Wednesday, September 20, 2017

Ohio and the Embarrassment of MOC

Today Ohio legislators will be introduced to the concept of "Maintenance of Certification" or "MOC" when House Bill 273 is introduced by Representative Theresa Gavarone (R) to the Ohio Health Committee. Most of the Committee members won't have a clue what MOC is or why they should care.

Lobbyists from the American Board of Medical Specialties (ABMS) and the American Hospital Association (AHA) will claim "the legislation puts patients at risk" and that "patients deserve to know their physicians are up to date" even though this statement flies in the face of the ABMS's own data and that of independent researchers. They even have the nerve to make statements like this: "Faced with a physician who was certified after residency who has not kept the certificate current, patients will be in the dark."

Like the members of these corporations ever set foot in a patient exam room...

Here's ABMS's ACTUAL history of promoting patient "safety" and knowing what patients think.

Recall that in 1969, Dr. Thomas Brem, former Chair of the ABIM and President of the "Advisory Board of Medical Specialties" (our current ABMS) testified before the House Committee on Interstate and Foreign Commerce, stumped for Big Tobacco by testifying "neither can offer unequivocal scientific proof that smoking does or does not cause cancer of the lung." Dr. Brem conveniently failed to mention he was receiving payments from "Special Account No. 4" that was maintained by tobacco company lobbyists. How many lives were affected by this testimony?

While we'd like to think this is just an isolated event, it was not. In fact, such corporate collusion has been the hallmark of the ABMS and their member boards as they shower themselves with lavish salaries and perks at the expense of vulnerable work-a-day physicians.

For her entire career as President and CEO of the American Board of Internal Medicine, Christine Cassel, MD served on the board of directors of the Greenwall Foundation, Kaiser Permanente, Premier Inc and other organizations with quality health care agendas at diplomates' expense while never disclosing these conflicts of interest. It was only after she joined the National Quality Forum (that receives the majority of its funds from government contracts), that these financial relationships were exposed. Citing the "distraction" of it all, she quickly resigned her affilitation with Kaiser and Premier, but not before bilking her unsuspecting ABIM colleagues for over $8.9 million and free travel for her spouse and helping to facilitate the $400 million purchase of CECity, Inc. by Premier (in which she held stock).

Robert Wachter, MD, the golden-boy of corporate medicine and promoter of hospitalist medicine, was also former chairman of the board of the ABIM for a time. He, too, would rather not discuss his "love agenda" for medicine once his relationship with IPC The Hospitalist Company was exposed by the Department of Justice for overbilling patients. It is no wonder he brought down his industry-sponsored blog, Wachter's World.

Nothing to see here, folks.

Other ABMS member boards and their corporate partners would also not like legislators to examine the American Board of Pediatrics, who saw no problem giving James Stockman, III, MD a $2.4 million golden parachute to help fund his car collection and retaining him to work eight hours a week for a $793,438 annual salary. Who funds such largess?

Working pediatricians.

James Puffer, MD of the American Board of Family Medicine and their directors have also enjoyed high salaries while quietly funding his organizations' Foundation's purchase of corporate office buildings and running for-profit real estate management companies. I'm not sure I've ever seen a clearer quality and patient safety initiative funded by diplomates.

The truth be told, MOC is a horrible embarrassment to our profession. We are doctors, for goodness sake. We are not funding vehicles for political and corporate agendas. It is sickening to me that we continue to see medical specialty societies joining the ranks of these highly-conflicted organizations so they can dovetail their lucrative data registries with maintenance of certification as their next sure-fire business model. Is spending time, energy and money lobbying on Capital Hill to keep such registries funded on the backs of working physicians more important than supporting doctors' effort to remain at the patient's bedside rather than at the keyboard?

It seems so.

MOC is coercive, hopelessly financially conflicted, and corrupt. Working physicians need Ohio representatives (and all state representatives) to examine the facts, not cave to the hospital and insurance company lobbies. Working doctors know the score now. Many any are quitting rather than subjecting themselves to MOC again and again just to keep money flowing to the ABMS and their member boards so they can keep working. Patients, particularly those in rural areas, lose when this happens.

From it's inception, MOC was created from lifetime board certification, not for patient care quality or safety, but rather so ABMS officers and directors could pay themselves handsomely. It continuation is fueled by deception, political agendas, and cronyism. MOC also requires coercion and strongman tactics to keep the money flowing. No matter how our own bureaucratic colleagues might sugarcoat MOC on the pipedream of assuring patient care quality and safety, critical examination of the evidence clearly demonstates what an embarrassement the program has been to the integrity of US medicine.

It's time to end it.


Monday, September 11, 2017

The American College of Cardiology and ABIM

I wonder how many American College of Cardiology (ACC) members are aware that the ACC entered into a "Memorandum of Understanding" with the American Board of Internal Medicine (ABIM), (along side the American College of Physicians and American Society of Clinical Oncology) "to explore development of collaborative pathways through which physicians can maintain board certification:"
“The ACC is pleased to join ASCO and ACP on exploring these additional pathways for cardiologists, oncologists and internists to maintain their certification. For cardiology, the ACC would provide clinicians with learning material and assessments modeled after its lifelong learning self-assessment program (ACCSAP). Helping our collective members in the provision of professional and compassionate care, while also keeping up with current knowledge, is a shared goal. We appreciate ABIM’s willingness to continue to listen to and engage with stakeholders in order to achieve this goal in a more effective manner.”

Mary Norine Walsh, MD, FACC
President, American College of Cardiology
What is not mentioned is the exchange of funds that will occur between organizations. How much will ABIM's inter-organization "certification" cost? Might this be one more financial bail-out strategy for the ABIM, given their long history of financial impropriety and rapidly depleting consolidated net assets? Why does the ACC insist on perpetuating MOC when the AMA House of Delegates voted to end the program? Might these organizations' own financial and political aspirations supercede the needs of their members? How much more money will practicing cardiologists have to spend to remain employed at their hospital systems now that MOC is increasingly tied to our credentials and insurance payments?

MOC has become one of the largest single causes of burnout and distrust in our professional societies that increasingly ignore their members' concerns in the name of political correctness and personal gain. This professional society collaboration is anything but helpful to resolving the MOC impass and only serves to strengthen our resolve to end it.


Monday, September 04, 2017

Our Unsustainable Fear-based ABMS Physician Credentialing System

"... diplomats would be asked, but not required, to renew the validity of the certificates at periodic intervals or face the uncertain consequences of loss of their status as certified internists, subspecialists or holders of certificates of added qualifications."
(Glassock, R. J., Benson, J. A., Copeland, R. B., Godwin, H. A., Johanson, W. G., Point, W., Popp, R. L., Scherr, L., Stein, J. H., & Tounton, O. D. (1991). Time-limited certification and recertification: the program of the American Board of Internal Medicine. Annals of Internal Medicine, 114(1), 59–62.)
* * *
"Candidates for Board Certification and Maintenance of Certification agree that their professional qualifications, including their moral and ethical standing in the medical profession and their competence in clinical skills, will be evaluated by ABIM, and ABIM's good faith judgment concerning such matters will be final.

ABIM may make inquiry of persons named in candidates' applications and of other persons, such as authorities of licensing bodies, hospitals or other institutions as ABIM may deem appropriate with respect to such matters. Candidates agree that ABIM may provide information it has concerning them to others whom ABIM judges to have a legitimate need for it.

ABIM makes academic and scientific judgments in its evaluations of the results of its examinations. Situations may occur, even through no fault of the candidates, that render examination results unreliable in the judgment of ABIM. Candidates agree that if ABIM determines that, in its judgment, the results of their examination are unreliable, ABIM may require the candidates to retake an examination at its next administration or other time designated by ABIM.

ABIM also may evaluate candidates' or diplomates' fitness for Board Certification – including their professionalism, ethics and integrity – in disciplinary matters, and ABIM's good faith judgment concerning such matters will be final."
(ABIM Online Maintenance of Certification Policies. Available at . Accessed 3 Sep 2017).
* * *
"ABIM's review of evidence seized from the Arora Board Review reveals you were a course attendee. As part of your Examination, you and all other examinees signed a Pledge of Honesty, agreeing among other things that you would not give or receive aid in your examination. The Pledge of Honesty also prohibits Examinees from disclosing, copying, or reproducing any portion of the material contained in the Examination. You were also provided with contact information for ABIM's Exam Integrity Hotline to report inappropriate behavior that occurred with the Arora Board Review course.

ABIM has ethical and professional concerns from arising from your conduct described above. As a result, ABIM is placing a copy of this letter in your file."
(Lynn O. Langdon, MS, Chief Operation Officer, ABIM "Letter of Concern" dated 8 June 2010)
* * *
"The American Board of Internal Medicine is moving against nearly 140 doctors who it says cheated on the organization's certification exams by seeking out, sharing and in some cases purchasing actual test questions from a board-review company.

Board certification isn't required to practice medicine, but is commonly needed for doctors of all stripes to secure hospital privileges or participate in insurance plans.

In suits filed Friday in U.S. District Court for the Eastern District of Pennsylvania, the ABIM alleges that five physicians infringed the organization's copyright on test questions. The suits also accuse them of misappropriating trade secrets and breach of contract."
(Hobson, K. "Medical Board Says Doctors Cheated" Wall Street Journal 9 June 2010.)
* * *
"I must say, candidly, that with over 50 years of law practice I have never before seen the likes of the repeated attempts by Dr. Westby G. Fisher to malign a person based upon an 11-year old “blip” in his long and successful career of public trust. It is, to be sure, unconscionable, to be using invective to shame the ABIM and, along the way, destroying the career and good name of a very honest, competent person, I know that if a member physician were similarly treated you would be mounting the ramparts to obviate its harm to his/her career."
(Letter from Sidney Baumgarten, Esq., Attorney at Law, to Alan J. Miceli, Editor, Philadelphia Medicine Magazine dated 27 Dec 2016)
How much money does the trademarked time-limited ABMS MOC® program generate annually for the ABMS and its member boards?

$392 million. Per. Year.

(This amount does not include the revenue generated by board review courses and study materials sold by colluding state medical societies and medical subspecialty societies.)

Fear and intimidation might sell MOC® for a while, but when the US medical education and credentialing system in the United States relies on fear for little more than its bloated bureaucratic and political purposes, it is non-sustainable. Practicing physicians like myself will not be ruled by fear-based policies and politics, especially when those imposing the mandate are completely unaccountable to our patients and our families.

I would encourage all of my readers to boycott the ABMS MOC® program (irrespective of the "kinder and gentler" model MOC® pivots toward), remain board-certified with the National Board of Physicians and Surgeons, and to consider joining Practicing Physicians of America, to protect our civil liberties of free speech and Fourth Amendment protections against illegal search and seizure.

Our ability to care for patients without such intimidation demands nothing less.


Thursday, August 31, 2017

Who Will Be Dr. Nora's Replacement?

Ladies and gentlemen,

With the cooler temperatures, kids heading back to school, and a new fall season soon upon us, there's excitement building in the air! The much-coveted position at the American Board of Medial Specialties (ABMS), President and CEO, will soon be vacant. In October, 2016, Lois Nora, MD, JD, MBA announced her upcoming retirement in December of this year after six years of leadership and the political jostling for her comfy salary, first class travel, and health/social club membership perks have been underway for some time.

Who will be her lucky successor? For that matter, who might be potential candidates for her position?

This is an important consideration for US physicians who increasingly find their ability to practice medicine compromised by the proprietary ABMS Maintenance of Certification® (MOC®) program. Since working physicians in America have no control over the selection of this lucky person, we can only venture a guess who might be considered. But there have been several recent hints in various media channels who might be throwing their hat in the ABMS-leadership ring. 

Here is a recent sampling:

1) Hal C. Lawrence III, MD - Executive Vice President and CEO of the American College of Obstetrics and Gynecology (ACOG)

Dr. Lawrence has demonstrated leadership and political moxie drafting the recent letter reportedly "signed" by 38 state medical societies and 33 medical specialty societies in support of a "re-directed" form of MOC® that helps preserves our current highly conflicted method of "professional self-regulation." Dr. Lawrence has also proven himself capable at helping preserve the American Board of Obstetrics and Gynecology subcontractor role as test developers for the ABMS if the status quo is continued. For these reasons, Dr. Lawrence appears well on his way as a possible Dr. Nora replacement.

2) Yul Enjes, MD or 3) Eric Green, MD - a.k.a. "The Doctors Who Defend MOC"

Dr. Enjes has first-hand experience with political cronyism in non-profits serving on the ABIM Board of Directors and as former Chair of the American College of Physicians Board of Governors. Dr. Enjes has cleverly laid low on his important role with supporting MOC - until this article - and can't believe state legislators should have a role protecting the doctor-patient relationship when the ABIM's practices of strong-arming physicians to spend $23,607 every ten years for their condo puchases has been so effective. As such, Dr. Enjes seems like a real ABMS team player!

Dr. Green, on the other hand, might be an equally formidable candidate since he appears to be a strong proponent of income distribution in the form of a "minor" MOC "tax on our time to help the public." His convenient ability of forgetting to mention there is no independent proof that MOC® helps anyone except ABMS revenues makes him a strong candidate for Dr. Nora's position, or any other ABMS member board.

4) Richard Baron, MD - war-torn but time-tested President and CEO of the American Board of Internal Medicine (ABIM) and ABIM Foundation.

There isn't a handsome salary out there Dr. Baron would refuse without having to see patients and Dr. Baron's former work at the Seamless Care Models Group at the Center for Medicare and Medicaid Services to secure MOC® as an (unproven) quality metric gives him a leg up on the other candidates. The only problem now is that Dr. Baron would have to accept a pay cut relative to his robust $849,483/year haul he receives from the ABIM and ABIM Foundation. Still, the ability to spend more time away from the office without the frontline controversy created by the ABIM Foundation's $2.3 million condominium purchase, ongoing anti-trust and physician suits, Cayman Island fund transfers and controversial income redistribution plans using ABIM diplomate testing fees to provide "grants" for various forms of "professionalism" in our nation's medical schools might be welcomed as the heat continues to be applied at the ABIM.

5) Darryl S. Weiman, MD, Professor of Surgery, University of Tennessee Health Science Center and author of "Maintaining My Surgical Certification" in The Huffington Post.

Dr. Weiman, who conveniently fails to mention the American Board of Surgery's conflicts in test development for the ABMS in his HuffPo piece, might be a shoe-in for the position since he appears to be facile at spouting veiled threats in the politically liberal US news and opinion media outlets like the Huffington Post. No doubt the ABMS board of directors love hearing him threaten that loss of maintenance of certification would mean "the public may perceive this as a nefarious way for the medical profession to lower its standards." Wow. Powerful stuff that means nothing to real patients. Since Dr. Weiman seems blind to the nefarious ways the ABMS MOC® program discriminates against younger physicians, uses undisclosed strongmen for protection, and promotes the use of our testing fees for their personal use, it's hard to see how such a fine candidate for Dr. Nora's position could possibly be passed over.

It's a crowded field already.

So who will be Dr. Nora's replacement? Will it be one of these folks or someone else? (The ABMS really needs your help deciding. Comments open.)


Friday, August 25, 2017

On State Medical Societies' Letter to End or "Redirect" MOC

On Tuesday of this week, a letter (with two appendices A and B) sent from 38 state medical societies and 33 professional medical associations to Lois Nora, MD, JD, MBA President and CEO of the American Board of Medical Specialties (ABMS) regarding the "contentious Maintenance of Certification (MOC)" issue was leaked to social media channels.  There are no signatures, no letterhead. Just a single contact person with a Washington DC phone number to control the message?* After brief background check, it appears the letter was legitimate and the product of several influential medical groups' efforts to alter the ABMS MOC program and coordinated by the Association of American Society Executives (AAMSE).

I was intrigued that a number of professional subspecialty societies joined with the state medical societies to request a meeting on 4 Dec 2017 with Dr. Nora to voice their concerns about MOC with the ABMS. Whether the ABMS will agree to a meeting or just use this meeting as another example of "listening" to more groups before fulfilling their own agenda remains to be seen. What is concerning to me, however, is that state medical societies felt they needed to ask Dr. Nora for a meeting when they are the ones that hold the ultimate accountability of self-regulation in their respective states. Shouldn't Dr. Nora be asking for a meeting with them? And why request a meeting with Dr. Nora on 4 December 2017 when she's planning on retiring later the same month?

I worry about the political and business naïveté' of these state medical organizations relative to the specialty societies who earn considerable annual revenues from MOC and may be recruiting them. It is concerning that the circulated letter uses the same talking points as the ABMS and their member boards. This letter quickly shifts from the concerns about MOC to the talking point that "this is not about MOC but professional self-regulation." The same concern of the potential loss of "professional self-regulation" recently appeared in a JAMA opinion piece supportive of MOC by a former American Board of Internal Medicine board director. It was also mentioned in an earlier May, 2017 email blast from the American College of Surgeons who opposed the anti-MOC legislation in Texas. Impressive "harmonization?"

There appears to be a consensus that using the strategy of holding loss of professional self-regulation over working physicians' heads will help us forget all that pesky corruption. Surely state medical societies do not want to buy into this kind of manipulation. Pity the poor physician who does not want to lose his ability to self-regulate his profession and rejects corruption. Where are they to stand? Might this talking point "harmonization" actually be a means to legitimize a "redirected" version of MOC?

The only thing I might say in reply is these organizations only took us half way there.

The current tone of this letter is not one of intolerance and repudiation of the corrupt ABMS MOC program, but rather a request to "redirect" it. In fact, this letter has a disconnect between wanting to "redirect" MOC with only two choices for practicing physicians: (1) propping up the current system of "professional self-regulation" or (2) something else. There is no clarity to the "something else." This is analogous to telling physicians that we'd better slip the Chicago alderman $200 per year, and be grateful for the protection. Why would state medical societies join in such a veiled threat?

Our current method of ABMS member board "professional self-regulation" using MOC has proven itself to be corrupt and laden with numerous undisclosed conflicts of interest, self-dealing, non-transparency, and intimidating strongman tactics. Should we be grateful to ABMS for this, given the nebulous alternative? Let's get the ominous alternative on the table. And why in this letter is there no possibility of a third choice when  an alternative model to MOC is developing in front of our eyes?

Naturally, the National Board of Physicians and Surgeons (NBPAS) has a monumental shortcoming. It fails to guarantee millions in educational fees to many of the subspecialty societies on this letter. One can see how this third possibility just isn't as, well, fun.

Perhaps that's the real reason this letter was released.

Physician members of these specialty and state medical societies should be aware they are playing into ABMS's hand with this letter and should be up to date on the options and the evolving consensus regarding legitimate professional self-regulation. To that end, the integrity and transparency of the NBPAS should be promoted in lieu of the ABMS. Indeed, the state medical societies of Texas and Pennsylvania have played important roles in placing physicians and their patients before the financial concerns of subspecialty organizations and ABMS member boards. This should set a precedent for state medical societies across the country. What they should NOT be doing is begging for a meeting with a lame duck President and CEO of the ABMS who are only looking to grow the frequency and cost of MOC in the name of "professional self-regulation" since the ABMS and their member boards are the ones that got us in this mess in the first place.

Radical reform of the corrupt MOC program is not paying the Chicago alderman $250 per year  instead of $200.

- Wes

Addendum 26 Aug 2017 06:23AM - Appendix B added and the origin of the letter (AAMSE) added.

* That individual, Hal C. Lawrence III, MD, ACOG Executive Vice President and CEO, has significant conflicts of interest with the ABMS. The American College of Obstetrics and Gynnecology (ABOG) are subcontractors for "Test Development" with the ABMS.

Wednesday, August 16, 2017

Fake News: Annals of Internal Medicine's Disclosures

On 15 Aug 2017, the editors of the Annals of Internal Medicine published the Study "Effect of Access to an Electronic Medical Resource on Performance Characteristics of a Certification Examination - Randomized Controlled Trial" that was heavily marketed front and center on their website using the happy physician testing picture shown to the left.

The article touted a comparison between open book vs. closed book testing that was conceived exclusively by the American Board of Internal Medicine and executed by their conflicted corporate partners at PearsonVue and a new $10.5 billion corporate heavyweight from the Netherlands, Wolters Kluwer. In a veiled attempt at full disclosure, the conflicts of interest of the study were carefully articulated in a lengthy disclosure statement hidden behind a paywall. True to form, nearly all of the editors of the article claimed "no financial relationships or interests to disclose."

Most internists in the U.S. know these editors' disclosure is little more than fake news. The Annals of Internal Medicine is an academic medical journal published by the American College of Physicians (ACP). On its last available Form 990, the ACP earned over $24.6 million in a single year selling their Medical Knowledge Self-Assessment Program to US physicians to study for their board certification and recertification examinations. Even the accompanying editorial was written by ACP's former senior executive vice president, Steven E. Weinberger, MD, who disclosed he was an employee of the ACP and earned royalties from authored material on UpToDate.

In addition, the supplement supplied by the authors had portions of the recruiting notice redacted so avoid true disclosure. But when a copy of the actual recruiting notice is revealed here, it is clear that PearsonVue had more than a minor role in the research and had access to the study registrants' names, addresses, and probably more.

Each of the 825 physicians enrolled in the study received $250, costing US physicians (who unwittingly funded the ABIM Foundation) $206,250 for "incentive payments" for this study, not including the time and salaries of those who conducted this study for the ABIM's benefit. None of the participants were told about the financial benefits to the ABIM, PearsonVue, Wolters Kluwer, or their content creators for participation in this study.

Such conflicted "research" published in an academic medical journal that misleads the public and US physicians represents little more than a free advertisement for the financial agendas of these colluding organizations and sets and incredibly low (and untrustworthy) bar for all of academic publishing.


Tuesday, August 15, 2017

Texas to JAMA: A Lesson on Self-Regulation

Texas Medical Association (TMA) spent no time responding to David H. Johnson, MD's veiled threat of loss of self-regulation with the passage of Texas Anti-MOC legislation, SB1148, published in JAMA 7 Aug 2017:
In a letter to the editor submitted to JAMA but not yet published, TMA President Carlos J. Cardenas, MD, agrees on the importance of self-regulation to his profession.

"It encompasses our responsibility and our authority to establish and enforce standards of education, training, and practice," Dr. Cardenas wrote. "We routinely defend that responsibility and authority in advocating against the intrusion of all third parties — such as government, private insurers, hospital administrators — into the practice of medicine."

But physicians in Texas and across the country, he argued, do not see the certifying boards as "self."

"They are, instead, profit-driven organizations beholden to their own financial interests," Dr. Cardenas wrote. "In fact, they are now one of the outsiders intruding into the practice of medicine."

Until the boards "completely overhaul their processes, finances, and lack of transparency," he concluded, physicians "will have no choice but to continue to seek statutory defenses against these third-party intrusions into our noble profession."
Here's a link to the full statement.