Medical competence is not a binary trait, but rather a continuous one. I think this is self-evident. Medical certification often models the issue in terms of the former rather than the latter, however. But the Geoffrey Rose argument about the total burden of hypertension owing more to those with moderate hypertension than those with more elevated blood pressure, may apply. It is shifting the average that may make a greater contribution to good medical practice than pulling out weeds at the left side of the distribution. Finding the weeds may disturb all the other young seedlings. What if our interventions at this extreme come at the cost of lowering the overall rate of growth? Who has skin in the game then?