Tuesday, April 29, 2014

ABIM Thumbs Its Nose at Senior US Physicians

Yesterday, the President and CEO of the American Board of Internal Medicine (ABIM), in a moment that must have been heartbreaking for him, found himself in the position of having to chasten more than 10,000 unruly senior US physicians, thanks to a petition drive.  In his statement, the aggrieved Dr. Baron, in a plea for common sense, bemoans the fact that physicians do not care enough about patient care or safety to spend $200-400 dollars per year for the ABIM.  This is what the benighted ABIM is up against!  Senior physicians are nothing more than penurious whiners who fail to be appreciative of the Mothership.

For those cynics out there might cast a jaundiced eye on the image of the ABIM as the Mothership,  let's not forget the sterling flotilla that the Mothership floats with.  Recall that the ABIM rides in the wake of the American Board of Medical Specialities (ABMS).  Recall that both the ABIM and ABMS arose from the shipyard of the Amedican Medical Association (AMA)  that produces the trademarked CPT procedure codes that Electronic Medical Record industry celebrates.  Recall that Dr. Baron hails  from the Center for Medicare and Medicaid Services.  Recall that the former president of the ABIM, Christine Cassells, had an exemplary friendship with Premier, Inc, a North Carolina company that provides group purchasing and performance improvement consulting for an alliance of 2,900 hospitals and Kaiser Foundation Health Plans and Hospitals. With these kind of credentials, physicians should trustingly take their hands off the policy rudder and know that their profession is secure.

How could doctors doubt the purity of the Mothership?  Given their tireless efforts on the behalf of physicians and our patients, we should, in fact, be holding a fund-raising drive for the ABIM!  How can we be unsympathetic to the responsibility and burden of reimbursing the ABIM's necessary expenses, such as Doctor Baron's $800,000 annual salary or the bottom line of their testing agency?  Don't doctors know that they are singlehandedly preserving the integrity of our specialties and subspecialties that the rest of us would squander willy nilly?

I'd like to reassure President Baron.  It appears we've reached a tipping point.  Physicians are starting to understand the need for active advocacy in protecting our patients and our medical profession.   Disturbingly for the current regime who have commandeered the dignity of practicing physicians for their own benefit, there are appear to be heavy seas ahead.


Monday, April 21, 2014

Paid NEJM Subscriptions: There's No Such Thing As A Free Lunch

My hospital system, like many hospital and academic medical centers in America, provides an open-access journal subscription to the New England Journal of Medicine (NEJM) for it's doctors on their private intranet. While I do not know the price of this subscription (I'm sure it's substantial), in the past I have thought it was a nice gesture by our hospital staff to keep doctors current with the latest medical information from the medical journal with the highest impact factor.

Now, I'm not so sure.

New conflict of interests between the NEJM and my hospital have arisen that make me question the wisdom of this policy of free subscriptions provided to doctors, not only our institution, but all other medical centers that offer such an free subscriptions to their medical staff.  As they say, there's no such thing as a free lunch.

Especially when the lunch being served supports tying Maintenance of Certification to maintaining doctors'  hospital privileges.

On 7 April 2014, the New England Journal of Medicine launched their NEJM Knowledge+ website, a product of the NEJM Group, a division of the Massachusetts Medical Society, that breathlessly markets their own costly version of preparing for the ABIM's MOC process to their readership.  A tiny sliver of their exhaustive marketing even promotes the use of their product during the few remaining non-medical hours of a physician's day:
"Whenever you’ve got a moment to lean back and reflect, Internal Medicine Board Review is there with you — whether it’s in line at the supermarket, in the parking lot while waiting for your child’s soccer practice to let out, or during an unplanned minute between patients."

Never is there a mention what NOT passing the ABIM MOC testing means to doctors and their families.   Never is mentioned that since the advent of MOC re-certification, the financial reserves of the ABIM and ABIM Foundation have increased substantially; in 2006 and 2007, the ABIM transferred $13 million to its "foundation."  Never is there a mention that reserves of this magnitude demand accountability to physicians upon which their system has been foisted without any unbiased scientific evidence of its merits.  Never is there a mention of the cozy financial relationship that exists between Area9 Labs (the manufacturer of the NEJM Group's new Knowledge+ website), McGraw-Hill publishing, and the NEJM. Never is mentioned how Area9 distributes and markets the web-based physician learning data it collects on the Knowledge+ website.

Most of all, there is never a mention of the ABIM's unrelenting efforts to link their MOC process to doctors' hospital privileges and their ability to practice their trade - hence where my concern with the conflict of interest exists when hospitals and medical centers purchase the NEJM free of charge for their physicians. Hospitals don't need to buy into this manipulation of their staff.  Almost every medical group has mechanisms to acquire continuing medical education for their staff that are open and not restricted to the ABIM's costs and onorous re-certification process.  By purchasing paid subscriptions to the NEJM, are our hospitals supporting the ABIM's proprietary, self-mandated and scientifically unproven educational process that ties passing a test to the maintenance of hospital privileges?

It is very troubling that the NEJM Group has decided to ally with the ABIM in its MOC efforts.  The ABIM leadership continues to exist under a non-transparent and unethical conflict of interest policy.   The ramifications of the conflicts that existed with former and current members of the ABIM leadership are only now coming to light. This leaves the ABIM's professional credibility seriously in question with physicians.  Is the money that the NEJM Group receives from doctors of all levels of training on their Knowledge+ website worth the damage to their credibility as they ally with the ABIM?

It seems so.  After all, the NEJM seems more concerned about its educational subscription fees than the ethics and scientific integrity of the training process they're promoting.

Because of the clear and present danger that the promotion of the ABIM's MOC process presents to physicians' reputations and their ability to practice sound medicine, I recommend immediate termination of free paid subscriptions to the NEJM for physicians at our institution and others like it until the NEJM Group abandons its support of the ABIM's highly-flawed and manipulative MOC process.

After all, the conflict of interest problems inherent to this cozy institutional arrangement between the ABIM, NEJM Group, and the nation's hospitals far exceed anything that existed when pharmaceutical representatives supplied doctors with free pens.


Sunday, April 20, 2014

Smile Because She Happened

“Don’t cry because it’s over, smile because it happened.”

- Ted Geisel (Dr. Seuss)

It seems just yesterday she came to us, quiet, silky, trusting, needing just a finger to rest her head upon.  Unwavering trust.  Unconditional love.  There in the morning yearning to go with us.  There in the evening, excited to greet us at the end of our day.  She was there before the iPhone and stayed true to us after.  She was the only dog my kids have ever known.

Dogs are a wonderful addition to a young family.  Ours taught us the meaning of devotion.  She taught our young kids the meaning of love.  She knew what we were thinking before we said a word.  When sad, she'd offer her head upon our lap; when happy, she'd show her unbounded joy by quivering her adorable stunted tail at a rate that none of us could fathom.  She would defend us against cement lawn ornaments that startled her, and threaten cats and squirrels fearlessly, as if we shouldn't put up with their misbehavior.

Her black tender nose saved the day more than once.  Perhaps her greatest moment was the day the family hedgehog was lost in the back yard during a brief moment of inattention.  The anxiety and family search party, despite their best efforts could not find the little creature.  But there, wagging happily, was a little dog pointing at a spot in the ground cover.  Beneath her, a hedgehog.  And with that, tears of joy and another family crisis averted.

Her love of tennis balls, like life itself, evolved over the years.  At first she'd chase them darting across the lawn in a burst of enthusiasm.  Who knew such a simple toy could engender such joy?  Then, as the years went by and her cataracts took her sight from her, she'd find their scent buried deep amongst thick bushes or hostas, wagging victoriously as she spirited them back home like treasures to store in our living room.  Once there, she'd lie on the floor with the ball between her legs, then shove the ball forward with her nose as if to say, 'Come play!"  We roll it back between her legs, and she'd shove the ball back to us over and over again in a game of blind dog catch.

Slowly, gradually, her hearing left her too, but her trusty nose would allow her to find her way, tail wagging all along.  We'd come home, the head would raise, the tail would wag, and our presence would be acknowledged as she had so many times before - quietly, graciously, and with a tender heart.

Now we are gathered for Easter, seeing her breathing quicken, even at rest.  We have to lift her to her favorite spot on our couch on occasion.  She's not as hungry at mealtimes now.  We know our time with her is short, but our lessons from her will last a lifetime.

And we can be happy.  Really happy.

That she happened to our grateful family.

Happy Easter.


Friday, April 04, 2014

The Business of Testing Physicians

If you want to understand the world of professional board certification, it is important to understand the business and politics of testing professionals. Such testing is big business. So big in fact, that huge international media and education companies that trade on the New York Stock Exchange have been created to service this need. According to one article on Reuters from 2012, "the entire education sector, including college and mid-career training, represents nearly 9 percent of U.S. gross domestic product, more than the energy or technology sectors."

Part of the expense of "maintaining" one's professional board certification goes for fees for the testing center where the computerized testing occurs.  Because cardiac electrophysiologists must hold two board certificates (Cardiac EP and Cardiology), we must pay for two rounds of test-taking fees: the first is included with our cardiology maintenance of certification (MOC), then we must pay a second $750 testing fee for the second EP test.  (Each test contained 180 questions - $4.17 per question).  I am assuming almost all of this goes to the company that administered my test: Pearson VUE.

ABIM holds a contract with Pearson VUE, a professional testing subsidiary of Pearson Education, the North American subsidiary of Pearson, PLC (NYSE: PSO) - an 9 billion dollar British corporation that claims it is the largest commercial testing company and education publisher in the world. It boasts Penguin Random House publishing and the Financial Times Group as some of its other far-reaching subsidiaries. Mr. John Fallon is the 52 year-old Chief Executive Officer of Pearson, PLC and earns a cool $2.55 million dollars annually while holding 282,147 shares of Pearson stock and plently of stock options.  He is joined by Mr. William T. Ethridge, age 62, who serves as "advisor" currently, but was previously responsible for the North American Educational Division of Pearson.  According to one source, William Ethridge was once chief executive of Pearson's North American Education division in 2008. According to Forbes, his total compensation in 2011 was $1,390,000 and he held a half million shares of Pearson stock at that time.

Pearson VUE states it "is built on a foundation of experience in electronic testing."  My experience with Pearson VUE was parodied in an earlier blog post. As I reflect, it seemed that Peason VUE was more concerned about storing my biometric palm scans and a digital photograph as much as they wanted to assure a fair testing environment. While the ABIM discloses this process on their website, doctors unaccustomed to such paranoid security measures are caught off-guard by these tactics and should be concerned about how this information is stored and used. Are previously-certified doctors really this sketchy?

Pearson VUE earns a pretty penny from its professional testing and its physician testing in particular. According to Pearson's most recent SEC filing:
"Professional testing continued to see good revenue and profit with growth test volumes at Pearson VUE up 25% on 2012 to almost 12 million [pounds] ($19.9 million). Key contract renewals included tests for the American Board of Internal Medicine, the Association of Social Work Boards and the Pharmacy Technician Certification Board. "
But profitting from physician education is a politically hot topic, too. Not surprisingly, Pearson Education seems quite active in this space spending $2,100,000 to lobby Washington during the last presidential election cycle in 2011 and 2012, contributing 7:1 to the Democratic side of the political aisle. Also, 6 of the eight current Pearson lobbyists have previously held government jobs.

Doctors should understand how and where their money and personal information are being used in the ABIM's MOC testing process, since much of those funds seem to support the corporations and political aspirations of those who are doing the testing rather than the needs of patients that the ABIM is pretending to protect.


Thursday, April 03, 2014

Mandrola: A Time-Out for ABIM MOC Mandate

From theheart.org (registration required), John Mandrola, MD calls for a "time-out" for the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) mandate:
The matter for debate is whether the ABIM method - and to be frank, it's arm-twisting tactics - is the best means to achieve physician quality.

Doctors are taught to be skeptical of evidence. Here, there is simply no evidence to judge. We can't know whether this brand of medical education achieves improved patient outcomes. Maybe it will. Maybe it will not. Or, perhaps it could make it even worse. How could aggressive education and measuring quality make things worse? Think heart-failure metrics and an 89 year old, who, a week later presents with a broken hip from all those evidence-based pills. I have many more examples, but I promised brevity.
Read the whole thing.

Some additional thoughts and suggestions to the ABIM:
  • Given the unproven nature of the MOC process to assure physician quality and the ethical breeches created by the ABIM's proprietary process, "board certification" as defined by the ABIM should revert to a lifelong certification to put the ABMS and its subsidiaries in competition with all the CME sources available.
  • The new ABIM MOC rules that are now set to go into effect 1 May 2014 can cause "sudden and unanticipated" revoking of Board Certification based on failure to completely comply with MOC at ANY TIME. This should not be permitted.
  • Since state medical boards are all headed by physicians, the marketing my the American Board of Medical Specialties and the ABIM that physician perform their MOC process to prevent government agencies from providing an alternative to their MOC process is pure propaganda. There are many many government and private agencies that monitor physician performance including hospitals, insurance companies, CMS, Medicare, Medicaid, trial lawyers, the Better Business Bureau to name a few.
  • The ABIM's "board certification" is based on test-taking ability and not patient care metrics. As such it cannot be considered a patient care quality measure of any kind and should not be tied to CMS Physician Quality Reporting System (PQRS) payments to those who care for Medicare patients.
I believe it would be in the best interest of the ABMS and ABIM to listen the the growing chorus of dissatisfaction that is currently echoing throughout the country. I know many physicians are already boycotting the process. Until the ABIM and ABMS change their policies this boycott will continue, especially since doctors know that the incomes of these societies are being directly paid by their physician fees.

Just sayin'-


Here's a link to an anti-MOC petition underway.