What the ABR Has Taught Me About Healthcare Quality
By Toby Gordon, ScD, ABR Governor
When asked if I would consider joining the ABR Board, I didn’t have to think twice before answering. While I had knowledge and experience in finance, management, and health policy, I knew I had a lot to learn. What is the “house of radiology”? Is there a list of acronyms I can study? I also had to do a deep dive into test design and get “walking around knowledge” about Angoff methods. The attraction for me was the chance to learn firsthand—so I can ultimately teach about it—the critically important role of professional medical organizations in ensuring quality in the U.S. healthcare system. While the public may hear about patient safety and malpractice matters or read doctor reviews on Yelp, the work of the myriad public and private entities that protect the public’s interest is not well understood even by people in healthcare. As I like to joke, I have a full employment guarantee as a professor of health policy and management to explain the competing priorities in achieving quality and access in the U.S. healthcare system.
First and foremost, what I want my students to understand is that the term “U.S. healthcare system” is a misnomer. There is no system, just loose parts flying in close formation. I call it the flying green spaghetti monster. No one person or entity is in charge. For quality oversight, we rely on federal agencies like the Food and Drug Administration, the Federal Trade Commission, and the Center for Medicare and Medicaid Services, and on state-level physician and hospital licensure authorities. But the mainstay of quality oversight nationally is the work done by professional medical organizations like the ABR and other ABMS Member Boards, the ACGME, and the colleges of each medical specialty. The founding principle of such organizations is professional autonomy to set and maintain standards to safeguard the public. They enjoy tax-exempt status with the IRS because they serve the public’s interest.
Much has been written about the history of professional medical organizations in the U.S., most notably by medical historian Rosemary Stevens, who has chronicled their roles and societal influences.1,2 The American Medical Association was formed early in our country’s history in 1847, followed by the creation of many other medical specialty groups in the 19th and early 20th centuries. In 1870, an association for hospital superintendents was created, similarly motivated to protect the public from unsafe hospitals. The AMA was a highly influential physician organization, so much so that after World War II, the AMA was able to effectively mobilize opposition to universal healthcare by expressing concern that it could lead to communism.
Today the power and influence of professional medical organizations is increasingly shared with federal and state governments and private insurance companies that play ever larger roles in determining quality standards and link performance to payment. The public probably doesn’t realize that behind the scenes, professional medical organizations and their volunteer workforce of physicians who are experts in their fields are the backbone of quality healthcare in the U.S.
One way to elucidate the complexity of quality oversight that we need the public to understand is by thinking how a patient in a hospital would determine the quality of the physician, the care team, and the facility. The short answer is that separate and distinct organizations—at the state, federal, and private nonprofit sector levels—work in an interconnected fashion, issuing diplomas, licenses, and certificates that signify successful satisfaction of requirements set by each entity. The hospital, for example, must have a license issued by the state; to get this generally requires accreditation. Such accreditation relies on hospital specific measures, as does the quality oversight process of Medicare, which looks at things like patient satisfaction, hospital mortality, and hospital-acquired conditions. But these are not physician-specific quality measures. For those, we look to how a physician meets the standards of professional medical organizations: graduation from a licensed medical school (LCME), training in an ACGME-accredited residency program, and board certification.
The physician, like the hospital, must obtain a state medical license, which requires passing exams administered by a nongovernmental organization, the USMLE, a private nonprofit entity. They also must have their professional credentials verified by the hospital, based on quality standards as defined in the hospital’s medical staff bylaws, another aspect of professional autonomy embedded in the quality oversight process.
Quality oversight therefore relies heavily on the work done by professional medical organizations, whose work has long been baked into the U.S. healthcare system. We don’t know how the system would perform if we weakened the professional oversight mechanisms that are in place. Physicians have individual accountability; without maintaining such accountability, the public could be harmed. It could be a costly social experiment to loosen the requirements, and if the medical profession relaxes its oversight, others may step in. Imagine large health information technology companies creating artificial intelligence algorithms for credentialing, or a government agency setting and administering standards. Or payors serving as the arbiter of quality. Like a Jenga game, pulling out one piece could weaken the structure, and the unintended consequences could be difficult to undo. As nonprofit entities serving to meet the public’s best interests, we must fulfill the inherent promise of our work.
The ABR’s first public board member, Dr. Gordon is a professor at Johns Hopkins’ Carey Business School with a joint appointment at the university’s department of surgery in the school of medicine and in health policy and management at the school of public health. She has extensive experience in healthcare, including serving as vice president of the Johns Hopkins Hospital and Health System, consulting academic medical centers, teaching, and conducting outcomes research in surgery focused on the relationship between provider experience, cost, and quality.
- Stevens, R. (1998). American Medicine and the Public Interest: Updated Edition with a New Introduction. Univ of California Press.
- Stevens, R. A. (2002). Themes in the history of medical professionalism. The Mount Sinai journal of medicine, New York, 69(6), 357-362.