There were surgery residencies when I was coming through training that bragged about having trainee divorce rates over 100%. Okay, that is an “old wives’ tale” or what is now more commonly called an "urban legend."

Surgeons go after each other like the Yankees and Red Sox. They challenge the management of patients and relentlessly pummel each other. They will challenge cases even when the standard was not breeched just to make sure they know why they did what they did.

I have some idea what it is like because my Internal Medicine residency was more “old school.” The Socratic Method was alive and well. Cardiology rotations were the epitome of the style. The Cardiologists always had interns shaking in their boots. They also caused an intern to faint during rounds once.

Most of us keep up with the latest literature. We go to national conferences. We use large internet databases. Still, there is nothing like constant review of your practice by colleagues to keep you at full speed. In general, that scrutiny is less after training.

As a profession we are not great at policing ourselves. Some of it is fear of the legal system. Some of it is the “everybody gets a trophy” mentality that rules the day. We have become masters of the cover-up at times despite evidence that admitting a mistake and saying “sorry,” might help us.

Doctors are sometimes allowed to practice despite substantial cognitive issues. Patterns of bad care are also left alone at times. Substance abuse is not always addressed either. I have seen examples of it all.

There are doctors fuming as they read this.

It is hard to change attitudes. Nobody likes situations that cause discomfort. The problem needs to be fixed and most of us realize that. Most of us also do not want to be "that guy."

There are some objective things which could be done.

In order to get a medical license you should have to complete a residency in a specialty. That means a minimum of 3 years of postgraduate training. Right now, it varies from state to state but you can get a license after finishing an internship in most places.

Second, we need a real measure of continuous learning tied to licenses. The current continuing medical education (CME) standards assure nothing. It is an excuse for organizations regulating the process to exist. CME can be obtained in many forms. I could get the hours to satisfy Alaska by surfing the net later today and that is ridiculous.

The way to do it is to make maintaining board certification a standard for licensure. It already is a standard for hospital credentialing in most of the country. The boards have all moved to systems that require recertification.

In Internal Medicine (IM) it means I need to recertify every 10 years. You have to do 5 modules for which you can use any resource you want and take a computerized test. It includes both general Internal Medicine and its subspecialties.

Outcomes data is helpful but also problematic. Some states require hospitals to report cases that were reviewed and felt to not meet the standard of care. This is not a bad policy but it ignores the outpatient side and that is where most of the care takes place.

We already track paid malpractice claims against doctors but that data has issues as well. Unfortunately, most filed cases are meritless and much of true malpractice never sees a claim get made.

Data needs to be treated with caution. If you choose to take care of sicker patients you are more likely to have less impressive numbers. The last thing we want is to encourage cherry picking the easy cases at the expense of the tougher ones.

Compilation of data, even if imperfect, can be used to identify potential problem providers. From there, medical boards need to investigate, review, and take action if needed. Unfortunately, the current method is more complaint based and prone to bias and error.

There are other issues. Training and what physicians should be doing with their training is a big one. Hospitals and surgery centers have some control. There is little to no regulation in the office setting. The discussion involves many treatments and procedures and the arguments get complex quickly.

Should credentialing issues rise to the level of government? It is a tough question. It is interesting how different the standards can be from city to city or even hospital to hospital. It can be a real eye opener to look at these questions.

It is not clear that better “autopolicing” of the medical profession would reduce costs. There is no way to know if it would change malpractice patterns.

It is clear physicians could do better.