Gladwell’s Principle of Legitimacy Revisited

So my wife says she thought of me and my issues with the Maintenance of Licensure (MOL) and Maintenance of Certification (MOC) last night when she saw a TV news spot about the Iowa State Fair decision to go cashless this year.

I have to admit that I didn’t see the connection at first. Then I remembered my recent post on the analogy of the struggle between physicians and large board corporations over MOC and MOL.

The Iowa State Fair Board probably hit the snag over the legitimacy principle when it just decided to switch to cashless transactions, using 50 cent coupons instead. Even the Governor of Iowa, Terry Branstad, asked them to think this one over.

The legitimacy principle? Recall my post above which highlighted this concept from author Malcolm Gladwell’s newest book, “David and Goliath.” According to Gladwell, the principle of legitimacy is connected to the perception of a powerful leader or group (say a government, medical board, or Fair board) and it rests on 3 basic premises:

  1. Whenever we’re asked to obey an authority, we like to feel like we have a voice in the matter. We want to be heard.
  2. The law that the authority is proposing should be more or less predictable.
  3. The authority has to play fair (no pun intended) and can’t treat one group differently from another.

So the Iowa State Fair officials didn’t give fairgoers or vendors as much as a by-your-leave about the coupon project. They just laid it on us. In fact, my wife says last night’s TV news program highlighted efforts by fair officials to pressure vendors into praising the new system to fairgoers. I couldn’t find any evidence for that in today’s news about the fiasco.

But we have a legitimacy failure here:

No stakeholder really had a voice in the project because no fair official thought of running a poll to see if anyone wanted the new ticket system in the first place.

There were speculations about whether or not it would or would not make money, based on how many ticket booths would be needed and where–so it missed on the predictability factor.

The Iowa State Fair was not perceived as fair (oops, did it again) because there was (I’m going to say) an unsubstantiated rumor that vendors were being coerced to sell the new system to customers.

So the reason why my wife thought of me when she heard the story was based on similar patterns in the failure of the principle of legitimacy with respect to the American Board of Medical Specialties (ABMS) and the Federation of State Medical Boards (FSMB).

None of the boards asked physicians first what we might think of MOC or MOL. They just dropped it on us. We had no voice in the matter.

The components of the MOC shift fairly frequently. For example, the American Board of Psychiatry and Neurology (ABPN) tells psychiatrists to check its web site often because requirements and activities change. It isn’t very predictable.

Certainly the boards have not been perceived as fair because the rules for MOC have been applied differently depending on when you were first certified. For example, if you were certified before 1994 you don’t have to participate. And there are some board leaders who have clearly been identified as not being compliant with the MOC–and it’s the system to which they require every other physician to adhere.

So how does an authority regain respect? Well, in the case of the Iowa State Fair, it looks like they gave up the idea of the coupons quickly. In fact, just today I found a new item saying it plans to cancel to the coupon idea.

Maybe the boards should talk to the leaders at the Iowa State Fair about the legitimacy principle.

Why do I have this craving for a corn dog?homemade-corn-dog


Gladwell, M. (2013). Rosemary Lawlor: “I wasn’t born that way. This was forced upon me.”. David and Goliath: Underdogs, Misfits, and the Art of Battling Giants. New York, Little, Brown and Company: 197-231.



  1. Jim, There are actually some radical groups of physicians in my own state who are advocating quitting the state medical societies and the AMA. They believe that these associations are ineffective and are actually aligned against practicing physicians in many ways and we need new organizations. I have always believed that physicians in general were too conservative to withdraw support from professional organizations and let them die on the vine. The fact that many of these proponents were involved in these societies at one point makes me less certain.

    It seems like physicians are at the point where they realize that working within these organizations won’t work and at least some want to start over. The MOC referendum on the APA ballot is a good example. As you pointed out it got more votes than any candidate on the ballot and the concerns of thousands of members were dismissed at that point.


  2. Jim, The problem is that there are plenty of precedents for authorities that lack legitimacy and regulate physicians. In fact, there is a long history of them starting with the failed political theory that physicians were perpetrators of fraud and abuse and that this was the reason for health care inflation. I can remember sitting in an emergency seminar at my clinic for all of the physicians and the people giving the presentation were talking about physicians like we were an organized crime family – right down to suggesting that they could send us to federal prison on a RICO violation if we improperly coded and that bill went out in the mail!

    What we are seeing with MOC and MOL is the natural conclusion of three decades of regulatory abuse of physicians. Lawyers would never tolerate what we put up with on a routine basis. Time to push back.


    • George, to carry the Iowa State Fair cashless-and-coupon-snafu analogy a little further: fairgoers threatened a boycott, which may have influenced fair officials, resulting in the rule’s almost immediate cancellation.

      Some physicians argue we should adopt a similar strategy, which is mass noncompliance with MOC, essentially a boycott. Do you think that kind of push back would work?


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