Rethinking Healthcare Credentialing

Sofia Ramirez

Okay, so, we keep saying this over and over, but it's because it’s the key point: if we really want a health system that serves everyone, we need to start with a shared vision of health and well-being for all—at the lowest possible cost. Not just financially, but in terms of time, energy, even opportunity cost. It shouldn’t feel like this constant trade-off for patients or providers.

David Caldwell

Right, like when they say "you can have two out of three: cheap, fast, and good."

Sofia Ramirez

Exactly. But here’s where it gets tricky. Even a perfect vision isn’t enough. We also need a critical mass of people—people who actually understand health as a, well, as a complex adaptive system.

David Caldwell

Wait, what? Complex adaptive system—we keep going over that. Is it like those AI systems that learn as they go?

Sofia Ramirez

Sort of, but not exactly. It’s about understanding that health isn’t linear. It's not like you implement one change and get a predictable result. We're talking about dynamic, interconnected pieces—patients, providers, institutions, even policies—that react to each other in sometimes unpredictable ways. So, to navigate that, we need these "systems stewards," people who really get it and can help guide the whole thing like an orchestra conductor.

David Caldwell

Hmm. So, it’s kind of like seeing the forest and the trees at the same time?

Sofia Ramirez

Yes, exactly. And once we have that critical mass, we can identify high-leverage points, the places where small changes lead to big results. It’s about always moving closer to that vision without wasting resources or getting stuck in bureaucracy.

David Caldwell

Alright, I like where this is heading. But for today, where does credentialing fit into all this?

Sofia Ramirez

Well, that’s what we’re diving into. Credentialing—it’s this outdated, overly rigid system that focuses too much on traditional pathways instead of actual competence. And you’ll see how deeply it impacts everything from labor shortages to patient outcomes.

David Caldwell

Got it. Let’s do this.

Sofia Ramirez

Alright, so where does credentialing fit into all this? It’s simple: our healthcare credentialing system is stuck in the past. It’s rigid, it’s expensive, and it doesn’t recognize competence where it matters most—on the frontlines of care. This outdated system impacts everything from labor shortages to patient outcomes, and we need to address it.

David Caldwell

Okay, but what exactly do you mean by "rigid"? Like, how does that play out for someone working in healthcare?

Sofia Ramirez

Good question. Take this as an example: say you’re a nurse practitioner or a physician assistant with 20 years of independent experience—decades of treating patients, honing your clinical skills, really mastering your craft. You're excellent by any criteria. But if you wanted to become a board-certified physician, the system would make you repeat med school and complete a three-year residency. That’s... absurd.

David Caldwell

Wait, wait. You’re telling me they’d have to start all over? Like they're brand-new?

Sofia Ramirez

Exactly. It’s all about following traditional pathways instead of focusing on what these individuals actually know or can do. Think about how much time, money, and talent that wastes—not to mention how it contributes to the physician shortage by making career progression so inefficient.

David Caldwell

But why do we even have a system that works this way? I mean, it feels like someone just said, "This worked 50 years ago, so let’s stick with it."

Sofia Ramirez

That’s not far off, actually. The whole structure—medical school, residency, board certifications—was designed in a completely different era, when medicine itself looked totally different. Back then, it may have made sense to prioritize those rigid steps, but healthcare today is way more complex and dynamic. Yet we’ve held on to the same old system that prioritizes credentials over competence.

David Caldwell

Alright, but sticking with this system—it can’t just be inertia, right? What’s the cost of all this in real-world terms?

Sofia Ramirez

The costs? Oh, they’re huge. For physicians, it means years of unnecessary training, racking up obscene levels of debt. And for patients, it creates a shortage of capable providers, which delays care and puts more strain on the system as a whole. Plus, it directly contributes to burnout. Imagine spending years training only to feel stuck in a system that doesn’t let you pivot or adapt your career without starting over.

David Caldwell

Burnout’s already a massive issue, so adding this kind of rigidity on top of it seems like pouring gas on the fire.

Sofia Ramirez

Absolutely. And let’s not forget what it does to patient care. When providers are burned out or stretched thin because we don’t have enough of them, who suffers the most? Patients do. And the irony is, this whole system is supposed to protect patients, yet by clinging to outdated credentialing standards, we’re doing the opposite.

David Caldwell

It’s like saying the system is built to keep the gates high, but we’re not even letting the most qualified people jump through them efficiently.

Sofia Ramirez

Exactly. And it’s not just about nurses and PAs trying to become physicians. Physicians themselves face these barriers if they want to switch specialties or transition roles. Healthcare is ever-evolving, but our career pathways don’t reflect that evolution at all. It’s holding everyone back—patients, providers, the entire system.

David Caldwell

Okay, this rigid system—it wasn’t just randomly created, right? Was there a point where it actually served the purpose it was designed for?

Sofia Ramirez

Actually, yes. The roots of credentialing go back to the 1800s, specifically to the founding of the American Medical Association in 1847. Back then, the medical field was, well, kind of a mess. There were so many unregulated practitioners—people with no formal training just calling themselves doctors. It was chaos.

David Caldwell

Wait, like actual quacks? The snake oil salesmen you always hear about?

Sofia Ramirez

Exactly. It wasn’t just a stereotype; it was a rampant problem. The AMA was created, in part, to combat that by professionalizing medicine. They pushed for standards in education and training to ensure that becoming a doctor actually meant something. And it worked… at least for a while.

David Caldwell

Okay, so it was about quality control. But how’d we go from that to, you know, this hyper-rigid system you’re talking about?

Sofia Ramirez

Good question. Initially, it was all about diplomas from medical schools. But soon, they realized that wasn’t enough to guarantee competence. Some schools were more, let’s say, lenient than others. So, the next step was state licensing boards, which added another layer of oversight. But even that wasn’t consistent enough, so we got board certification—this national system to measure specialty-specific competence.

David Caldwell

And now it’s just certification on top of licensure on top of diplomas. It feels like it’s snowballed.

Sofia Ramirez

Exactly. Each step was introduced to solve a legitimate problem of its time, but over the decades, they’ve become these rigid gates, layered on top of each other with no flexibility. The whole system’s stuck in the mindset of 19th- and early 20th-century medicine. Imagine applying 1800s solutions to today’s dynamic and collaborative healthcare environment—it just doesn’t work anymore.

David Caldwell

But I guess back then, medicine wasn’t seen as the kind of complex system we were talking about earlier, right?

Sofia Ramirez

Right, it wasn’t. And to be fair, back then it didn’t need to be. Medicine was simpler in many ways. You didn’t have the vast array of treatments, specialties, or technologies we have now. The challenges were different. But instead of adapting to fit modern healthcare, the system just doubled down on those outdated structures.

David Caldwell

So, the system kept evolving... but only in the slowest, most piecemeal way possible?

Sofia Ramirez

That’s one way to put it. It’s like we’ve carried pieces of the past forward without stopping to ask whether they still serve us—or if they’re actually holding us back.

Sofia Ramirez

So, building on what we just discussed, let’s shift focus to what could fix these issues—a competency-based model. At its core, it’s about evaluating healthcare providers based on what they can actually do, rather than the number of years they've spent training or the specific pathway they followed to get there. Think real-time simulations, procedural skill logs, scenario-based assessments—all of these tailored to reflect real-world conditions.

David Caldwell

Okay, real-world conditions—so you’re talking about things like... I don’t know, maybe managing a trauma patient under pressure or diagnosing something really tricky, right?

Sofia Ramirez

Exactly. For emergency physicians, for instance, you might test their ability to manage multiple high-stakes situations at once. Or take a neurosurgeon—assess their precision and critical decision-making during simulated complex surgeries. It’s about skills, not time spent sitting in lectures or fulfilling arbitrary requirements.

David Caldwell

That makes a lot of sense. You know, this reminds me of how we hire in the tech world. It’s less about where you got your degree and more about proving, you know, that you can code, build, design—or whatever the role calls for.

Sofia Ramirez

Exactly! And healthcare could learn a lot from that approach. A competency-based system not only saves time but also keeps the focus on outcomes.

David Caldwell

What about expanding it to other fields though? Like paramedics or respiratory therapists?

Sofia Ramirez

And here’s where it gets really exciting. This could apply to so many roles across healthcare—nurse midwives, nurse anesthetists, paramedics, even respiratory therapists. Imagine if we had pathways to scale their expertise efficiently, or even allow career pivots without forcing a complete restart.

David Caldwell

And we’re still making sure they’re not just, you know, winging it—this is all about proven competence, real skills?

Sofia Ramirez

Absolutely. And it’s not just that it works—it works better. Alongside streamlining certifications, we should include ongoing evaluations, like scenario-based testing or certified logs of every procedure performed. It’s rigorous; it’s fair. And it’s built for the dynamic challenges healthcare providers face every day.

Sofia Ramirez

But as promising as this all sounds, why hasn’t a competency-based system become the norm yet? A big reason? Cultural resistance. Medical boards, specialty organizations, educational institutions—these are stakeholders that have spent decades, if not centuries, holding tight to their control over the certification process.

David Caldwell

Yeah, but isn’t some of that control important? Like, isn’t that what keeps standards high?

Sofia Ramirez

Of course. I’m not saying we shouldn't have standards. But there’s a profound difference between maintaining quality and refusing to adapt to modern realities. These groups often frame it as protecting patient safety, but in many cases, it’s more about protecting their own authority or maintaining the status quo.

David Caldwell

Okay, so let’s say we get past the politics. What would this even look like? I mean, could we avoid turning it into a total free-for-all with no consistency?

Sofia Ramirez

Great point, and that’s where standardized, scenario-based evaluations come into play. Specialty boards would still certify competence, but we’d use tools like exams, simulations, patient and procedural logs, letters of recommendation, and continuous assessments. Consistency would be baked into the process, but without all the rigidity of current pathways.

David Caldwell

So, the boards keep some authority, but it’s less about ticking boxes and more about real knowledge and skills?

Sofia Ramirez

Exactly. Think of it as a dynamic, real-world testing model. Imagine a simulation where an emergency physician has to handle multiple critical cases simultaneously, or a neurologist navigating complex diagnostic challenges. These assessments wouldn’t wipe out the boards’ role—they’d raise the bar for assessing actual competence.

David Caldwell

Alright, that makes sense. But even if we prove this model works, how do we scale it? It feels like a massive shift, especially for a system that doesn’t move quickly.

Sofia Ramirez

True, change would take time. But we could start with pilot programs—small-scale, targeted models allowing us to test the water. These programs could use adaptive platforms, even integrating AI to standardize evaluations across regions or specialties. Over time, those learnings could inform larger-scale change.

David Caldwell

So, kind of like a proof-of-concept approach—learn as we go, adapt where needed.

Sofia Ramirez

Exactly that. And as we build out these systems, we’d be solving not just one problem, but many: reducing medical debt, addressing burnout, fixing labor shortages—all while improving patient care outcomes. Because at its heart, this system would focus on what really matters: competence.

David Caldwell

Right, bringing it back to what you said earlier—it’s not about the title, it’s about what you can actually do. Honestly, it just feels like common sense.

Sofia Ramirez

It does, doesn’t it? But common sense isn’t always so common, especially when tradition gets in the way. Still, if we all approach this with the mindset of improving care for patients, I think we’d find more allies than critics. We just need to start the conversation—and keep pushing forward where it matters.

David Caldwell

And hey, maybe we’ve done a little of that today. This has been fascinating—big systems-level problems, but also some really hopeful ideas. I’ve learned a ton, as usual.

Sofia Ramirez

Thanks, David. I always enjoy these conversations. And for our listeners, I hope this sparks some new ways of thinking about the healthcare system—and how we can transform it together. On that note, we’ll see you next time.