Sunday, April 17, 2016

Rethinking Our Medical Education and Publishing Bureaucracy

Medicine has an image problem.

On one hand, medicine is full of wonder: incredible technology, incredible innovation, and incredibly bright people.

On the other, medicine is full of avarice, full of greed, and full of waste, much of it by the very same folks who bring us all that medicine has to offer: the Accreditation Council for Graduate Medical Education (ACGME).

The ACGME is an incredibly rich and powerful organization in medicine. It is comprised of the American Medical Association, (AMA), the American Board of Medical Specialties (ABMS) and its 24 member boards (including my "favorite", the American Board of Internal Medicine (ABIM)),  the American Hospital Association (AHA), the Association of American Medical Colleges (AAMC), the Council of Medical Specialty Societies (CMSS), the American Osteopathic Association (AOA), and the American Association of Colleges of Osteopathic Medicine (AACOM). Collectively, member organizations of the ACGME represent an annual burn rate of almost $1 billion dollars for medicine (Latest annual income figures from Guidestar.org: AMA ($261,328,052), AHA ($126,339,392), ABMS and its 24 member boards (Approximately $300,000,000; $54,454,584 for the ABIM alone), CMSS ($967,541), AOA ($44,376,054), AACOM ($10,855,122)).

As part of the ACGME's "Vision" statement, they "imagine a world" where residents and fellows are "prepared to become Virtuous Physicians who will place the needs and well-being of patients first."

This is where the ACGME's "vision" clashes with reality.

Right now, the average "Virtuous Physician" has a median debt load of $180,000 before they graduate from medical school and patients are experiencing bankruptcies from health care as our Medical Education Establishment dines at the Four Seasons and takes a few more reps in the gym.

The ACGME and their kin are still living in the world where first class air travel, memberships at health clubs, and $2.3 million condominiums with chauffeur-driven Mercedes S-class town cars are the norm. The ACGME seems blind to the irony of serving Virtuous Physicians while having one of its core values the "Engagement of Stakeholders" like their "friends in accreditation" at the Accreditation Council for Continuing Medicine Education, the Joint Commission on Accreditation of Hospital Organizations, the National Board of Medical Examiners, and the Federation of State Medical Boards, who foist educational programs like their unproven and wasteful Maintenance of Certification (MOC) program to fund their largess.

So it should come as no surprise that even our most "prestigious" academic journals like the New England Journal of Medicine (NEJM) are joining in on the fun. This week they permitted a promotional "perspective" piece entitled "What Do I Need to Learn Today - the Evolution of CME" to be published by the head of the Accreditation Council for Continuing Medical Education (ACCME), Graham T. McMahon, MD. Like other accreditation organizations within the ACGME, Dr. McMahon enjoys paid first class airfare and health club membership while promoting the legitimacy and expense of the costly and unproven ABMS MOC program that finds itself in a whirl of ethical controversy already. Meanwhile, the NEJM is selling its expanded and remarkably expensive  "Knowledge +" MOC educational product without ever acknowledging this conflict to its readers in this week's issue.

Our tired and inefficient "non-profit" bureaucratic medical education system better wake up soon to the new reality in medicine: practicing physicians and their patients are feeling the adverse effects of all those health clubs and first-class airfares.

In this time of serious cuts to patient care budgets in medicine, it's time our Medical Education and Publishing Establishment starts "learning what it needs to do today" besides stumping for wasteful "CME" programs and harvesting its budget from those who are finding it harder and harder to believe that our expensive medical education bureaucracy has their best interests in mind.

-Wes

10 comments:

20/20 Views said...

This burns me up!

NEJM + ABMS/ACGME = a sickening collaboration where medical science meets greed, politics and corruption.

I am disgusted by the New England Journal of Medicine's decline in scientific reputation and apparent lack of ethics. Just look at the money arrangement between the NEJM and the ACGME/ABMS oligarchy.

Who and what else is screwing us against our will from under the ABMS/ACGME bed sheets!

They can screw whomever they want, but just pass a law to leave me out of it like the recent legislation passed unanimously by both houses in Oklahoma. Oklahoma with its "anti-MOC conflicts of interest law" will find no shortage of physicians. I'm sure of that after their now famous "freedom from MOC bill."

Every state should sign a bill banning all these tangled conflicts of interest.

Every state should follow suit and do the right thing or medicine will soon be totally owned by the corrupt elite. The ABMS/ACGME is party such corruption and greed. It is unfathomable that we allow it. It a breach of ethics and professionalism.

If anyone is concerned with morality, it is morally wrong to pay into the "pay to play" MOC scheme. It was devised by the ABMS and the revolving door cartels to take our money, live high on the hog and give zilch in return for it--except bad science, propaganda, and a whole lot of pain and suffering.

Consider this fraud perpetrated by the ABMS/ACGME. Everyone knows MOC is mandatory and the elite medical oligarchy lies about it. MOC is tied to everything--employment, credentialing, hospital privileges. It is anything but voluntary.

I suggest we sue the ABMS and all the rest of this corrupt crony education/ publishing cartel until they pay with OUR hard-earned MOC fees. I want these elites to lobby for similar OKLAHOMA FREEDOM FROM MOC legislation to be introduced and passed in every state.

Anything short of that in all 50 states and territories is fraud on the part of the ABMS/ACGME.

Let some of the less corrupted or decent NEJM of medicine staff/editorial team lead the charge to pass legislation in all states to end MOC/slavery or I believe they will soon find that their subscription base will decline along with their reputation and ethics.

From the New England Journal of Medicine's Knowledge + NEJM.org

"Although maintaining certification is not mandatory, ABIM encourages physicians to participate to demonstrate to colleagues and the public their commitment to lifelong learning."
http://knowledgeplus.nejm.org/certification-moc/abim-moc-requirements/

Anonymous said...

Well said, Wes! I whole heartedly agree. We need to end this corruption. What is medicine about? What is life if not for living decently and serving others as best as we can. Have we all lost our minds that we accept such a corrupt bureaucracy to rule over us--ruining everything we worked so hard for. Look at how we and our patients are made to suffer while "THEY" fly ultra-first class, lobby and dine with 'stakeholders' to our detriment. And they don't even report it on their taxes.
So much corruption. It really is like a fish in water.

Anonymous said...

Look at the state of affairs in medicine. Physicians and patients are struggling to maintain quality of care in a period of tight control and useless/abusive oversight. Endless committees/boards and their affiliates wielding a lexicon of restrictions and reductions. All suffer from this imposition of corrupt power.

Medicare patients struggle, for example. They often can't afford medications or physician visits. Physicians have become "click clerks" tied to the electronic health record, their data all exposed, completely hackable. Each click creates reductions in pay and at the same time greater risk and liability.

The false sky created by lazy, greedy idiots is dangling from the clouds ready to fall on our heads at any moment.

And get this. ABIM cronies run the NQF and AHRQ. A Wall Street banker runs Medicare--lies through his teeth about making CMS better, "more meaningful" with new innovative technologies and so on. Whose technology? The special interests are everywhere with ties to the ABMS and their corporate sponsors.

Medicine, unless the course of corruption is reversed is headed for ruin and will be under complete control by people who have no clue about how to create a thriving viable healthcare delivery system. They only know how to rip off the elderly and pensioners to increase their share price or board salaries.

Look at "Archangel" Robert Wachter with his silver tongue. He sorely falls into this category of dethroned servants of humanity--now totally corrupt and a liar in the fullest extent of the meaning. What a let down for all of us. He'd rather read Milton's Paradise Lost than lift a finger helping a patient and accepting the real liability for it. Only from a distance from patients does he make his money. Wacther and the rest of the board and filthy rich management under Adam Singer of IPC (now Team Health) the Hospitalist Company swept under the rug their obvious guilt. The SEC rushed through their sale of the company to Team. I am speaking about cutting corners and Medicare fraud the passed on--visible clearly in the SEC filings. What harm has been done to patients at IPC! and Wachter was instrumental in trying to bury it in a propaganda campaign that cost millions. It was a say-nothing fix-nothing sell the company fast cover-up scandal. The SEC had complaints and lawsuits but still pushed the sale through in a few weeks. Why? Who applied the grease and at what cost?

Imo, Wachter has done more to shame the democratic party than anyone I can think of in recent history other than Chris Cassel and Rich Baron. Democrats have now become servants of the ultra-rich. Bob has handed us over to a one-party system of corruption. Sorry for harping about this newest Lucifer to rule in hell.
http://www.ahrq.gov/news/blog/ahrqviews/index.html

Why am I harping about this corruption and the money grubbing practices of our bureaucratic political leadership? They are not leaders at all, but self-serving clever swine. I want to know when the revolt is going to reach the saturation point where something is done to correct this.

The ABMS, ACGME and their associates enhance their profligate lifestyles and expand their bureaucratic waistlines by continuing to eat our lunch.

Lisa said...

It's been corrupt for years and only when the purse is hurting are doctors speaking up. I am sad for this group. I also noticed that #DoNoHarm is used to invoke privilege when doctors are saying it. It seems like there are more nurses who say it and mean it for real, so I have grown in my respect for nurses, not that I disrespected them before.

I value good doctors and have always tried to participate in moving on behalf of what is right and good for doctors, because of course, this trickles down to patients and impacts the whole nation. I'm still patriotic, one of my unrequited loves.

But one thing I've noticed is that if I tweet something that impacts doctors power & money, then the doctors who follow me on twitter are retweeting that. But when I tweet things that are an issue of public health that would save someone's life, awareness raising about something that the social media user who is looking for healthcare, because let's face it, only the welfare tourists can get in to see doctors while they that pay cannot afford, the doctors who follow nearly never will retweet something that might save a life. It's not why people do medicine: it's for the money and the status, to get into the country club even if you're from a trash family.

American doctors like doing doctors without borders/ MSF because "it's about saving lives where people don't have healthcare access" but you will certainly let neighbors die in the street. Pay up or drop dead if you live here. Medicine is only this idealistic helping others and saving lives if we can be really xenocentric. Screw Americans. This should be about separating those compartments of our lives where we help other nations, but plunder our own citizens: This is the American KoolAid. Who knew Jim Jones was a kinder gentler and less kooky kook?

There are still a few good doctors. I still value those good doctors, will encourage them, and maybe even go to one. You have as a group gone bat crazy though.

x said...

dr wes, i have watched ur blog since past 2 years and respect u for ur selfless work.

the growth of these greedy organisations is not just a coincidence. it is a planned ploy of health care bureaucracy to make the physicians feel helpless. only a helpless physician can be bullied to blindly put more patients into hospice care or practice the choose wisely guidelines without thinking humanely.

ethical and confident physicians are the last hope for this country. luckily there is still fxnal judiciary in this country (although i dont think the current system is designed to keep it independent anymore).

all we need to do is find those few independent minds in judiciary and just laws approved.

i pray that this country survive and we can avoid failure of another democracy.

Anonymous said...

Dear Comrades:

Dr. Wes has just described the American version of the Communist Party Elite Medical Politburo!

They claim our intellectual property. They claim our patient data bases. They will soon want your clinic office and buildings as well. No private property in the Philly style USSR. No Freedom of Speech. No Fourth Amendment. They claim our lives.

Not fascism. It is Crony Communism!

God save the Great State of Oklahoma!
Go Sooners!
How do I get an Oklahoma License?

Jackson said...

Piratical!

A house with no name said...

Incomprehensible how Wachter, Cassel, Baron, Holmboe, Nora, et al are not sanctioned by their 'board'. Not one revocation. Not even a letter of reprimand for their SINS against humanity, physicians, the ABMS, and the healthcare delivery system.
Not even a press release from the democratic party denouncing them for their subterfuge and heinous actions. Look at the cumulative effect to the ethical image.
Medicare fraud, egregious conflicts of interest, propaganda, demonization, misuse of power, and possibly bribery/barter/undisclosed exchange of some kind to win global contracts and influence. The 'Singapore connection' would reveal a great deal to extend the ABMS corruption in arenas outside the US.

The lack of action by the ABIM to investigate Wachter and IPC, Cassel and Kaiser, Baron and his brilliant conflicts of interest, Holmboe and the Singapore deal and how that was achieved is unfathomable. This shows how connected the whole mishmash really is. It tells us a lot. More than words ever could.

What a fiction the quality assurance industry is! And the phoneys in charge.

Publication X said...

Choosing Wisely. When something sounds too good to be true, it probably is. Is Choosing Wisely teaching a medical student or resident to be a true scientific investigator or a true believer. To any normal thinking person that is not in a state of psychological "fear or awe" the campaign to cut costs the mechanical way produces the opposite effect in our medical community, especially the medical students and physician trainees.

By the time we really see what harms are being done through the practice of shallow medicine and superficial fixes for cost overruns in healthcare many patients will have suffered from this unproven experiment. Publishers and societies are embracing this campaign. Why? Really go into it and find out for your self the truth or the age of the "thinking physician" may be over. We will be entering the age of the "automaton healthcare provider."

Choosing Wisely has already travelled half way around the world before truth has had a chance to get its running shoes on. Let's try to catch up with it and examine it scientifically and not in terms of mindless acceptance. I would also like to know from a practical point of view who is profiting from it and who is being shortchanged?

Choosing X over Y. Why? said...

Diagnostic Tests, Uptodate and Choosing Wisely at Hopkins
“We use our medical training to say it could be X, Y or Z. We then use UpToDate to walk us through these different scenarios, what tests to consider ordering or not ordering, and suggested courses of treatment.”
In this way, UpToDate also helps reinforce Choosing Wisely, a nationwide initiative embraced by Johns Hopkins Medicine that seeks to educate physicians and patients about more than 250 tests and procedures that are often unnecessary or inappropriate.
http://www.hopkinsmedicine.org/news/articles/news-you-can-use-uptodate-web-based-resource-for-clinical-decisions

Choosing Wisely Australia
http://www.choosingwisely.org.au/home

Choosing Wisely and NPR
http://www.choosingwisely.org/resources/updates-from-the-field/how-a-morning-commute-led-to-choosing-wisely/

Harvard Vanguard and Choosing Wisely on Colonoscopies
http://www.choosingwisely.org/resources/updates-from-the-field/harvard-vanguard-reaches-consensus-on-colonoscopies/

ABFP, Knowledge+ NEJM and Choosing Wisely
http://knowledgeplus.nejm.org/choosing-wisely-in-the-daily-practice-of-family-medicine/

Uptodate: Choosing wisely in headache medicine: the American Headache Society's
http://www.uptodate.com/contents/acute-treatment-of-migraine-in-adults/abstract/18

Uptodate: Choosing wisely and pediatrics
http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/70

Uptodate: Choosing Wisely in Newborn Medicine: Five Opportunities to Increase Value.
http://www.uptodate.com/contents/long-term-neurodevelopmental-outcome-of-preterm-infants-management/abstract/9

I-Tunes and Choosing Wisely Canada
https://itunes.apple.com/us/app/choosing-wisely-canada/id933897108?mt=8

AAPMR and Choosing Wisely
http://www.aapmr.org/quality-practice/evidence-based-medicine/choosing-wisely

ICSI and Choosing Wisely
https://www.icsi.org/_asset/p7rm82/ICSI-CW-Final-Results.pdf

Texas Medical Association Withdraws Choosing Wisely "Culprit Valve" Recommendation
https://www.texmed.org/Template.aspx?id=32571
ACC withdraws CW recommendation
http://www.choosingwisely.org/societies/american-college-of-cardiology/

Choosing Wisely and the American Society for Radiation
http://www.practicalradonc.org/article/S1879-8500(14)00164-7/abstract

Choosing Wisely and AACE/Endo
https://www.endocrine.org/membership/email-newsletters/endocrine-insider/2013/october-17-2013/endocrine-society-and-aace-recommend-best-practices-in-choosing-wisely-campaign
https://www.texmed.org/Template.aspx?id=32571

"The Choosing Wisely campaign makes no provision to scientifically research its own efficacy, but academic centers are making plans to independently report on the impact of the campaign. The campaign has been cited as being part of a broader movement including many comparable campaigns. The German Network for Evidence Based Medicine considered adapting concepts from the program into the German healthcare system. In April 2014, Choosing Wisely Canada launched. Choosing Wisely Canada is organized by the Canadian Medical Association and the University of Toronto, and is chaired by Dr. Wendy Levinson. The services targeted by the Choosing Wisely lists have broad variance in how much impact they can have on patients' care and costs.
By 2015 and following the Choosing Wisely precedent established in the United States, health leaders from Australia, Canada, Denmark, England, Germany, Italy, Japan, the Netherlands, New Zealand, Switzerland, and Wales committed to bring ideas from the Choosing Wisely and sometimes even the actual campaign itself into their own countries."
https://en.wikipedia.org/wiki/Choosing_Wisely

AACE withdraws for Choosing Wisely Program
https://www.aace.com/files/Choosing-Wisely-Campaign.pdf