulate analyses to clinical and non-clinical aspects of the American medical pageant approaches a disaster for the American medical community.  The forum remains but its previous glory does not with no means of recapture, other than maybe hiring their real scholars and conversation makers as the more beneficial trolls paid to post.  Every bit as self-inflicted as the leadership generated attrition of Conservative Jewish institutions but a public loss just the same.

Have I passed through the exit door for the last time?  Probably not, though even though the offensive posters seem gone, beneficially provocative replacements needed to enhance an attractive physician forum don't seem all that highly desired.