Primum Non Nocere

Primum non nocere - latin for "first, to do no harm" - is a philosophy working physicians aspire to throughout their careers when caring for patients. It defines a bioethical baseline for physicians and should be their guiding light in clinical decision making throughout their careers. Unfortunately, as is too often the case when politics and power enter the picture, it is easy for physicians to fall prey to avarice and greed, placing their financial and political interests before their patients and physician  colleagues.

Such is the case, in my opinion, with the bureaucratic ranks within the academic House of Medicine. Today, it is "pay to play" for hundreds of thousands of US physicians thanks to the American Board of Medical Specialties (ABMS)/American Board of Internal Medicine(ABIM)'s Maintenance of Certification (MOC) program.

As I mentioned in an earlier blog post, I received a notice in late November of this year by US mail that I had to earn 100 Maintenance of Certification (MOC) points, or I could see a "change in my certification status." The ABIM webpage displays that notice prominently as well.

Recall that I certified in both Cardiac Electrophysiology and Cardiology with the 2013 testing cycle. At that time, according to the ABIM's website and this archived webpage from January 18th, 2013, MOC required that I perform 100 MOC points every 10 years. When I purchased MOC and registered to take my recertification test in October 2013, this is what I thought I was purchasing.

Now I find the ABIM has changed the rules. Now we must perform 100 MOC points every 5 years.

Needless to say, I had only 10 MOC points when I received that notice from the ABIM after the Thanksgiving holiday. I had vowed not the earn another point until it might be needed 10 years from the data I enrolled for my MOC exam and have been working to end MOC through conventional channels since that time. I have talks at the AMA House of Delegates, Ohio Health committee, and help with the Texas anti-MOC legislation as proof of that effort. One guy doesn't stand a chance, I learned.

Still, I became worried about the implications of now needing another 100 MOC points and the time, focus, and commitment required so I could keep seeing patients. I searched for ways I could fulfill my requirements without paying the ABIM another dime.

This is where things got interesting.

It seems I pre-paid for "30 MOC points" - one for a 2017-2019 Hospitalist Update, a 2017-2019 Internal Medicine Update, and a "Care for the Underserved" module that offered 10 MOC points. (The other offerings that might have been there before had "expired.") These thirty points wouldn't be enough to get me where I needed to be by 21/31/2018. Furthermore, learning about these non-applicable topics to my specialty seemed to be a waste of time. Still, I needed points, so I did what I could and even performed the Hospitalist update. I was surprised to find that the ABIM's own Robert Wachter, MD, "Mr. Hospitalist" himself, helped author this module.  Because it was outside my wheelhouse, that module took way too long to successfully complete, but I finally did it to earn my "points."

Nothing to see here folks...

I was getting concerned. I checked the Heart Rhythm Society's webpage hoping they would have a module closer to my specialty that I could complete quickly and was surprised to find that they could only offer me 6.75 MOC points if I purchased a $650 Medical Knowledge update in Electrophysiology - a cost of $96.30 per MOC point! That was an astronomical price per MOC point and one that wouldn't get me anywhere near my goal of 100 total points.

I moved on.

The ABIM site suggested I look at the various offerings provided by the ACCME at http://www.cmefinder.org - a horribly rudimentary website that had poor filtering capabilities for the offerings I might need. They sent me to this hospital system and that hospital system with ways to game the system, but nothing would work for me or each offering gave me 0.5 to 1 MOC point each. Everyone, it seemed, were more than happy to offer a point here or a point there, but every point required a post-MOC survey of how I liked it, it the exercise was free from commercial bias, etc. - all very time-consuming - so I kept looking.

I turned to the American College of Cardiology's website since I am a Fellow of the American College of Cardiology and looked at their MOC offerings. I still needed a LOT of points if I was to make 100 by 12/31/2018. That's when it struck me: this was the plan! Whether you're an ACC member or not, you've got to pay the Man.

There, on the ACC's MOC webpage was this offering: ACC Self Assessment Program 9 (ACCSAP9) for $1600 in return for 155 potential MOC points good through mid-2019, a bargain-basement price of $10.32 per MOC point!

Left with few options this late in the do-or-die MOC extortion game to keep my hospital privileges and insurance payments coming, I purchased ACCSAP-9.

Before I could get started, I had to agree to a "Credit Agreement." In that agreement I had to agree to "read all text, watch all presentations and answer all questions within the topic for which you claim credit. You must obtain 70% or better on the questions, but you may answer the questions as many times as necessary to achieve that score."

Please.

Then there was the indemnify and hold harmless "Disclaimer" clause of the Credit Agreement: "The American College of Cardiology is not responsible for the results obtained from the use of the information contained in this publication... The American College of Cardiology does not warrant the information contained herein is in every way accurate or complete, and disclaim all responsibility."

Ahem, isn't this WHY we're being forced into this expensive exercise? If I can't rely on them to assure patient and "the public's" safety, what good are these "Knowledge Assessments" for patients?

Having no choice but to "agree" to their terms, lest I lose my hospital privileges and insurance payments to my hospital on 1 Jan 2019, I reluctantly clicked "I agree" and started the arrhythmia section of the testing the week before Christmas.

My wife and kids were not pleased.

"Dad, be here now. It's Christmas! Here you are, 35 years of experience, doing these mindless exercises and getting all stressed out. Haven't you done this long enough?"

"Honey, it's always me doing everything for Christmas while you get all stressed out and have to sit at that damn computer, doing quizzes. Will it ever end? How many years has it been?"

I realize that they are right. Years of being Mr. Good Guy while they lost out on their father. Experience means nothing to the ABMS. Money is everything with MOC. It is clear to me now that the "lifelong" educational system for physicians is horribly broken - a once reasonable voluntary system of continuing medical education required for state licensure, has morphed to an do-or-die extortion scheme for doctors' money. It's not about the patients or the doctor. These organizations  indemnify themselves of this responsibility. It's just about the money.

And for hospitals and insurers, it's about control of the doctors to keep their profits high.

The ACC - our cardiovascular specialty society that looks more and more like the AMA, has found a way to get rich - very rich - using the threat of my loss of privileges to fund their organization via the ABIM's MOC program. No wonder they collaborate.

The American College of Physicians (ACP) has their Medical Knowledge Self-Assessment Program (MKSAP) likely does the same thing. So does the American Board of Pediatrics. Whether the ABMS member board is a "continuous certification" or MOC participant, the ABMS mothership keeps the money flowing to all of these entities who claim to educate using computer products while hiding behind "Disclaimers" that relinquish their responsibility.

Buying a product in 2013 thinking one thing, only to find it's another, is fraud as far as I'm concerned. Doctors like me don't like being swindled and forced to play games that have no meaning so they can keep providing patient care. There simply are not enough hours in the day for any of us to put up with these shenanigans required by the members of the Accreditation Council for Graduate Medical Education (like the ABMS) for their financial benefit. They are not only hurting doctors, but hurting their families at Christmas time, too. The ACGME members and ABMS Vision Commission should each carefully read how the ABMS MOC program has harmed doctors in this latest serious anti-trust Complaint filed in federal court against the American Board of Internal Medicine.

The "ABMS Vision Commission's" Draft Report fails to disclose these potential harms caused to physicians by MOC and its numerous conflicts of interest. Do they really think their assets will  indemnify them of their responsibility to the well-being of working US physicians, and in turn, their patients?

I think not.

Primum non nocere.

-Wes