Wednesday, December 13, 2017

It's Official: MOC® is Dead. Let the Cover-up Begin

It's official: MOC is dead.

You heard that correctly doctors, the American Board of Medical Specialties' Maintenance of Certification® (MOC®) program is over, finished, kaput.

The one thing that resonated loud and clear from the December 4th meeting in Chicago of the multiple specialty societies and state medical societies that were in attendance was "the current MOC® process is problematic."

But don't get too excited.

In a remarkably Orwellian twist of fate, a new "vision initiative" to reinvent "Continuing Board Certification" was just announced by the original MOC® creators serving as the "Planning Committee."
The Planning Committee is comprised of representatives from the Accreditation Council for Continuing Medical Education (ACCME), Accreditation Council for Graduate Medical Education (ACGME), Coalition for Physician Accountability, Council of Medical Specialty Societies (CMSS), Council on Medical Education (CME) of the American Medical Association (AMA), the public, and the American Board of Medical Specialties (ABMS).

Jo Buyske, MD, ABMS/ABS
Sandra Carson, MD, CMSS/ACOG
Joyce Dubow, Public Member
Jack Evans, Public Member
Larry Green, MD, ABMS/ABFM
Thomas Hess, JD, ABMS
Lynne Kirk, MD, AMA CME
Graham McMahon, MD, ACCME
Thomas Nasca, MD, ACGME
John Prescott, MD, AAMC & Coalition
Stephen Wasserman, MD, ABMS/ABAI
Steven Weinberger, MD, CMSS/ACP
Norman B. Kahn, Jr., MD, CMSS, ex-officio
Lois Margaret Nora, MD, ABMS, ex-officio
You just can't make this stuff up.

We now see the ABMS and their sycophants at the ACGME, AMA, American College of Physicians, CMSS, and American College of Surgeons taking nominations for 21 to 25 individuals to serve on the planning Commission. This Commission will "bring together multiple stakeholders to assess the current state of continuing board certification and vision its framework for the future. ... Specialty societies, state medical societies, academic medical centers, hospitals and health systems, other health care systems, consumer organizations, patient advocacy organizations, ABMS member boards, and other groups are encouraged to submit nominations."

This is not rebranding.

This is not just a "pivot" to a new model.

This is an attempted cover-up.

Unless and until there is a full investigation of wrongdoing of these institutions regarding MOC®, including, but not limited to, potential tax fraud, misuse of physician testing fees for personal use, civil liberties violations, strongman tactics, and even possible racketeering, the current "vision initiative" should not be allowed to go forward, lest it happen again.

After all, medical professionalism demands accountability and many, many doctors want to see justice served.


Addendum: Nice to see at least one medical society voiced concerns regarding MOC at the December meeting.

Tuesday, December 12, 2017

We Believe the Working Physicians

Lately, it seems we can't go another day and not hear about another individual, once held high as an icon by their adoring followers, falling from their elitist pedestal in shame when revelations of their lewd and morally reprehensible behavior are ultimately exposed. As Elizabeth Nolan Brown of the New York Times astutely observed in response to the prevailing zeitgeist:
Social media takes a lot of punches for enabling sexual harassment. But the past two months have shown that it has also provided consumers with an unprecedented power to make their market preferences heard loud and clear. And right now, the market is demanding that companies do something about sexual predators and pests in their midsts.
I believe a similar movement extends to the regulatory world of academic medicine, too. The anti-MOC (Maintenance of Certification) movement, facilitated in large part by social media unconstrained by medical journals owned by self-adoring academic medical societies, is unlocking the self-locking doors of the Accreditation Council for Graduate Medical Education (ACGME).

This is not to say that all academic physicians are bad people. On the contrary, just like not all journalists and actors are sexual predators, not all individuals in positions of power within the ACGME construct or medical societies are bad people. But power and money do things to even nice people. Some people see how easy it is to take advantage of those less prominent, yet no less important, than they are. The blinding influences of money and power permit morally reprehensible behavior to be ignored by others who also benefit from that behavior but don't say anything. Soon, given an inch, a few influential people in positions of power take a mile and before long, they quietly become pests in US medicine's midst too.

Such has been the story of the ABMS and their member boards since the introduction of time-limited board certification. Using highly respected members of the medical community as their work-a-day pawns, these leaders stroked the egos of their revered physician educator colleagues by providing them first class air fare, accommodations at five-star hotels with dinners at the fanciest restaurants with exquisite wine samplings for test writing junkets as their network of carefully-chosen collaborators grew. In return, the leadership of these organizations were held high as moral icons above reproach as plans were hatched for the next test-writing retreat in Costa Rica. Black tie events at the Four Seasons (or similar venue) reinforcing their behavior for the "common good" of medicine become commonplace. Using these respected adademics as self-adoring apostles of the ABMS  leadership, more like-minded individuals were recruited using this simple formula based on avarice, narcissism, and greed: give economically disadvantaged academic physicians a glimpse of what they could have if they worshipped the materialistic world of the ACGME and these riches could be theirs, too. The host of corporate interests like testing companies, publishers, single payer advocates, pharmaceutical and insurance companies, and every medical supply chain company wanting the selling/purchasing power of physicians in their back pocket would make sure of it.

Soon, ABMS Board certification went from a lifetime credential to a time-limited one quite easily: by the threat of "uncertain consequences" by the boards and their medical society sychophants. Dazed and confused, unsuspecting working physicians were dragged into the PearsonVue testing back offices for "recertification" testing using threats to their character and intellect. Those threats became real as practicing doctors realized their "voluntary" board certification process was no longer voluntary, lest they lose their job if their once specialty certification expired and was no longer considered valid by their employer.

And so it has been for years until a few brave souls came forward and questioned the status quo. Thanks to social media, scores of hardworking physicians are waking to their own #MeToo moment as subjects of extortion, strongman tactics, civil liberty violations, and being used as research subjects without their consent. None of this was done to benefit patients they now realize thanks to social media, but to line the pockets and fund the political agendas of a few influential members of the untouchable medical credentialing cartel.

This new movement has even shown that intimidation of a vulnerable physician work force won't hold back the truth.

It's a new time in corporate America, just like it's a new time for the ACGME.

Not only do we believe the women, we believe the frontline working physicians, too.


Wednesday, December 06, 2017

On the December 4 Meeting of the Untouchables

From the invitation-only December 4, 2017 meeting on Maintenance of Certification (MOC®) practicing physicians were not allowed to attend, came this synopsis from Ohio:
Fellow Council members,

The following are my thoughts following the long-anticipated MOC® meeting in Chicago. An official report that will be distributed to the general membership will follow.

The meeting was hosted by the American Society of Anesthesiologists in Schaumburg, IL. The auditorium designed to hold 150 people, was filled to standing room only.

A bit of background, this meeting was the brainchild of Donald Palmisano, Jr., CEO Medical Society of Georgia, and Hal Lawrence III, MD (Executive Vice President and CEO) ACOG. (Editor's note: The American College of Obstetrics and Gynnecology (ABOG) are subcontractors for "Test Development" with the ABMS.) During the interim and annual meetings at the AMA, the state and specialty societies meet. It was during this meeting in Chicago that the idea for today's meeting was formed.

Dr. Lois Nora, current President and CEO of the American Board of Medical Specialties spoke first. In her 20-min remarks, she acknowledged each of the points raised in the letter penned by the state and specialty societies. Dr. Nora's term ends on December 30, 2017. Her successor is Richard E. Hawkins MD, who is leaving his position as Vice-President of Medical Education at the AMA to take this position.

Her Key Points:
  1. Committed to improving continuing certification
  2. Add state society representation to the Committee on Continuing Certification
  3. Admits that the current MOC® process is problematic
  4. MOC® should not be used as the only criteria for state licensure, credentialing, or employment
  5. Agrees that professional self-regulation is valuable
  6. Asked that the states not support anti-MOC® legislation (citing possible unintended consequences)
Summary of the comments from state and specialty society representatives:

  1. Physicians insist on trust, input, transparency, and improved communication from the boards
  2. Create a process that is developed with us not forced upon us
  3. Process should not be punitive. Use the carrot and not the stick
  4. MOC is an irrevocably tarnished brand
  5. Following initial certification, the high stakes exam should be only one of several options
  6. Create a process that is fair to physicians holding more than one certification
  7. Several specialties have already implemented processes that offer ongoing demonstrations of competency as an alternative to the high stakes exam.
  8. Two specialty societies (Family Medicine and Psychiatry) stated that they were considering up thir own boards as a solution
  9. Anesthesia was the only specialty that admitted that reducing the burden on physicians had a negative effect on their bottom line
  10. Multiple states vowed to continue legislative efforts until tangible efforts in the MOC® process can be seen
  11. Need for dur process for physicians whose ability to work has been adversely affected by inappropriate use of MOC®
  12. The hospitals (AHA) and insurers (AHIP) should be invited to the discussion as they are the entities most likely to use MOC® inappropriately.

Please note that I spoke personally to the organizers of this meeting to request that Ohio be included in future discussions regarding MOC.

Respectfully submitted,

RF Chatman MD, MPH
President, Ohio State Medical Association
It appears the thrust of this "meeting" was to try and get states to NOT pass anti-MOC legislation. It didn't take long for an analysis of the Ohio synopsis to appear in my inbox from one observant physician (printed here with permission):
It seems to me as though this debate has now been quietly and cleverly re-framed in terms of retaining and "improving" (compulsory) MOC®.

Remember, it is only made "compulsory" through collusive "enforcement" by those twin paragons of virtue, the insurance and hospital corporations.

"No more high stakes exams we promise" they cried. The implied subtext being that the obligatory ABMS MOC parasite will remain Ebola-like, in some mutated and quiescent form, and continue to infect us all.

Debating the "character" of MOC® was four years ago. Pretty please. That didn't work. Now the issue is not MOC® but the utter and complete repudiation of ABMS lock, stock, and barrel. (Editor's note: Recall the AMA House of Delegates already voted to do so in June, 2016. We now see the AMA's answer to that resolution: to place physician puppets in position of power at the ABMS to assure their lucrative international medical data mining project grows ever stronger and more valuable.)

MOC® should be in reality just another innocuous and palatable Continuing Medical Education (CME) option, but has become a forced and toxic one. A most profitable and poisonous bubbling brew concocted and fed to us by our "peers in leadership positions." The ABMS have become the very caricature of witches on MacBeth's "blasted heath."
The ABMS and their 24 specialty lackeys should now go off and hawk their wares like any tawdry CME street vendor in the chaotic for-profit "medical education" bazaar. Through their grotesque avarice the ABMS have irreparably tarnished their brand. No physician will ever respect them again. Ever. They are done.

Why on earth does anyone even stoop to converse with the ABMS anymore? It is too late for that. As Texas Medical Association President Carlos J. Cardenas, MD said "Physicians in Texas and across the country... do not see the certifying boards as 'self.' They are, instead, profit-driven organizations beholden to their own financial interests. In fact, they are now one of the outsiders intruding into the practice of medicine."

States should pass their anti-MOC laws, the ABMS and its apologists should be disregarded, and we all should move on.

Why did the state medical societies, which (with very few exceptions) also lack any standing amongst rank and file doctors, even bother to meet with the ABMS?

It is a total charade, a Jersey boardwalk puppet show populated by unrepresentative and self-aggrandizing narcissists lobbying each other. What on earth were they doing, imploring the ABMS on a bended knee to change their wicked ways?

"My" state medical society (sadly not one of the exceptional ones and one having less than 5% of state physicians as members) has no right to negotiate the character of MOC® on my behalf. It is too late for that. The state medical societies have become little more than the mini me's of the hated and corrupt AMA.

The single demand going forward should be to break up the ABMS monopoly and open up the market to competing boards like the NBPAS, recently delineated in an article by an FTC member. Let the physician marketplace decide which boards truly represent their interests. Period.

The hospital and insurer enforcers should be met head on now. Forget the disgraced ABMS. The MOC® debacle has catalyzed the onset of a transformative phase in medicine, one we physicians must be the first to recognize and guide.
Somehow, I didn't think I could improve on this cogent analysis.


Sunday, December 03, 2017

When Medical Subspecialty Societies Do Harm

Pediatrician Meg Edison, MD gives her take on her "MOC failure:"
I am a diplomate of the American Board of Pediatrics against my will. I find it morally reprehensible to financially support an organization that harms fellow physicians. I find it demoralizing to know my money supports their lobbying efforts against our state MOC legislation. Yet I paid in order to see my patients. I paid so I could still be a doctor. The American Board of Pediatrics could ask for another $1500 next year, and I’d have to pay again. There is no choice.

Is it possible I was targeted for being so outspoken on MOC? Possibly. My initial letter to the ABP has over 100,000 views. My medical society has used me on the cover of their magazine and their website dedicated to fighting forced MOC. The ABMS Senior Vice President knows me by sight, and has watched me testify against forced MOC in our state capitol on multiple occasions.

But I’ve been contacted by countless quiet Michigan physicians threatened and decredentialed for simply refusing to pay for MOC. It doesn’t matter who you are, an outspoken physician with a state medical society behind you…or a solo practitioner quietly trying to stay afloat…you must comply.

I don’t know the solution to this problem. It seems like every legal, logical, and ethical boundary that should prevent a certifying company from gaining such absolute unchecked power has been ignored, and every professional organization that should help us is impotent.

My state medical society has held clear policy opposing board certification, let alone MOC, for insurance plan participation for 20 years. They’ve been negotiating for 20 years, yet aggressive MOC discrimination continues. The AMA has strong policy opposing MOC abuse, but refuses to do anything. The FTC should see this monopoly as a clear anti-trust violation. They are waking up, but still not acting. I am baffled the IRS doesn’t question the million dollar salaries raked in by these “non-profit” organizations. It seems like this would be a slam-dunk class action lawsuit for some smart law firm, but no one is interested in the case. State legislation is likely our best bet, but the lobbying power of insurers, hospitals, the billion dollar ABMS certification industry and their codependent specialty societies is nearly impossible to fight.

If nothing is done, ABMS will win, because their entire coercive business model relies upon our professionalism. As physicians, we take an Oath to “Do No Harm”. We promise this to our patients.

My first emotion when I heard my patients were forced to receive care in the ER was not anger at ABMS. It was gut-wrenching guilt. I dared to speak. I dared to fight. I underestimated their power. I was stupid enough to think MOC was a physician issue. It never crossed my mind that my patients would be harmed. I know better now. The next time they ask for another check, I will comply, and they know that. I just hope something is done before then. Primum non nicer.
Read the whole thing.


Tuesday, November 28, 2017

Despite Known Conflicts, ACC/HRS Endorse MOC

The Heart Rhythm Society (HRS) and American College of Cardiology (ACC), two organizations who stand to gain handsomely from their NCDR procedural registries, published a carefully-worded combined statement on "Lifelong Learning Requirements for Clinical Cardiac Electrophysiology (CCEP) Specialists" in their respective journals this week.

In a glaring ommision, the publication concerned itself with how Relationships With Industry (RWI's) were handled by the authors, but failed to address the many known RWI's of the bodies that "approved" their statement, including the ACCME, ABMS and ABIM. These relationships include the known collusion of the ABIM with CECity, Inc (held by Premier, Inc, the largest hospital purchasing consortium), the Massachusetts Medical Society and its NEJM Group, the multibillion dollar Netherlands publisher and owner of UptoDate, Wolters Kluwer, PearsonVue, and the myriad of test security companies who benefit from the unproven MOC mandate.

These are not minor conflicts.  They strike to the very core of the integrity of our profession and physicians who must place the interests of our patients before all else. Setting the "rules" for lifelong learning is not required, integrity and honesty in dealing with patients is what is needed instead. Those internal principles cannot be simply articulated in the form of a published "guideline."

This blog has carefully articulated the many civil liberties violations and ethical breaches perfomed by the ABIM (all sanctioned by the ABMS and perpetuated by the AMA) for the past four years. Financial cover-ups, tax fraud, HIPAA Business Associate Agreements that are not optional, and the use of a team comprised of a felonious "Director of Investigation", ABIM staff members, and members of the ABIM legal team to obtain physician emails covertly, so they could use that information to discredit and intimidate physicians, are our reality.  Yet the ACC and HRS have decided to turn a blind eye to the corruption because it might disturb their business model.

Using hugely conflicted certifying bodies to certify a professional position statement document is a problem the ACC and HRS have chosen to ignore to their detriment and the detriment of our professional integrity.


Monday, November 27, 2017

Thanksgiving 2017 and the Grooming of Physicians

"Fun, flexible, and refreshing way to earn your credit! Take a break from the bird and have your hand at a few."

So said the American Board of Pediatrics' (ABP) Thanksgiving 2017 tweet seen here (now deleted).

As if family time and the true meaning of Thanksgiving mean nothing to the American Board of Pediatrics (ABP). Rather, David G. Nichols, MD, the President and CEO of the ABP, must need to assure his Christmas bonus.

Boasting that "20,000 physicians enrolled in Question of the Week" (QOW), as if there was another option for pediatricians caught in the regulatory capture vice-grip of MOC®, speaks volumes about the motivation of this organization. In fact, the real world reality is that not signing up and paying for "QOW" risks a practicing pediatrician's ability to participate in insurance panels or to maintain their hospital privileges.

The Thanksgiving message from Richard Baron, MD, President and CEO of the American Board of
Internal Medicine, was equally troublesome given the reglatory capture realities of the ABIM's MOC® program, too:
"Thank you for all you do every day."
You're welcome, Rich.

Now tell us, given the spending, financial shenanigans, and legal fees incurred by the ABIM and ABIM Foundation lately, are the ABIM and ABIM Foundation insolvent as at least one accountant suggests?

Given the realities of the ABMS MOC® program that both organizations promote, placating physicians with such messages at Thanksgiving is akin to a child molester grooming his victims to earn their trust; it's about as ethically moribund as it gets.


American Academy of Pediatrics "Sets Sail" to Track All US Children

The American Academy of Pediatrics, (aka, "Big Brother") wants to track your children. Physicians who support the program can earn MOC® credits, too:
The Academy has set sail to be the first entity to collect, store and analyze health data on all U.S. children. The board agreed to commit $583,000 in resources from the Tomorrow’s Children Endowment to begin development of a child health clinical data registry, which is expected to unfold over five years. This unprecedented initiative, called Clinical Health Information and Longitudinal Data Registry (CHILD), is the outgrowth of two strategic plan objectives:

Use data and metrics to develop and priori­tize areas of need for child health policies. Provide state-of-the-art pediatric practice information in the context of a changing industry and professional landscape. Data would be captured through electronic health records, integrated health care systems, payers and existing pediatric disease registries. Data elements would include well-child and sick visits, chronic disease diagnosis and management, specialty care, and developmental and behavioral care. The registry also would include a patient portal to allow parents and patients to input data, while alleviating complications surrounding privacy laws.

Christoph U. Lehmann, M.D., FAAP, medical director of the AAP Child Health Informatics Center, and professor of pediatrics and biomedical informatics, Department of Medicine, Vanderbilt University School of Medicine, presented project details to the board, including the following primary goals:

Create substantial improvements in child health and well-being. Accelerate advances in child health. Improve outcomes for children using data. Demonstrate the trajectory of child health through adulthood. Among the benefits of this registry, Dr. Lehmann said, are tracking childhood health and illness trends, which would help draw conclusions on a number of areas, including gaps in care, treatment options and regional variations in care. The data also will help inform the creation of AAP guidelines and policies, and provide guidance to payers.

Members could use the data to help create reports for quality improvement projects, as well as for meaningful use and Maintenance of Certification, Dr. Lehmann said.
What could possibly go wrong?


Friday, November 10, 2017

The History of the ABIM Art Collection U.S. Physicians Have Never Seen

They were the glory days; a time when the ABIM was still respected; a time before the World Wide Web and moving diplomate testing fees from the ABIM to a secretly-created shadow "Foundation" could occur below the radar.

John A. Benson Jr., MD and Harry R Kimball, MD were the first two Presidents of the ABIM appointed after the bylaws were changed to pay officers salaries. Dr. Benson was the first President of the ABIM from 1975 through 1991 and ran the organization from his home in Portland, OR, leaving his academic and clinical practice for the administrative world of the ABIM save for one long-time physician-patient he kept while serving in that capacity.* Dr. Kimball, his all-too-willing successor from 1991 through 2003, understood the number of doctors being trained was finite and paying executives would be difficult without a new business model. It was Dr. Kimball who conceived of "maintaining" one's board certification through ABIM's Continuing Professional Development (CPD) program to keep the money flowing. But the initially voluntary program flopped as doctors saw the program for what it was: an unnecessary distraction from their busy practices. So CPD would have to become mandatory. His like-minded colleagues at the American College of Physicians (who would also financially benefit) could see to that, and soon money flowed like honey. So much, in fact, that something had to be done with all that money earned by a so-called "non-profit."

It was under Dr. Kimball's direction as ABIM's Chairman of the board from 1989-1990, the ABIM Foundation was secretly created in 1989. Multiple money transfers from the ABIM to the Foundation were made to facilitate lucrative investments with (the now-defunct) 1838 Investment Advisors. For a while, it was a win-win for both corporations. So many trades were made that ABIM paid nearly a quarter of a million dollars annually for their services.

With that money flowing to the ABIM, nearly $90,000 of artwork was purchased for their Walnut Street offices in Philadelphia in 1997 and 1998. We know this because the ABIM offices were later renovated in fiscal year 2003 as the computerized testing age came to Philadelphia. At that time, the value of that art work was disclosed on ABIM's IRS tax forms (see here, here, and here).

In total, it appears $89,874 dollars worth of some kind of art adorns ABIM office walls, thanks to ABIM diplomates. No wonder they "surprised" Dr. Kimball with a black tie event and had the first "Kimball Lecture" in honor of him in August, 2004!

But then 2005 came.

The gravy train ended when 1838 Investment Advisors' fund lost 74% if its value and mysteriously disappeared:
"The silence has been deafening," said one money management executive in the region, who declined to be named. It's as if they "fell off the face of the earth," said a pension consultant, who asked to remain unidentified. One private equity veteran, who declined to be named, said it's unusual for a firm with such a long history to simply disappear. The firm traced its lineage back to Drexel and Co., a banking and investment management firm founded by Francis Drexel in Philadelphia in 1838.
Principles from 1838 Investment Advisors were holdovers from the Drexel Burham Lambert that came under investigation for illegal activities in the junk bond market for stock manipulation. Since that gravy train collapsed, another hopeful investment was made in real estate: a condominum puchase in December 2007.

The ABIM Foundation was never about "medical professionalism" or "Choosing Wisely®." It was a "get-rich-quick" scheme using diplomates' testing fees for the organization's own corporate benefit.

That is, until it wasn't.


* Interview with Dr John A Benson, Jr, MD, conducted April 27, 1999, page 18.

Thursday, November 09, 2017

Combating MOC Abuses

Thanks to the Orlando Medical News for their comprehensive coverage Tuesday on the American Board of Medical Specialties' (ABMS) Maintenance of Certification (MOC) scandal.

Physicians' best approach to collapse the current ABMS monopoly on credentialing standards remains mass non-compliance.

Employed physicians (like myself) are finding noncompliance impossible without jeopardizing their employment, since many hospitals require their physicians to be "board certified" in their specialty. Since ABMS no longer "recognizes" lifetime certification as a valid credential (except for older "grandfathered" physicians who obtained their board certification before 1990), younger (more economically vulnerable) physicians risk the loss of employment if they do not participate in MOC and agree to the ABMS's "HIPAA Business Associate Agreement," becoming little more than data entry clerks for the lucrative insurance, pharmaceutical, and hospital industries.

Is this really what our patient's want?

I don't think so. Most patients I know would like to see their doctor look them in the eye rather than at a computer screen. Most want to be viewed as humans rather than a data profit center. And all of them want to spend more than 8 minutes with their physician.

So how do physicians combat MOC? How do we preserve our ability to work without having to make extortion payments to the ABMS and their member boards just for their political and personal benefit?

The fight against MOC continues on many levels, but it is a long, difficult, and expensive David-vs.-Goliath battle:
  1. The development of an alternate certification board that is affordable and does not require physicians to comply with the ABMS/ABIM HIPAA Business Associate Agreement and comprised of highly-respected unpaid members of the physician community who understad the conflicts of interest inherent to the ABMS member board construct and is gaining acceptance hy hospitals accross the country.

  2. State-by-state legislation efforts outlawing the use of MOC as a condition of insurance panel participation, hospital privileges, or state licensure.

  3. Persuing other legal avenues, including anti-trust and class action suits against members organizations of the Accreditation Council for Graduate Medical Education, among others.

I would encourage employed physicians who are given a professional stipend from their hosptial systems for professional society memberships to seriously consider using some of those fees to join Practicing Physicians of America in lieu of other conflicted professional and subspecialty organizations as we continue to push back against the MOC mandate (an example of to testimony and evidence provided the Ohio Health Committee here). Other areas to contribute include becoming certified by NBPAS or contributing to their advocacy efforts. It costs nothing to join the Facebook group Physicians Working Together, too. That group offers lots of productive ideas on how we can work collectively to restore the integrity of our profession.

It is only through a corrodinated effort from a large portion of the working physician community that our freedom to truly work in our patient's best interest without unnecessary and unproven third party interference can be restored.


Wednesday, November 01, 2017

The Hidden Message Coming From the AMA

This morning I received a press release from the American Medical Association (AMA) that said "New AMA Research Finds One in Five Physicians Ready to Reduce Clinical Work Hours." The press release pointed to "new research" (sorry, it's behind a pay wall) that appeared in the Mayo Clinic Proceedings from "experts" from the AMA, Mayo Clinic and Stanford University. The lead author of the research was Christine A. Sinsky, MD of the AMA.

But what Dr. Sinsky fails to disclose in her article in the Mayo Clinic Proceedings, is she is also a Director of the American Board of Internal Medicine (ABIM) and a member of the Board of Trustees of the ABIM Foundation, serving as the Vice Chair. This is not a minor lapse in disclosure, since the ABIM Foundation and the entire national Maintenance of Certification debacle may become one of the largest medical education corruption stories in modern medical history. Funneling over $78 million dollars for ABIM testing fees behind physicians' backs to fund the ABIM Foundation appears of little importance to Dr. Sinsky. She is more concerned about our psychologic well-being rather than the behavior of the Foundation she runs with our Maintenance of Certification (MOC) cash. This corruption renders Dr. Sinsky's arguments why physician burnout is at an all-time high mute moot. Turning a blind eye to the facts only deepens physician frustration with our current bureaucratic leadership.

If Dr. Sinsky is so concerned about physician burnout, why isn't she the leading spokesperson at the AMA insisting the leadership there end MOC as it was resolved by the AMA House of Delegates in 2016?

Perhaps it's because she's too conflicted to understand the problem.


Tuesday, October 31, 2017

ABIM and the Human Diagnosis Project

Just when you thought it couldn't get worse, look what your ever-increasing American Board of Internal Medicine test fees are paying for now:
Fostering broader access to affordable, trustworthy, and meaningful artificial intelligence is a key goal for many in the industry, including an international group of stakeholders working on the Human Diagnosis (Human DX) Project.

Spearheaded by prominent organizations including the American Medical Association, American College of Physicians, and American Board of Internal Medicine, the initiative plans to bring quality specialty care, backed by artificial intelligence, to underserved patients around the globe.
... yet another unproven political agenda.


Monday, October 30, 2017

ABIM Foundation - Five Years Later

A new public relations push for the ABIM Foundation and its Choosing Wisely campaign recently circulated in the press and MedPageToday. This quote from Richard Baron, MD, president of the American Board of Internal Medicine (ABIM) and the ABIM Foundation (which created and promoted the "Choosing Wisely" campaign) caught my eye:
"Here we are 5 years later; today, 80 [medical] societies have lent their intellectual capital to thinking about this," Baron said. "How do we judge success? We go back to the idea that this is about supporting people having difficult conversations ... [and] health systems around the country are using this as a structure to have these conversations."
Health care organizations ARE using this as a structure to have these conversations. In fact, as has been systematically uncovered in this blog and elsewhere, the ABIM Foundation has spend the last five years spending our secretly funneled testing fees for themselves. Look at the data, pulled from IRS tax forms by Mr. Charles P. Kroll, to understand the magnitude of what has occurred:
While few can argue with the well-meaning effort to limit procedural overuse in medicine, but using physicians' testing fees to promote this program and to line its supporter's pockets without earning any program revenue could be one of the largest white-collar medical education Ponzi schemes (as Elizabeth Rosenthal, formerly from the New York Times, suggested) in the history of US medicine.


Sunday, October 29, 2017

Kroll: How the War Against MOC® is Being Won

The war against Maintenance of Certification® (MOC®) is being won through social media and "memetic warfare." Spend 23 minutes to fully comprehend what's happening to the ABIM, the ABMS, and their member boards, including the American Board of Surgery, and the American Board of Pediatrics.

Forensic accountant, Mr. Charles P. Kroll, explains:


Saturday, October 28, 2017

ABIM Tax Filings Show More Important Discrepancies

When was Christine Cassel, MD ever the Senior Vice President and Chief Financial Officer of the American Board of Internal Medicine?

ABIM 2011 Form 990, Page 1 - Signature Line

McGladrey LLC has a long history of accounting deficiencies, but this one might take the cake. ABIM's paid McGladrey LLC a whopping $361,753 for "accounting/consulting" services in fiscal year 2011. This amount is over three times the usual accounting fees ABIM historically paid. 


Was there such significant cover-up that ABIM's true Chief Financial Officer at the time, Vincent Mandes, wouldn't sign the tax form?


PS: Recall that the AMA House of Delegates requested a formal independent audit of the ABIM. The AMA asked Richard Baron, the President of CEO to respond to that request. An independent audit was never granted. Instead, Richard Baron, MD issued this statement.

Sunday, October 22, 2017

What ABIM and Theranos Have In Common

Mr. Chris Jennings
(photo from their company website)
Meet Mr. Chris Jennings, a "consultant" to American Board of Internal Medicine (ABIM) in fiscal year 2010. Mr. Jennings has also served as an advisor to Theranos, the health care technology company recently labeled as a fraud.

Mr. Jennings is the founder and President of Jennings Policy Strategies, Inc., a company with whom, according to their 2010 Form 990, the ABIM "consulted" for a cool $120,000 for fiscal year 2010. (Here's documentation of a portion of that amount).

There's only one problem.

According to the Center for Responsive Politics, Jennings Policy Strategies, Inc was not really a "consultant," but rather a registered lobbying firm in Washington DC in 2010. Just as before, it appears the ABIM has failed to disclose lobbying activity with this firm on their 2010 Form 990 disclosures, choosing instead to label the activity as "consulting." Given this, it appears fraud may involve more than Theranos.

This begs the question: where's the IRS?


"Clinton Aide Joins Obama on Health Care," New York Times July 7, 2013.
"Clinton Campaign Advisor Also Advised Fast Faltering Health Care Company," Free Beacon 11/12/2015.
Health Care Affairs blog bio.
ABIM IRS Form 990 - 2010

Friday, October 20, 2017

What is MOC®? Why Is This Important?

What is Maintenance of Certification® (MOC®)?

Is it an educational program for physicians? If you think so, you are wrong.

MOC® has almost nothing to do with physician education, but according to the contract we must sign, involves "certain health care service operations, including practice assessment and evaluations." Most importantly, it allows physicians' personal and practice data to be shared with an unlimited number of third parties through a HIPAA Business Agreement.

Let me be clear. MOC® is not really about physician education. Instead, MOC® allows a physician's personal data to be shared with data registries and large corporations who profit from those data. For instance,  our MOC® and survey data are shared with (sold to?) Premier, Inc. (PINC, the $4.3 billion owners of CECity, Inc.), the largest healthcare performance improvement company that serves 3,900 hospitals and health systems and approximately 150,000 other providers and organizations." (Remember, Christine Cassel, MD, former President and CEO of the American Board of Internal Medicine, served on the board of Premier, Inc at one time and earned plenty of money and stocks in that capacity while at the ABIM.)

It also allows physician data to be sold to ABMS Solutions, LLC, a for-profit wholly-owned subsidiary of the American Board of Medical Specialties that is based in Atlanta, Georgia, who then sells your MOC® status, updated every 24-hours, to others, and a company never mentioned in disclosures published in our major medical journals. They will also plan to share these data with the Disciplinary Action Notification System database owned by the privately-held non-profit Federation of State Medical Boards that solicits "Affiliate Members, Official Observers, and Courtesy Members."

Again, MOC® is not about physician education. It is about collusion with multi-billion dollar companies, including Wolters Kluwer, and Pearson, LLC, and even our own politically-powerful American College of Cardiology that who owns the NCDR procedural registries and sells access to them to hospitals with MOC® as its demographics supplier (a full explanation of how this works is available here).

Why is the understanding of this "definition" of MOC® so important?

Multiple states are enacting legislation to prevent MOC® as a cudgel to limit a physician's ability to hold hospital credentials, be on insurance panels, or obtain state licensure. Our physician data are that important to these companies they will stop at nothing to be sure we sign that MOC® agreement.

What if the ABMS re-brands MOC® to some other "product" at their December 4th meeting with all of those state medical societies frustrated with what MOC® has become? Might the American Board of Medical Specialties and their collaborators skirt existing "anti-MOC®" legislation? Current anti-MOC® legislation must anticipate this and not include "MOC®" but "MOC® or any other health care serve operation that may include practice assessment or evaluations that requires a physician to sign a HIPAA Business Agreement to which they are not parties" in their language.

Physicians enacting anti-MOC® legislation need to understand the legal definition of MOC®. That way they can write legislation that is lasting, meaningful and enforceable, irrespective of how MOC® is ultimately re-branded.

MOC® is broken and must end. Not because it's a failed physician education experiment. It's broken because of its threats to physician civil liberties and threatens the doctor-patient relationship at it's most intimate level, thanks to the age old business motivators, money, power, and greed.


Wednesday, October 18, 2017

Why the IRS Needs to Investigate the ABIM

Monday, the bureaucratic side of the House of Medicine, via the American Board of Internal Medicine, announced their new-and-improved fee structure for Maintenance of Certification®. Lots of fancy corporate spin was used to justify the need for cash, with even some "discounts" (that failed to include the test facility fee as before) were promised for those silly enough to pre-pay for their strongarmed fees.

According to ABIM's publicly reported mission statement:

Board certificaiton, and MOC® in particular, are no longer voluntary for US physicians. I believe (and I do not say this lightly) placing such a statement on an IRS form in this day and age constitutes fraud. MOC® has been cleverly incorporated into hospital bylaws and insurance panel requirements thanks to (1) the public sharing of Margaret O'Kane on the National Quality Forum and the American Board of Medical Specialties board and (2) Richard Baron, MD's work at the Seamless Care Model Group of CMS. Clever corporate inner dealings have benefitted their self-proclaimed corporate partners at FigMD, Kaiser Foundation and Hospital Group, the now defunct IPC The Hospitalist Company, Premier, Inc,, CECity, Inc., ABMS Solutions, LLC, the NEJM Group, Wolters Kluwer, and Pearson Education. As such, ABIM is no longer a charity organization, it is a for profit business. They have never shown improved quality of care no prevented injury to the public (state medical boards address poor quality and behavior by physicians). Rather, like many successful for-profit companies, the organization has promoted the self-inurement of its leadership, board of directors, and academic affilitates through political influence and self-dealing. It is now well-documented that at LEAST $78 million dollars from ABIM diplomates were secretly funneled to the ABIM Foundation for their benefit. Condominium purchases, health club memberships, spousal travel, Cayman Island Investments, a lavish $1.2 million golden parachute for Christine Cassel, MD and an annual salary from Richard Baron that approached $850,000 in fiscal year 2016 are realities and not usually the hallmark of a legitimate charitable organization that provides voluntary benefit to the public. Neither is the repeated convenient misreporting on tax forms from 2008 through 2013 that has occurred, including (at a minimum) misreported dates and place of origin of the ABIM Foundation, lack of disclosure of depreciation of the condominium or the disclosure of lobbying of Congress on those forms either.

At the very least, it is time for the Internal Revenue Service to reevaluate the non-profit status of the ABIM. Taxpayers (and physicians who have no choice but to participate in this costly charade) deserve no less.


Monday, October 16, 2017

Hurting for Money, ABIM Raises Fees 12%

(Click image to enlarge)
The American Board of Internal Medicine, over $57 million in debt on paper (or, said another way, with only $13.6 million in remaining in its consolidated assets when combined assets of its shady ABIM Foundation are included), had the nerve to publish its 2018 fee schedule today and it's a doozy.

Without answering the evidence supporting corruption and self-dealing made before the Ohio legislature on 11 October 2017, the ABIM and its leadership continue to market their shakedown of US physicians as providing "Choice. Flexibility. Value." They're even bragging that if you bend to their extortion and pre-pay, you'll be getting a good deal.

Physicians are not idiots.

I would encourage physicians to use the National Board of Physicians and Surgeons ( instead of the ABIM Maintenance of Certification for documentation of their commitment to life-long education. This ridiculous charade has to end.


Wednesday, October 11, 2017

My Remarks Before the Ohio Health Committee On MOC®

Here is the testimony I delivered today at the Ohio Health Committee hearing on Ohio House Bill 273 sponsored by Representative Teresa Gavarone in Columbus, Ohio. (Each committee member was handed this evidence packet to refer to before I spoke):
Dear Honorable Committee Members:

Thank you for the opportunity to speak and to provide evidence to the citizens of Ohio regarding my remarks today. My name is Westby G. Fisher, MD. I am a triple ABMS Board-certified practicing internist, cardiologist, and cardiac electrophysiologist from the Chicago Metro area representing Practicing Physicians of America, a group I co-founded that represents over 40,000 frontline practicing US physicians of all specialties and from all 50 states (including Ohio). We vigorously support Ohio’s House Bill 273 that restricts the hospital and insurance industry’s ability to prevent experienced physicians from practicing their trade on the basis of an unproven, costly and time-consuming proprietary marketing product called “Maintenance of Certification.”

I stand before you, on behalf of my working colleagues, as a bedside treating physician with a valid state license. I am not a paid lobbyist. I do not have a political agenda to serve. I do not have hundreds of millions of dollars of funding behind me. I represent the doctor see when you walk in a hospital or a clinic office, feeling scared, vulnerable, or sick.

The issue pertinent to this legislation is the proprietary product owned by the American Board of Medical Specialties (ABMS), a private non-profit corporation, and marketed by their 24 subsidiary specialty boards, as “Maintenance of Certification.” Maintenance of Certification is sold above and beyond physician’s initial lifetime Board Certification, a voluntary credential physicians obtain by taking a test to demonstrate competence in their specialty. I stress again, Maintenance of Certification is NOT to be confused with initial ABMS Board Certification, a voluntary once-in-a-lifetime credential analogous to the “bar” examination performed by the legal profession. Most physicians I know, including me, understand the value of initial, lifelong certification with ongoing Continuous Medical Education training. We should note that Ohio physicians have a proud tradition of supporting one of the strongest Continuing Medical Education (CME) requirements after their initial Board certification for maintaining their licensure, requiring 100 hours of CME every two years.

Maintenance of Certification was conceived by the American Board of Internal Medicine, the largest member board of the American Board of Medical Specialties that certifies on quarter of all US physicians, they claimed, to assure “continuous professional development.” Initial voluntary attempts to market this extra distinction failed because doctors already took responsibility for their own Continuing Medical Education and did not see additional centralized Maintenance of Certification testing as helpful or appropriate.

Sadly, this initial failure to voluntarily engage America’s doctors resulted in a new chapter of coercion and threats to physicians that continues to this day. In 1990, the American Board of Internal Medicine abruptly announced the end of life-long Board certification, claiming doctors needed to “keep up” with medical advances and threatened “uncertain circumstances” if they did not participate in Maintenance of Certification. To avoid significant backlash of the entire physician community, they grandfathered senior, predominantly male physicians certified before 1990. Younger doctors, closer to training, reluctantly complied.

Despite 30 years of existence, time-limited certification has never been proven to improve patient safety or care outcomes compared to lifetime Board certification. To be even more clear, let me emphasize that doctors are not picking up their Maintenance of Certification board review packet in order to figure out how to deal with a complicated patient down the hall. This is not the way it works on the ground. Instead, younger, more economically vulnerable, and increasingly female physicians were discriminated against with this change that persists today. The change also converted the once “voluntary” aspect of lifetime board certification to a mandate, since more hospitals insisted their physicians be board certified (as did insurance companies), thanks to their lobbying efforts. Through this clever regulatory capture, employed doctors were left with no choice but to sign a MOC contract that relinquishes their free speech rights and requires they become research subjects without informed consent.

Using the very real threat of the loss of employment, repetitive physician re-certification by way of Maintenance of Certification instantly became a remarkably successful business model for these non-profits, providing the American Board of Medical Specialties $343 million in revenue from certifying and recertifying US physicians in 2011 alone. In fact, the costs of board re-certification for the average physician have mushroomed 244% in the last 15 years, over 4 times the rate of inflation each year.

In 2005, the American Board of Medical Specialties registered the Maintenance of Certification® and MOC® trademarks and insisted all of their member boards end lifetime certification and would only recognize time-limited re-certification as valid while also adding the requirements to perform Practice Assessment, Patient Voice and Patient Safety exercises for physician to perform every 7-10 years, too. These represented even more precious hours of physician time as well as fees. The inevitable consequences of this monetary goldmine were predictable, especially when they operated with little to no oversight for years.

It is important to note that the requirement for time-limited Board certification (as opposed to lifetime Board certification) pre-dated the world wide web. But as the web grew, so did practicing physicians’ ability to fact-check the claims made by the ABMS and their member boards. Many of those facts uncovered are in the packet included before you. By 2013, physicians uncovered inconsistencies between tax filings and ABMS member board web page disclosures. They found bylaw changes that permitted unlimited conflicts of interest. They found undisclosed lobbying. They uncovered the secret funneling of over $77 million of their physician testing fees piecemeal from 1990 to 2007 to create the ABIM Foundation that was supposed to define and promote “medical professionalism.” Excessive salaries, multi-million dollar golden parachutes, first-class and spousal air travel, health club memberships, luxury condominium purchases, and off-shoring of our testing fees for retirement funds doctors learned, were all funded by us. Even a felonious ex-cop who had been fired from the Washington DC police force for inciting reprisals against a journalist was hired to serve as “Director of Test Security” for these organizations making them more akin to a protection racket than a protector of the public. It is no wonder, then, that legal fees at the ABIM and its Foundation have grown from an average of $146,000 per year before Maintenance of Certification was introduced to over $1 million per year after Maintenance of Certification was introduced for its defense against physician lawsuits. Ironically, we pay those fees as well. Anti-trust suits and class action law suits are pending against the ABMS and American Osteopathic Association. Rest assured anyone speaking in opposition to House Bill 273 somehow has a financial interest in the program or the data they sell. Keep that in mind in the weeks ahead.

Physician shortages and burnout are real problems today and affect every state in the union. How does Maintenance of Certification affect this? No one has bothered to conduct a study examining the psychological, economic, or employment outcomes of highly experienced physicians who fail a re-certification examination of which there are many. Nor has there been a study on the impact that Maintenance of Certification testing has on a doctor’s loyal patients. Hundreds of tweets and emails I receive each year speak to the reality of the tremendous negative effect on decent, highly-respected colleagues too embarrassed to go public with their failure, many of whom quietly leave medicine. The Maintenance of Certification profit-making machine is creating a physician brain drain and a shameful exodus of too many good people.

This is why 23,000 US physicians signed an online petition to end Maintenance of Certification monopoly. That is why the Pennsylvania Medical Society issued a formal “Vote of No Confidence” against the American Board of Internal Medicine in June of 2016. That is why the AMA House of Delegates (including the Ohio delegation) voted to end Maintenance of Certification at the same meeting. This is why a new, competing board called the National Board of Physicians and Surgeons led by unpaid board members to independently verify a physician’s participation in Continuing Medical Education was created and a growing number of hospitals accept as an alternative to participation in Maintenance of Certification. And that is why the Ohio State Medical Association has voted to support this bill. Physicians across the country are not blind to the corruption, and the burden to practicing physicians and their patients is not trivial. Twenty three states have introduced similar bills to this one, and 8 have enacted those laws.

Despite all of this, I am sure that opposition to House Bill 273 will remain strong. When one considers the numerous subspecialty board review courses that exist, and the gauntlet of tests a physician must endure to become licensed, certification of physicians is a $2 billion dollar-a-year enterprise. Our opposition will tout the duration, breadth, and scope of training required by ABMS member boards as the best validation of physician knowledge, while ignoring a physician’s clinical experience entirely. But as Dr. William Osler famously said, “He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.” The fact that this shameful bureaucratic continuous re-credentialing system has wrapped itself in a blanket of highly respected, well-meaning physician contributors should surprise no one, but it does not change the facts. In other states, opponents to similar bills as Ohio’s House Bill 273 have been strangely silent about the corruption, preferring instead to focus on the public’s “need to know” talking points as a way to spin away from the ugly truth. Why is that? Do they believe corruption is inevitable? Do they assume practicing physicians will just shrug and write another check?

Winston Churchill once said, “Criticism might not be agreeable, but it is necessary. It fulfills the same function as pain in the human body. It calls attention to an unhealthy state of things.” Maintenance of Certification is very unhealthy for our profession. The time we take away to defend our profession in this very sad chapter of our profession is time we take away from our patients, including your constituents. That is why we need your help and your attention to this uncomfortable matter.

In closing, of course initial board certification is important but this has nothing to do with repetitive re-Board certification known as MOC. Of course physicians want to self regulate and want to participate in CME, but they should not have to prop up coercive program based on threats to our integrity and civil liberties for their profit. Scare tactics about patient safety and physician self-regulation are just that; last ditch efforts of intimidation to prop up the gravy train.

Thank you for having the courage to vote against the status quo, against the multimillion dollar lobbyists, and thank you for protecting Ohio physicians and their patient’s access to them by voting in favor of House Bill 273.

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.