On tedium

Writing posts like this one is why I bother with a pseudonym.  Flimsy as it may be, it allows me to engage in the occasional screed with slightly less worry that the Hammer of Doom will descend upon me.

Before I go any further, I apologize for writing a post that’s probably too much inside baseball.  If you’re not interested in the annoying tedium of practicing medicine (and who could blame you?), just skip this post and wait for whatever awesome thing Rose has coming next.

Still here?

It turns out that being a licensed, certified and credentialed medical provider means facing an endless stream of pointless, irritating tasks that have little or nothing to do with the actual care of patients.  One of the bits of sympathy I actually feel for Rand Paul regards his objection to the certification process for ophthalmologists, and his desire to create a less onerous process for maintaining certification in his field.  The American Board of Pediatrics has, in recent years, created new requirements for maintaining certification that are difficult to understand and bear little relation to delivering competent care.  I don’t know a single pediatrician who thinks they are a good idea.

On top of that, if you want to have admitting privileges at a hospital, you have to complete a mountain of paperwork every couple of years.  The paperwork is bad enough, but (at least at the hospitals where I’ve had privileges since leaving fellowship) you also have to do these unbelievably irritating computer-based learning modules (with tests to confirm mastery!) every year.  The subjects include such things as how to dispose of toxic chemical spills and how to avoid sexually harassing people.  What makes it especially galling is not only that almost all topics covered are completely irrelevant to the work I do at the hospital, but I’m required to take the same damn learning modules every year despite the fact that they have not changed one jot from the year before!

None of this is what’s gotten my dander up today.  No, today I’m in a swivet about something Massachusetts is foisting on those of us lucky enough to be licensed to practice within its borders.

One thing that physicians are required to do by pretty much everyone (hospitals,  and both licensing and certifying boards) is continuing education.  And I have absolutely no objection to this requirement.  Indeed, I think requiring medical providers to keep learning is a very good idea.  So no beef with the requirement per se.

In keeping with this requirement, I get frequent e-mail alerts from the medical school where I am on faculty about various Continuing Medical Education (CME) events that I can sign up for.  The subject line of one of them caught my eye the other day.  It read: ALERT: Satisfy State Medical License Requirements Now!  “Hello,” thought I, “what’s this?”

You see, Massachusetts doesn’t just require one to get a certain number of CME hours per licensure period.  No, it also requires that at least some of those hours pertain to certain subjects.  Up until recently, this was limited to ten hours of risk management.  Put simply, that means instruction in how to practice medicine in such a way as to avoid getting sued.  While I can understand the argument that all of us could use the occasional brush-up on medical ethics and patient relations, I think it’s kind of silly to require it every two years.  (See above re: my objection to repeating lessons that haven’t changed one iota since the last time I took them.)

However, the e-mail didn’t have to do with those requirements.  No, there are new ones!  Silly, silly new ones.

Turns out the legislature, in its wisdom, is now requiring CME in both pain management and end-of-life counseling.  The former is limited to those physicians who prescribe controlled substances.  The latter is, apparently, for everyone.

This makes me want to beat my head against a rock.  Yes, I prescribe controlled substances.  However, the controlled substances I prescribe (and that quite rarely) are either to refill a prescription for a stimulant (eg. an amphetamine) for ADHD (I don’t do primary management for this diagnosis, so I would only be doing refills) or the (very) occasional benzodiazepine (eg. Xanax or Ativan) for panic disorder.  As a pediatrician, it is incredibly rare that I prescribe a narcotic for pain relief.  And a psychiatrist who prescribes controlled substances is even less likely to prescribe them for pain relief than I am.  But apparently if you prescribe any controlled substances, you must meet the new pain management CME requirement.

But at least the pain management requirement gestures in the direction of clinical relevance.  The end-of-life counseling piece doesn’t even bother with that.  From what I can tell, if you’re licensed to practice any kind of medicine in the state of Massachusetts, you have to fulfill the requirement, even if your work will never involve that kind of discussion in real life.  Forensic psychiatrist?  Pathologist?  Radiologist?  Doesn’t matter!  The new requirement is for everyone.

Meaningless busywork is a hallmark of lousy policy.  I understand the good intentions behind the new requirements, and there are a couple of factors that mitigate the burden a bit.  (You can count the pain management and end-of-life counseling CME toward the risk management total, and you can do self-study to meet it instead of having to attend a course.)  But hooking the goals of education about particular kinds of practice onto the machinery of everyone’s licensure is too broad a solution to the problems meant to be addressed, and only serves to add one more task to the already task-laden endeavor that is current medical practice.

Russell Saunders

Russell Saunders is the ridiculously flimsy pseudonym of a pediatrician in New England. He has a husband, three sons, daughter, cat and dog, though not in that order. He enjoys reading, running and cooking. He can be contacted at blindeddoc using his Gmail account. Twitter types can follow him @russellsaunder1.


  1. ISO9001 is, in theory, a way for a corporation to avoid the “what happens if so-and-so gets hit by a bus?” problem by making sure that all problems have processes and the processes are documented to the point where the FNG can pick them up and resolve a problem quickly and efficiently.

    In practice, it’s meetings.

    • Or, in my case, it’s shrieking at a computer when it quizzes me about patient care protocols in departments where I don’t work, or about minor crises in which the only possible reason I would be put in charge is if every other adult employee had been somehow incapacitated (in which case there are bigger problems to deal with than how to clean up spilled cleaning materials).

  2. It really seems, in the interest of fairness, that the State of MA require surgeons and oncologists to take classes on talking to their patients about whether or not they’re really ready to have sex.

  3. “What makes it especially galling is not only that almost all topics covered are completely irrelevant to the work I do at the hospital, but I’m required to take the same damn learning modules every year despite the fact that they have not changed one jot from the year before!”

    if it makes you feel better (it won’t) i’m required to take similar modules about patient care. i don’t do patient care. i’m not even inside a hospital most of the time. it usually takes me ten or eleven tries as i’m only paying half-attention to the module – which you cannot read, but is read to you by a narrator!

    • One small silver lining is that some of the quizzes have such an obvious halo around the correct answers that you can skip right over the learning module and still pass.

      A female coworker mentions that a toxic chemical has been spilled in a nearby hallway. Do you:
      A) Say ‘Not my problem, sweetheart. What do I look like, a maid? Now pour me some coffee.’
      B) Say ‘I liked working on this unit better when you broads wore tighter scrubs.’
      C) Calmly and respectfully review the Toxic Chemical Disposal materials available at the nurse’s station with her, and alert the appropriate maintenance personnel
      D) Totally lose your shit.

  4. Medical licensing could be made a great deal simpler. But first, it would have to start with a proper security and encryption mechanism. Problem is, as you say, it’s the states who are constantly screwing with the process.

    Once the security mechanism was in place, we’d have a proper grip on certification and revocation. It’s fairly straightforward to implement all these cert maintenance schedules thereafter. Integrating pharma and hospitals would be a matter of granting, revoking and modifying prescription and admission privileges.

    What is it about health care which brings out these administrator’s inner Kafka? It has to be the most screwed up industry in the world, American health care. There’s an old saying in consulting: health care is where IT goes to die.

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