All Commentary
Wednesday, October 19, 2016

Why Doctors Should Be Certified Like Airline Pilots

Airline pilots are highly trained professionals who are more personally responsible for the lives of their customers on a minute by minute basis than most physicians.

Doctors talk a lot about “evidenced-based” medicine, but they often don’t extend scientific reasoning to the economics of medical licensure. As Upton Sinclair said, “It is difficult to get a man to understand something when his salary depends on his not understanding it.”

First Do No Harm

Naturally, MDs and others who face competition from these nurses are ferociously opposing the proposal.

As an experienced physician, medical educator, and libertarian, I am convinced that our current medical licensure laws do more harm than good. And as a consultant for the Arizona medical board, I know first-hand how opaque, arbitrary, and difficult it is to assess and regulate medical practice. Having testified before state lawmakers, I have seen first-hand how special interest pressure regularly trumps facts and common sense.

Free-market adherents have made only small gains in fighting back medical licensure during my 50 plus years in the profession. Osteopaths have joined hospital staffs over the objections of medical doctors. Nurse midwives, nurse practitioners, and certified nurse anesthetists have been partially liberated from governmental overreach in many states, although there is much more to do.

Studies show that empowered nurses improve access to effective health care, and patient satisfaction is well-documented. These facts have emboldened the Veterans Administration to propose allowing advanced practice nurses to practice to the full extent of their training and experience in Veterans’ hospitals. Naturally, MDs and others who face competition from these nurses are ferociously opposing the proposal.

Even if advanced practice nurses get the privileges they deserve at Veterans hospitals, any attempt to enlist their aid for future reformation of the licensing system is unlikely to be successful. If the past is prologue, the MDs will most likely co-opt them, as they did osteopaths years ago, into joining with the same MDs who previously opposed them, to suppress future competition.

Certify Doctors Like Pilots

Clearly, something different is needed if we are to see a meaningful movement towards a free market in medical practice. Libertarians have proposed abolishing the current system of licensure altogether, substituting certification by private organizations instead. While theoretically desirable, there is no meaningful public support for, and strong special interest opposition to, deregulation.

Airline pilots are highly trained professionals who are more personally responsible for the lives of their customers on a minute by minute basis than most physicians.

I contend that government licensure doesn’t have to be abolished to achieve market reform; it can be de-politicized instead. We could move towards a system based on certifying demonstrable knowledge and skill, rather than conferring licensure based primarily upon successful completion of an approved training program. The criteria by which the states issue driver’s licenses, or the Federal Aviation Administration certifies pilots, are just two instructive examples.

Applicants for a driver’s or pilot’s license have to meet specified, transparent, and objective criteria for basic knowledge and demonstrable skill. It matters not which driving or flight schools they attended. They are being examined for the results of training, not where they completed it. In these cases, the licensing process has not been taken over by the very professionals who are regulated, and who then restrict potential competitors from entering the pool of future applicants.

Airline pilots are highly trained professionals who are more personally responsible for the lives of their customers on a minute by minute basis than most physicians. Yet, the process by which the government certifies pilots has never become a major political issue.

A basic, entry-level airman’s certificate can be obtained by objectively mastering basic knowledge and practical skill. An aspiring pilot needs to show up at a flight school, pay for the instructor and the plane, receive the prescribed amount of training and flight time, take both written and practical flight tests, and pass a health examination. If successful, the FAA will certify the pilot to fly single-engine airplanes in clear weather, whether or not the training was taken at an FAA-approved flight school. Pilots then can obtain further training and be tested for advanced privileges (which is analogous to medical specialization), like flying by instruments or a multi-engine aircraft.

We Have the Tools

A similar process could be used to certify an entry-level basic health care provider. A baseline of pre-clinical knowledge is necessary in anatomy, chemistry, physiology, pharmacology, etc. Why should it matter where an applicant for a medical license learns these? Standardized tests can be administered to ensure an applicant is fundamentally grounded.

Electronic badges could be awarded to acknowledge achievement.

Medical education has incorporated newer methods of training as well as assessment of competence. Technology now enables online learning, interactive virtual reality software, and video-monitoring of patient encounters. Taking a medical history, performing a physical examination, formulating a diagnosis, testing for that diagnosis, initiating appropriate treatment, and performing CPR are separate clinical skills requiring training and experience. Objective testing for each of these skill-sets could certify an entry-level practitioner regardless of whether they learn it at a school of nursing, medicine, osteopathy, or some future innovative training center. Electronic badges could be awarded to acknowledge achievement.

Just as now, further supervised training would be necessary before independent practice would be permitted. However, postgraduate programs that offer additional training would be able to select from a wider pool of potential applicants, and be able to choose candidates they feel best meet their standards regardless of their professional degrees.

Labs for Reform

While no nation has adopted a free market in medicine, the government of Singapore has utilized competition to help control costs in their highly respected health care system. For example, when plastic surgeons tried to prevent general practitioners from performing liposuction in their offices, the country’s licensing authority refused to buy the claim that only specialists were qualified to do the procedure.

Competition will enable the institutional framework to evolve smoothly.

They convened experts from both groups to enumerate a set of objective criteria specifying competence and good medical practice. Any physicians who met the criteria, regardless of training, were allowed to perform the procedure. Those who were unable to meet the criteria could not argue that political whim was the reason for their exclusion. Within a few years, many generalists voluntarily discontinued the procedure under the influence of market forces. While one small example, it does provide a proof-of-concept.

One advantage of our federal system is that each of the 50 states and the federal government can be laboratories for innovation. The federal government led the way in incorporating osteopaths into the staffs at federally-run hospitals, and may now do the same for advanced practice nurses. Because the federal government can circumvent state licensing restrictions in federal facilities, federal agencies could establish skills-based criteria for their health care providers and become an agent for change. Any single state could also do the same legislatively.

No one knows how much training and experience is required for any given medical skill. Each of the major stakeholders could be enlisted in drawing up criteria for competence, as was done in Singapore. This process changes the calculus for political debate and action.

These reforms can be accomplished gradually and incrementally, and under our existing laws regulating health care. Competition will enable the institutional framework to evolve appropriately without the sudden and radical changes that make many reforms politically unfeasible. It may not result in a perfectly free market, but as we say in surgery, “perfect is the enemy of good.”

  • Dr. Murray Feldstein is a Visiting Fellow in Healthcare Policy at the Goldwater Institute.