Sen. Rand Paul's somewhat quixotic 1990s-era effort to start an organization to certify opthalmologists in competition with increasingly onerous and expensive old-guard practices gets an interesting write-up in the Washington Post. Unlike early coverage that treated the then new senatorial candidate's National Board of Opthalmology as odd or dodgy, David A. Farenthold's Post piece is ultimately fair, quoting other eye surgeons who praise both Paul's medical skills and his effort to establish an alternative to the existing board certification process. That's the way that it should be, considering that his complaints about the established process are shared by plenty of physicians, and his try at creating an alternative choice, though it ultimately failed, is a cherished dream of many doctors.

The American Board of Opthalmology is the "official" certifying organization for eye surgeons. It operates under the umbrella of the American Board of Medical Specialties (ABMS) along with 23 other member boards. Certification is nominally voluntary, but the ABMS has convinced many hospitals and health organizations to require it for employment, and the various boards constantly threaten that insurers will demand it, too.

Certification was at first a lifetime status, and it still is for older docs grandfathered in under the original rules. But newer physicians in all specialties under the ABMS system have to jump through hoops every few years for Maintenance of Certification. That two-tiered system, with the old guard holding a lifetime ticket while younger physicians spend time studying for exams, conducting surveys, engaging in projects, and writing big checks to the certification boards is what set off Paul back in 1999. He decided to create one relevant exam, at a lower cost, that would be offered to everybody.

"The difficulty was probably harder, [and] it was more clinically relevant" than the old board's exam, Dr. Marc Jones told Farenthold.

That sounds familiar. My pediatrician wife describes the recertification process she's undergone (structured the same way as the opthalmology one) as only "slightly less ludicrous" than the original exam. Near total irrelevance to actual clinical practice is her major complaint about the process. Then there's the time devoted to studying rather than seeing patients or remaining current in the field. She also resents "projects" like "handwashing" that seem to assume that no doctor would use soap and water unless it was required for certification.

Widespread controversy over (and opposition to) the certification process is detailed this month in Contemporary Pediatrics, along with the weak evidence that it improves outcomes.

Along those lines, says one 2006 paper in the Journal of Evaluation in Clinical Practice:

No evidence supports the touted clinical benefit of specialty board certification. Specialists in clinical medicine and surgery are unamenable to simplistic evaluation by examination, yet specialty board certification remains an ersatz standard of doctors' clinical quality in the absence of supporting evidence.

The author of the Contemporary Pediatrics article penned a separate opinion piece calling for major changes in the system.

Like many of my colleagues in clinical pediatric practice, I hold the MOC program in low esteem—even more so after managing to finish my Part 4 projects in the nick of time to complete my first 5-year cycle. After investigating the controversies surrounding MOC certification (see "The MOC controversy: Issues and answers"), I believe MOC is an unnecessary program, and one that only adds to our workload.

So Rand Paul's National Board of Opthalmology didn't come out of left field; it arose out of widespread (and continuing) opposition to a bureaucratic process that many doctors in multiple specialties perceived as favoring established players and enriching certification institutions without improving the quality of care.

"Dr. Paul was the one that organized us. Because he was the only one who really came out and said, 'We should have our own board, and have our own tests,'" Farenthold quotes another opthalmologist as saying. "We all felt the same way. He just, he had the voice."

"It was a good idea," says another doctor in the article. "It fell on its face," Conrad said. "But I liked the idea."

Unfortunately, with what sounds like an abundance of both idealism and impracticality (not uncommon in the medical field, in my experience), Paul staffed the new organization with friends and family, failed to file paperwork, and ultimately had to shut his operation down. Basically, it was a failed business effort against an entrenched player in an attempt to serve what seems like a ready market.

There are certainly plenty of doctors who wished he'd succeeded.