This story is not just about physical infrastructure but also about expertise and the relation between expertise and ‘practice’. It is tempting to imagine that certification is about a moment in time, but this is not how medicine or many other areas of high level skill work. The example of surgery is perhaps the easiest, but the same holds for specialties such as imaging, dermatology or histopathology, where perceptual skills are important. How may moles or melanomas you report a week is not the only determinant of competence, but it is a key variable once you pass the novice stage. You know more than you can say, but you only know what you know if you keep doing it every day. The concert pianist still practises his scales every day. BTW, at last, in terms of safe health care, people are beginning to focus once again on diagnostic ability — or lack of it. You cannot control costs or think seriously about medical errors without an obsession about diagnosis and the system wide factors that undermine it (The National Academy of Sciences report is here).