Clear evidence of our bureaucracy run amok is found in the rapidly growing area of certification. Years ago people would get hired for a job, perhaps, but not necessarily after specific training in a vocational school, college, or university, and would then proceed to learn the trade through years of applied work. Trainees or apprentices early in their careers may be designated as such, but the general public had enough common sense to determine whether someone seemed to know what they were doing and were worth employing for a specific task.
Through time, systems developed for the certification of people as experts in their particular trades. Early on, these were guilds of successful tradesmen. Later, various boards arose to certify and license doctors, pharmacists, and veterinarians. Attorneys are certified as fit to practice through their Bar Associations. A number of factors have contributed to the development of these certification systems including 1) a rapidly expanding knowledge base in society which has made it impossible for people to know enough to judge for themselves whether the people they want to employ actually know what they claim to know; 2) experts in various fields wanting to preserve the integrity of their profession from people who may try to claim expertise that they do not possess; and 3) governments wanting to protect citizens by providing a mechanism for determining whether people are the experts they claim to be.
In recent years, however, the certification system has become a behemoth with such complexity and momentum that attempting to even slow this monster, let alone begin to reign it in, is an impossible task. A quick search begins to reveal the size of the problem. In any given state, the number of certified occupations runs into the hundreds: the state of Washington lists almost five hundred. Certifications run the gamut from accountants to zoologists, and just listing all of these along with their basic requirements could easily fill a book.
You can become a certified aircraft fuel distributor, a certified tattoo or body piercing artist, a certified snowmobile dealer, a certified egg dealer, a certified East Asian medicine practitioner, or a certified fur dealer. There are certifications for firearms, fireworks, fire sprinklers, you can even become a certified fire protection engineer. You even need certifications for your leisure activities: certified martial arts participants, wrestlers, kick boxers, and whitewater river outfitters. You can be a licensed seed dealer, shellfish harvester, waste tire carrier, or taxidermist. And let’s only hope that Anthony Weiner found himself a licensed sex offender treatment provider.
“So why is this system so out of control?” you may ask. “Each of the factors driving these listed certifications appear to be noble goals. Isn’t the whole certification system a good thing?” To answer these questions, we must reexamine the factors driving the system and explore their “dark side’”. Each of these has what we could generously call a contraposition, or more cynically call their seamy underbelly or ‘dirty little secret’.
Let us start with #1 above. The human knowledge base is rapidly expanding to such an extent that even your exceptional ‘Renaissance man’ or polymath cannot know everything. Theoretically, at one time, it may have been possible for someone to know the sum of human knowledge, and over the years there have been a number of claims of people who in fact did so. These range from Aristotle in ancient Greece to Leonardo da Vinci, Athanasius Kircher, Gottfried Leibniz, Thomas Young, and Max Weber. Of course it is impossible for any of these men to have known everything known to humans in their time, but these well read individuals of high IQ and high capability at least could hold their own on just about any conceivable topic. No one in the last hundred years could make such a claim, and in recent decades just knowing the index has become a challenge. The extent of human knowledge continues to expand at exponential rates. In the future it may be possible for an artificial intelligence to once again know everything, but that is a discussion for another time.
The problem is that knowledge is expanding at such a rate, that any system attempting to certify someone as an expert is out of date by the time it is established. Just as software standards run years behind the cutting edge of innovation, and are often useless by the time a standards organization can put them together, the certification tests in rapidly growing fields are hopelessly outdated. In my occupation, cardiology, the science has advanced very rapidly, and old standards of care are often being revised and retooled, if not overturned entirely.
This creates a huge quandary for people who are making and taking the certification tests. If a newly published study overturns an old way of thinking, and a question about this particular topic appears on the recertification boards, how is a knowledgeable expert to answer? Do you answer the question with the knowledge as it was at the time the board question was likely written, or do you answer with the newer, and (presumably) more correct information in mind? This becomes even problematic for people who are performing research. These people may have knowledge that is not yet available to the general public, and so they may be forced to answer questions with information they know to be wrong. And the more cutting-edge an expert is, the more difficult this task becomes, and the more that expert may get ‘wrong’ on an outdated recertification board test.
An entire industry has sprouted up in order to prepare people for the certification tests. A common theme of these board prep courses is knowing what the “proper board answer” is, regardless of the state of knowledge in that given field. We have essentially built a surreal alternate reality of “meta-truth” that needs to be studied and mastered in order to pass the board certification tests. And the saddest reality of this alternate universe is that the true experts – the people with the best, actual, cutting edge knowledge – are the ones who have the hardest time with it. The average schmoe who doesn’t keep up with what is really going on in any given field will probably do just fine on the test.
“So if it is so hard to figure out who really is an expert in any given field, why do we do it?” you may ask. Well now we get to the dark side of #2 above. Attaining a level of expertise in any field is difficult. It takes time, dedication, and will to become a master of a craft. People who have dedicated their lives to any particular trade tend to become very fond of their work, and they want to defend that trade from outsiders who have not worked as hard as they have. This is a very natural human instinct, and there is not necessarily anything wrong with it.
However, it is not the master of any given profession who feels threatened by interlopers, it is the novice. The person who is least sure of their own ability will feel most threatened by someone else’s ability to outperform them. And so the certification system tends not to be built by the best people in any given trade, but the worst, because they want to create a back-stop to prevent any others from overtaking their “turf”. It is these people who are so uncertain of their own skills that they must find some way, some badge, some stamp-of-approval from “on high” to prove they are worthy of their title. So they create a certification system that gives the illusion of expertise for all of the people who pass the bar. But we know that not all ‘experts’ are equal, and we should not pretend that it is so.
There is an old joke in medicine: What do you call the guy who came last in his class at medical school? Answer: Doctor. Part of the problem with branding everyone who passes the board exam as an ‘expert’ is that the system can now treat all of the doctors as interchangeable widgets. In our current system no doctor is allowed to charge any more for his or her services than anyone else, and the insurance industry and government can choose to pay whatever they like for those services. The doctors just have to shut up to get paid. In a just system, skilled doctors would be able to charge more than unskilled doctors, and patients would be able to determine if the extra cost is worthwhile. (Yes, this happens in some very small slivers of the industry such as dermatology and cosmetic surgery where society has determined that it is OK for ‘optional’ medical procedures to be paid for out of the system, but for most of medicine doctors are paid whatever the Medicare system determines to be enough.) If you want to see the best cardiologist in the world, shouldn’t you have to pay a premium? In other sectors of the economy, the cost of item, service, or experience often goes into our calculations of quality and value as consumers. But this market signal and tool for competition is often not available in health care.
The Maintenance of Certification system (MOC), the Patient Protection and Affordable Care Act of 2010 (PPACA, or ‘Obamacare’), and the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), all treat doctors as interchangeable widgets. You cannot charge more or less than anyone else, regardless of your level of service or expertise. The sad fact is that the doctors who really care and want to spend the time with patients get paid the least, because they have put patient care first, and are not in it for the numbers. The cold, quick, calculating doctor who works as a machine and never makes an emotional connection to any patient will get paid the best. Time and thinking are not rewarded, but getting people through the door is.
This brings us to the dark side of #3 above, which is the certification industry enriching itself in the process of all of this certification. Each of these certifications requires a fee which must be paid to cover the costs of the test. But is that all it covers? Recent investigations of the depths of corruption in the American Board of Medical Specialties (ABMS) and their underlying partners in crime – in my case the American Board of Internal Medicine (ABIM) – have found that the people making these systems up, who we have already determined are the least capable in their milieu, have been enriching themselves on the backs of the hard working doctors in the field. Not only do these “doctors” (I use quotes because for the most part these people do not actually see patients) pay themselves high six-figure salaries, three to four times that of their working physician counterparts, they lavish upon themselves benefits such as paid first-class spousal travel, chauffeur driven town-cars, and condominiums. We are talking about millions, if not billions, of dollars at play in the physician recertification industry.
It is time to put a stop to this entire culture. We need to return to our roots and abolish the entire certification system. “What?” you ask “you mean even doctors and lawyers?” Let us build a new system where people can be knowledgeable about and thus feel comfortable with the level of expertise of their brethren. But let us also build a system where the true expert can be paid his or her worth.
Photo by Jeffrey Beall