Two Surveys: US Physician and Surgeon Perspectives on ABMS Board Certification

At the beginning of this year, Practicing Physicians of America (PPA), a 501c6 physician membership organization (with whom I serve as an unpaid board member),  collected results of a voluntary survey via social media channels on ABMS physician and surgeon Board certification. The method of data collection using social media. The data collection is  novel compared to previous surveys conducted on this topic and for a while represented the largest reported survey on Board certification ever performed. We submitted the results to JAMA (and later to the Annals of Internal Medicine) in hopes they would be published. They were not. As is true with most surveys, bias was a prevailing concern.

Shortly after our survey was being circulated, the American Board of Medical Specialties introduced their own survey on Board certification to pre-chosen "stakeholders" on Board certification. In July 2018 they announced the results of their survey. They had received responses from "36,392 people, including 34,616 physicians, 1,373 non-physician providers and stakeholders involved in the delivery of health care, and 403 members of the general public." To the best of my knowledge, the text of their survey was not made available to the public.

Since we were waiting the reviews of PPA's survey for months, we were prohibited from publishing our results. After considering the reviewers' comments (which were very thoughtful), I think the odds of ever publishing such a survey of this type in a peer-reviewed scientific journal are low. Hence, the board of PPA has allowed me to announce the results of our survey publicly via this blog and (hopefully) Doximity so these results may be interpreted alongside the survey results reported by the American Board of Medical Specialties' Vision Commission. Admittedly, our survey asked different questions than that conducted by the ABMS, but the results are not only notable for their differences, but also for some similarities.

By way of background, here are the 32 questions we asked in the PPA survey.

Here is the full paper (with some minor edits) we submitted for peer review that was NOT accepted for publication. This pdf includes the background for the survey, the methods used, the results obtained, and a discussion of those results, as well as references, figures and tables.

Similarities of PPA survey to the ABMS Survey on Board Certification:

• Both ABMS and PPA surveys used SurveyMonkey to collect responses


• A large number of physicians responded to both surveys. Still, the PPA survey represented only 0.92% and the ABMS survey represented only 4.5% of the total US physician population in 2016. Neither survey mitigates potential under-coverage bias and non-response bias.
• In the PPA survey, 93% of physician respondents were board certified vs 96% in the ABMS survey.
• In PPA survey, 80% (4973/6004) participated in MOC; in the ABMS survey, 69 percent of respondents were currently enrolled in a primary specialty MOC program, and 33 percent are currently enrolled in a subspecialty MOC program
• Costs, burden, and the lack of true reflection of their abilities as clinicians were of significant concern to physicians in both surveys

Differences of PPA survey from the ABMS Survey on Board Certification:

• PPA survey used logic to limit responses from clinically-active physicians only
• PPA survey attempted to geolocate physicians by IP address and excluded non-US physicians
• PPA survey included MDs and DOs; it is unclear how many ABMS physicians were MDs or DOs.
• PPA survey was simply distributed to physicians via social media, not targeted groups like the ABMS survey. Heavy contributors to the PPA survey included members of the Pennsylvania Medical Society and Doximity.
• Discontinuation of "continuous certification" was not offered as an option in ABMS survey. Ending MOC and reverting to lifetime certification with CME was offered as an alternative in the PPA survey.
• PPA survey assessed physician perceptions of the negative consequences, contract obligations, and potential conflicts of interest of MOC; ABMS survey did not address these issues.
• PPA survey specified physician-respondents' specialties and state of origin. ABMS survey did not.

Finally, here is a pdf of the Powerpoint presentation I presented in June 2018 at the AMA House of Delegates meeting in Chicago summarizing findings from the PPA survey.

Major Findings of the PPA Survey

7007 physicians responded (52% male, 48% female)

Demographics

• Every US state was represented, with the largest being PA (910), CA (506), TX (504), FL (406) being the largest physician participants
• Responses came from 24 different subspecialites, with the largest being family medicine and pediatrics
• 19% of physicians had at least one "grandfathered" certification.
• 65% of the respondents had 10 or more years of clinical experience
• Of the physicians with initial ABMS board certification, 80% participated in MOC.

Major Findings

• 90% of all respondents thought board certification should be a lifetime credential with CME used for ongoing education.
• 95% felt MOC increases burnout.
• 53% of respondents estimated costs (direct and indirect) were more than $4000.
• 94% were unaware their data were being sold.
• 80% felt IRB and informed consent should be required for research conducted by the boards.
• 86% perceived MOC could threaten their right to work.
• 8.4% failed a recertification examination.
• Of the 394 physician that failed recertification, harms experienced included psychologic harms (more than 56%), 10% lost of hospital privileges , 5% lost their job, 8% lost insurance panel participation, and 17% plan to retire rather than retaking the re-certification examination.

I hope these data are informative and provide a balanced perspective of a large cohort of US physicians' and surgeons' perspectives on ABMS Board initial and "continuous" certification.

Physicians and others are welcome to use these data under a Creative Commons license (see below), we just ask for appropriate attribution.

-Wes

P.S.: Physicians desiring state-specific data regarding the PPA survey results are welcome to contact me via Twitter or email.


Survey of US Physicians and Surgeons Perspectives on US Board Certification by Practicing Physicians of America is licensed under a Creative Commons Attribution 4.0 International License.
Based on a work at http://www.practicingphysician.org.

How Practicing Physicians Can Double Their Money

From now until we reach our contribution goal, an anonymous donor(s) has/have graciously stepped up to match, dollar-for-dollar, physicians' contributions to Practicing Physicians of America's GoFundMe page to fund the litigation factual and legal investigation and the drafting of proposed complaint against the American Board of Internal Medicine, the ABIM Foundation, their directors, executives, and perhaps others under federal antitrust laws and state consumer fraud and deceptive trade practices acts to bring an end to MOC™ nationwide.

After four years of bring this issue to my readers on this blog, the AMA, and state legislatures, too many questions and conflicts of interest remain about the financial and political shenanigans of these organizations. While the ABIM claims they have "listened," they still have failed to stop the ability of the proprietary ABMS MOC™program from potentially affecting a physicians ability to retain hospital credentials and insurance payments if they don't pay for the program; in other words, their right to work.

Hundred of physicians have been adversely affected by this program already. For every physician who drops out of medicine because of refusal to play along, approximately 2000 patients are affected in turn.

So please give generously. After all it's a "two-for-one" special going forward!

Thanks everyone (and thanks to our special donor(s))!

-Wes

P.S.: Again, here's that link to donate: https://www.gofundme.com/practicing-physicians-of-america

MOC's Greatest Lesson

Yesterday, I read with interest the American College of Obstetricians and Gynecologists widely circulated piece authored by Lucia DiVenere, MA entitled, "MOC: ACOG's role in developing a solution to the heated controversy" published in the August issue of OBG Management. By carefully listing the numerous physician concerns with MOC (costs, relevance to practice, lack of data to improve care, relationship to licensing, employment, privileging, and reimbursement), the article reinforced many of the issues on this blog while being simultaneously crafted to sound as if ACOG was really "listening" to physicians concerns about ABMS Maintenance of Certification (MOC).

It didn't take long for me to realize the article was really about the tired trope that the "ACOG asserts the importance of maintaining self-regulation." The leadership within the ACOG and Ms. DiVenere herself can hardly be described as "self" as far as working physicians are concerned. Ms. DiVenere is Officer, Government and Political Affairs, at the ACOG and OBG Management contributing editor. And while she "reports no financial relationships relevant to this article," her very job may have depended on writing it.

Which leads me to MOC's Greatest Lesson that it consistently teaches working physicians, both young and old: In medicine, it is okay to lie, cheat, and steal.

I do not say those words lightly. Everything MOC touches is corrupt. For a once simple medical accolade to be allowed to secretly morph into a one-billion-dollar-a-year enterprise and physician cudgel to fund the bloated bureaucratic and political aspirations of the Accreditation Council for Graduate Medical Education is beyond me. Yet this is precisely where working physicians find themselves. Are these the ethics to which we want our young doctors of tomorrow to aspire? Should they model turning a cheek the other way to ignore the implications of these actions on our patients just so specialty societies can maintain handsome salaries, political power, and "self-regulation?"

Despite all that has been uncovered by following the money, I still can't believe it's taken one simple GoFundMe page three months to raise $150,000 from working physicians to fight this corruption.

It seems MOC's Greatest Lesson has been taken to heart.

-Wes

On Trust

Elizabeth A. McGlynn, PhD, immediate past chair of the ABIM Foundation and Vice President for Kaiser Permanente Research and Executive Director of the Kaiser Permanente Center for Effectiveness and Safety Research (CESR) with Richard Baron, MD, President and CEO of the American Board of Internal Medicine,  at the 2018 ABIM Foundation Forum on "(Re-)Building Trust"

Recently, the ABIM Foundation hosted a webinar entitled "(Re-)Building Trust." Oh, the irony. The fact they need to have such a conference is telling of the dire straights the staid and outdated medical credentialing complex has become.

As physicians who funded the ABIM Foundation, why do we fund such nonsense?  The American Board of Internal Medicine has never sufficiently explained why this organization felt compelled to use over $78 million of physician testing fees to create the ABIM Foundation or how and why it uses that money. Is it really to fund such conferences?  Or might conferences like this really be a distraction for the real reason the ABIM Foundation was created: their retirement fund. By the way, whatever happened to those funds shipped off to the Cayman Islands? Why will we lose our privileges at hospitals or insurance payments if we don't pay into this scheme? And why is the ABIM Foundation colluding with Kaiser Permanente directors? What does Kaiser get for this relationship?

If physicians trusted the ABIM, we would not have to ask such questions and the ABIM Foundation would not have to hold conferences on "re-building" trust.

Three years ago, Richard Baron, MD issued the now infamous: "We got it wrong" mea culpa press release when the 2014 iterations of Maintenance of Certification (MOC) foisted on US physicians resulted in a powerful working physician backlash. Lots of soft-shoe, "listening," and MOC program changes have occurred since then. But in reality four years later, little has changed other than parsing our payments into annual aliquots rather than a single lump sum every-10-year payment. The growth of fees is back on schedule, climbing an incredible 276% in the past 18 years.  Even the ridiculous Part IV of MOC is back as before.

It is hard to trust any business, especially a nonprofit organization when they ignore the customer.

We should not lose sight that physicians are the customer of ABIM, not patients. We pay for their medical accolade and the paper certificate that ABIM issues when we successfully complete our initial Board certification and (now) subsequent MOC requirements.

There are many within the US medical board credentialing system who feel otherwise; for them, they are there to serve "the public." Yet this deflection is little more than a propaganda message created to justify their use of our money for their political and financial purposes.

When we see our funds continuing to be wasted at Las Vegas convention venues for American Board of Medical Specialties meetings with their "stakeholders" we realize that this old-school attitude of colleague disrespect and self-importance is endemic to the entire US medical board certification and medical credentialing industry. Hard to re-establish trust with overt demonstrations such as these.

-Wes

PS: Wonder what you can do to change things?  Donate here and get a free book at the same time! We're 78% of the way there!

Moving Mountains By Example: Doctor Inspires Others to Fund Anti-MOC Legal Effort

In a reaffirming gesture of solidarity, San Francisco cardiologist Michel Accad, MD has offered to supply an electronic copy of his book "Moving Mountains: A Socratic Challenge to the Theory and Practice of Population Medicine" (seen on Amazon) free of charge to anyone donating $50 or more in the next two weeks to our legal effort to end the onerous and unproven ABMS Maintenance of Certification (MOC™) program nationwide.

 Dr. Accad's affable and insightful personal blog (Alert and Oriented) and podcast (Accad and Koka Report) co-produced with Philadelphia cardiologist Anish Koka, MD, have garnered wide physician followings by respectfully and thoughtfully discussing timely issues that matter to doctors. (My recent 46-min podcast discussing this funding drive with them can be heard here).

While the sponsor of the legal effort, Practicing Physicians of America (on whose board I serve), has already reached over 75% of the $150,000 funding goal, I hope Michel's generosity will inspire many other physicians to join this funding drive in hopes working physicians of all ages can help end - once and for all - the expensive, onerous, and corrupt ABMS MOC™ program that has the potential to unjustly limit a physician's right to work.

-Wes

Federation of State Medical Boards Attempts to Legislate Away Liability

In a press release, the Federation of State Medical Boards (FSMB) announced their support of the “Occupational Licensing Board Antitrust Damages Relief and Reform Act of 2018 (H.R. 6515),” introduced by Rep. Mike Conaway (R-TX) and co-sponsored by Rep. Lamar Smith (R-TX). According to the press release:

H.R. 6515 eliminates fiscal antitrust damage liability for state licensing boards-including state medical boards- their members, and staff who are acting within their statutory mandate to protect the public. Currently, board members and staff are exposed to personal liability and treble damages for actions taken as part of their service on a board. The lack of protection has had a chilling effect on the willingness of some individuals to serve on boards, causing some board members to resign for fear of personal financial liability.

It is interesting that this new bill attempts to circumvent the 2015 Supreme Court decision that held professional boards could not make decisions that potentially violated antitrust laws and quashed competition. The justices, in an opinion by Justice Anthony Kennedy, agreed with the government’s claim that although state entities are usually exempt from federal antitrust laws, the exemption did not apply because the board was not actively supervised by the state and because it was made up of self-interested private businesses.

The FSMB President and CEO, Humayun Chaudhry, DO, MACP has quite a history of working with similar self-interested private businesses.

In fact, Dr. Chaudry has long supported the notion of Maintenance of Licensure (MOL) that required Maintenance of (board) Certification (MOC®) and "lifelong learning." Chaudhry chaired a CEO Advisory Council (comprised of a slew of non-governmental U.S. medicine regulatory organizations) that advised the FSMB's Board of Directors and worked with an FSMB MOL Implementation Group (with Richard Hawkins, MD, the current President and CEO of the American Board of Medical Specialties (ABMS), in 2009). That group recommended that physicians actively engaged in the Maintenance of Certification (MOC) program of the American Board of Medical Specialties, or the Osteopathic Continuous Certification (OCC) program of the American Osteopathic Association, should be recognized as "substantially in compliance" with any MOL program that is adopted by a state. Because of this tie between MOL and MOC, the activities of the FSMB in the state of Ohio were met with formal opposition from the Ohio State Medical Association in 2012.

No wonder the board members from various state medical boards have resigned from their positions out of liability concerns. They understood there is credibility to the Federal Trade Commission's concerns that were upheld by the U.S. Supreme Court.

Legislators (especially Rep. Mike Conaway and Rep. Lamar Smith) would be wise to realize that the multi-million dollar FSMB has financial conflicts of interest that may cause more harm than good to our patients.

-Wes

P.S.: Like the FSMB, ABMS collusion with state medical societies regarding MOC® is also evident in this recent ABMS press release.