Monday, March 30, 2020

The Great Suppression

Interesting opinion piece from the American Institute for Economic Research appeared online framing the "Great Suppression:"

I write on Saturday morning March 28, and right now there are two contrary strains about to collide. On the one hand, you have scientists reducing their death-rate predictions further and further, lopping off zeros by the day. On the other hand, this is accompanied by appalling levels of despotism, even to the point of National Guard checkpoints at state borders and restrictions on what you can buy even at “essential” stores. This gigantic gap between emerging professional medical consensus and appalling policy ignorance is revealing as never before the practical impossibility of scientific public policy.

Then you have the cascade of unintentional and unexpected outcomes of the rush to coerce. It began with Trump’s disastrous block on flights from Europe that sent millions scrambling for tickets and led to an unspeakable crush of people standing shoulder-to-shoulder at our nations’ airports, contradicting the demand that people social distance just when the virus was revealing itself as highly contagious. The very opposite of intended results!

That’s just the beginning. I doubt seriously that the political class in this country, as low a regard I have it, set out to destroy all that we call civilized life, instantly generating millions of unemployed workers and bankrupt businesses all around, not to mention a pandemic of utter hopelessness on the part of vast swaths of the world’s population. Still, this is what they have managed to achieve. This is what their pretense of knowledge – as opposed to actual wisdom – has unleashed on the world, with incalculable human cost.

As for economics, are we talking recession? Depression? Those words indicate cyclical changes in business conditions. My friend Gene Epstein suggests another term for what we are going through. The Great Suppression. There will be months, years, and decades in which to more clearly observe the countless ways in which the supressors piled error upon error, blockage upon blockage, to add to the grotesquery.

What truly should inspire us all right now are the grocers, pharmacists, truck drivers, manufacturers, doctors and nurses, construction workers, restaurant workers, service station attendants, webmasters, volunteers of all sorts, philanthropists, and specialists in a huge variety of essential professions who keep life functioning more or less. And let us not forget the “unessential” people (it’s an incorrect and vicious term) who have innovated ways around the Great Suppression to continue to serve others, keep the rent being paid, and food on their tables. They are the means of salvation out of this mess.

The market, hobbled and bludgeoned, still loves you.

As for the politicians, Andrew Cuomo has admitted some of the error. In a much-welcome change, he has even deregulated medical services. There’s just a hint of humility and humanity embedded in these statements and actions. We need more of that, vastly more, if only to contribute to calming things down long enough to gain some perspective, and, hopefully, some eventual realization that in the “land of the free and the home of the brave” a virus should be regarded as a disease to mitigate and cure, not an excuse to bludgeon life on earth as we know it.

-Wes

Saturday, March 28, 2020

Adjusting to Our "New Normal"

It's hard to image what life was like a month ago since so much has changed. The world seems surreal right now: little to no traffic, the hustle and bustle of our cities gone, and the quiet. So much quiet.

Life has changed significantly in our home, as I attempt to strip at my backdoor after returning from work, wash my hands, wipe my keys, phone, and wallet down, then head up stairs for a shower and change of clothes before familial reentry. I sleep in a different bedroom, shower in a different bathroom, and wonder (like a worker after the Chernobyl accident) what my viral "load" is at any point in time. Every accidentally-aspirated chicken noodle soup noodle and results in a coughing spree clears a room. I scratch my nose: "do I need to wash my hands again?"

Life as a physician is really weird now. We are healers and potential vectors all at the same time.

Yet so far we are lucky. Italy announced 969 deaths in a single day yesterday. Many, if not all of them, died alone. The ripple effect on their families must be enormous. And the poor doctors, nurses, health care workers there. New York is starting to feel this too. Will it get this bad here?

Our hospital system has been very proactive and open about the situation with us. They acknowledge the worldwide shortage of personal protective equipment (PPE). They are conserving necessary supplies for those most likely to confront new patients or those with suspected or confirmed COVID-19. All OR's and emergency procedures require full PPE, which is awkward when a non-COVID-19 patient enters: where is the transition to full PPE made? In the holding area? The lab itself? It's all a work in progress. Ventilators? Enough now, but later? Sands shift.

Still, it's impressive to see an ambulance bay converted to a negative flow screening area. Separate hospital's ICU and inpatient ward adapted for designated for COVID-19 patients. Contignecy plans for overflow are already in place. Outpatient drive-thru testing established for people who are most likely to warrant testing and have taken an online screening questionnaire. Six-foot markers are on the floor in the cafeteria, meetings, if they occur at all, are via Zoom or teleconference. Nearly all patient visits are virtual. Elective cases are a thing of the past. 425 physician volunteers are on standby - for extra duty - sometime.

At first, then percentage of people tested with positive coronavirus tests in 24 hrs was 15.8%, then 17.2%, and this AM was 19.1%. 7% of those hospitalized. Lots and lots of testing, planning, wondering, waiting. Today we admitted more people in a single day than everyone that was admitted when we started monitoring a week ago. It's coming.

The preparation seems so logical, but I wonder: will we be overwhelmed? We really don't know. But the non-COVID patients are still out there too: the LVAD patients with ICD shocks, the kids with broken bones, the baby deliveries, heart attacks, cancer patients, and patients with complete heart block, and more. They haven't stopped coming but they, too, are scared.

It's reassuring to see so many good folks giving it their all: from the doctors, nurses, administrative staff, clerical workers, laboratory staff, environmental workers, engineers and transporters. We work together - we have to - and with that effort comes the rekindling of respect for the special skills of everyone.

Once relatively simple things to treat take much more strategic coordination now. Atrial flutter w/rapid rate in a patient with fever and cough just a month ago would get a TEE/cardioversion without a moment's hesitation. Now, that patient is COVID-tested, isolated, procedures performed in full personal protective equipment, and tensions between colleagues heightened. The truth is, the vast majority of us that contract the disease will recover, but no one wants to be that other statistic. Patients need us. Families need us. So we wear a mask, we wash our hands, we wipe our tools, keys, keyboards, phones, then strip, wash and reenter. Are we effective? Honestly, I have no idea, but what else can we do?

Thanks to everyone who have sent prayers, words of encouragement, and support by staying home. We will all get thorough this.

Take care out there and take comfort in the fact that you're not alone.

-Wes

Tuesday, March 17, 2020

The "Risk and Distraction" of MOC

From the American Board of Internal Medicine:
We did not come to this decision lightly, but we believe removing the potential risk and distraction of sitting for a spring exam is the right thing to do for our diplomates and for the country at this time. Learn more: https://www.abim.org/media-center/Coronavirus-Updates.aspx
Physicians can help make sure this risky, unproven, and "distracting" ABMS board "maintenance of certification" (MOC) requirement never returns by supporting the plaintiffs working to end this monopolized program here.

-Wes

Saturday, February 08, 2020

MOC's Sword of Damocles and the Platinum Rule

The current issue of Mayo Clinic Proceedings has an article entitled "Maintenance of Certification and the Platinum Rule: An Existential Crisis" by Richard G. Ellenbogen, MD, E. Sander Connolly Jr, MD, and Fredric B. Meyer, MD. I encourage all to read it and the accompanying editorial by Suzanne M. Norby, MD from the Division of Nephrology and Hypertension and Mayo Clinic.

It is clear that MOC has morphed into a money-making endeavor for legions of third parties, including insurance companies, hospitals, and a myriad of other corporate interests eager to capitalize on the control and sharing of physician data. While the concept of using the "Platinum Rule" to guide the evolution of MOC is a step in the right direction, the "MOC existential crisis" will not end until the "Sword of Damocles" (as the authors aptly put it) is removed from working physicians' heads. We simply cannot work with the threat of the loss of our professional careers if we fail to purchase the unproven MOC (and any other required "continuous certification" product).

The ABMS MOC paradigm will only survive if becomes truly voluntary and its lack of purchase will not affect our right to earn a living.

-Wes

P.S. (Updated 9 Feb 2020 @ 13:45PM CST) As we have seen time and time again, the physician influencers and apologists of the American Board of Medical Specialties (ABMS) have historically abandoned their moral imperative to working physicians and their patients to “first, do no harm.” Corporate interests invariably supersede this ethic. It should come as no surprise, then, that the lead author of this piece has a similar track record working for the National Football League.

Physicians wishing to support the plaintiffs in their ongoing effort to end Maintenance of Certification are encouraged to contribute here.

Tuesday, February 04, 2020

PA Medical Society and MOC

Are medical societies advocating to end the unproven American Board of Medical Specialties' Maintenance of Certification (MOC) mandate or are they burying the controversy?

In 2016, the Pennsylvania Medical Society (PAMed) issued a strongly-worded "Vote of No Confidence" against the American Board of Internal Medicine (ABIM).

Good luck finding that earlier statement on PAMed's webpage concerning MOC now.

Instead, we see the following soothing pablum regarding PAMed's MOC position:
PAMED Position

Supports efforts to:
  • Improve MOC
  • Prohibit MOC as a condition of licensure, insurer credentialing and reimbursement, or hospital admitting privileges
The accusations in PAMed's original 2016 Vote of No Confidence against the ABIM were significant:
" Through their marketing efforts, the ABIM has worked hard to give the impression that their recertification exam demonstrates competency. However, despite numerous calls to substantiate this assertion, the ABIM has been unable to provide reliable independent evidence that a secure, high-stakes exam, taken every 10 years by some and for which other are "grandfathered" and therefore exempt - leads to better patient care. This is because while the overwhelming majority of practicing physicians pass the ABIM recertification secure, high-stakes computer exams, this test and the MOC process have no correlation to how well a doctor can take care of a patient. Shockingly, countless medical leaders. numerous national mainstream publications, and several forensic accounting reviews have published information which suggests the ABIM's motivation for their recertification process was primarily driven by little more than financial mismanagement."
In 2017, a resolution was passed by the AMA House of Delegates demanding an independent audit of the ABIM. This lead to the following response from the ABIM to James Madara, MD, President of the AMA. In that response by the ABIM, the American College of Cardiology was quoted as vouching for the ABIM's financial statements because of this statement issued to their membership:
In addition, the ACC's accounting staff have reviewed and discussed the ABIM’s publicly available financial statements with an outside accounting firm and have found the statements to be in compliance with Generally Accepted Accounting Principles, as utilized by not-for-profit organizations in the United States.
The problem is, the AMA and the ACC have interests in selling physician data and each organization has representatives on the board of PCPI.org alongside representatives from UnitedHealthcare. PCPI and the ABMS share the same office address. Therefore, the financial "audit" demanded by the AMA House of Delegates in 2017 and accepted by the AMA's President Madara was never "independent."

Pennsylvania physicians represented by PAMed need to confront their medical society's current leadership concerning MOC and the lack of independent financial audit demanded by the AMA House of Delegates. One thing working physicians in Pennsylvania (and elsewhere) don't need: corporate physician shills more interested in themselves and their political aspirations than the support of front-line physicians who care for their citizens.

-Wes

Sunday, January 26, 2020

The Certified Deceit and Exploitation of US Physicians

For the past seven years, I have devoted a significant amount of my time to investigating and telling the true story of US physician "board certification." That story has been one of deceit, private back-room deals, profiteering, and (worst of all in my humble opinion), the exploitation of working physicians and the patients for whom they care.

This writing has not come without its personal and professional costs, but when the story is one that affects the corruption of the largest single contributor to the US economy, what else should I have expected?

As I reflect on what this side job has exposed, it would be naive and dishonest to suggest that physicians are exempt from bearing some responsibility for rising healthcare costs in America. But it may go much further than that: our medical profession and its hallowed physician education regulatory system comprised of the unchecked Accreditation Council for Graduate Medical Education (ACGME) might be the very reason things were allowed to become so out of control. Our non-profit tax laws with their opaque reporting requirements have allowed huge "non-profits" to go unchecked in America - and most of those "non-profits" are in healthcare. (Just take a stroll by the American Medical Association (AMA) building in downtown Chicago sometime to get a feel for the magnitude of the problem.)

Why should the physician education and credentialing systems in America be exempt from such corruption?

Well, they are not.

From the earliest reports of a multi-million dollar condominium purchase by the same non-profit organization that created the "Choosing Wisely®" campaign to promote health care cost savings, the hypocrisy of US board certification was laid bare. With not-so-difficult internet Google searches, it was just a matter of time before the multiple deep-pocketed corporate ties between US physician board certification and Big Tobacco, Big Insurance, Group Purchase Organizations, and the Health Care Quality and Safety Industry became evident. Even our most widely respected health care journals, many of which were owned by state medical societies or physician specialty societies, published innumerable articles with an editorial blind eye to these financial conflicts. Even the Chief Medical Officer of the American Board of Internal Medicine is just a hired corporate consultant. To that end, is it any wonder that the so-called "voluntary" ABMS board certification product is now anything but voluntary for physicians, as trillions of health care dollars exchange hands in hospitals and insurance companies whose corporations believed the published propaganda?

This is why the "Maintenance of Certification" (MOC) story must be told and understood. Continuing the cover-up only serves to fan the flames of physician burnout and risks loss of more frontline highly-trained physicians to other professions.

Thankfully, the true history of AMBS board certification was recently published online. But it was not published in a medical journal. It was published in the public Siva v. American Board of Radiology antitrust lawsuit case docket.

And what a complicated and tortuous story it tells.

It is a story of public deception.

It is a story of physician exploitation.

It is a story of greed.

It is a story of trying to use Maintenance of Certification to control state's sovereignty over medical licensure.

It is a story of money for bureaucrats, hospitals, and numerous corporate interests at the expense of the youngest and most vulnerable physicians.

It is a story of a sophisticated self-serving physician education and credentialing racket.

And now, you can read the 79-page story here.

Let's hope Judge Jorge Alonso (who initially dismissed the case against the American Board of Radiology) reads it, too.

-Wes

P.S.: Please consider supporting the Plaintiffs in their ongoing David vs Goliath MOC legal battles.

Wednesday, January 15, 2020

Who Is the ABIM Chief Medical Officer?

Drs. Richard G. Battaglia and Richard Baron
(Image from the ABIM Blog)
Who is Richard G. Battaglia, MD?

In 2015, the American Board of Internal Medicine (ABIM) announced Richard G. Battalgia, MD as their new Chief Medical Officer (CMO). This was the same year the American Board of Medical Specialties (ABMS) paid $922,479 to PriceWaterhouseCooper LLP (PwC) for "Management Consulting:"
What the ABIM website fails to mention with their announcement, is that Mr. Battaglia worked for PwC for 14 years, 3 months before being "hired" by the ABIM.

Is Dr. Battaglia, the ABIM CMO, concerned about medical education of physicians or merely a consultant purchased by the American Board of Medical Specialties to "clean up" the ABIM Maintenance of Certification (MOC) mess?

The ABIM website only says this about their CMO:
"Dr. Battaglia, a board certified internist, is Chief Medical Officer (CMO) of the American Board of Internal Medicine (ABIM). There, he leads ABIM's effort to incorporate feedback from practicing physicians and key stakeholders into clinical aspects of all of ABIM activities, including Certification and Maintenance of Certification (MOC).

Previously, Dr. Battaglia served as a primary care internist with Health Care Plan/Univera, a multi-specialty, staff model practice in Western New York before transitioning into leadership roles, including Medical Director of the Medical Centers Division and Senior Vice President, Medical Affairs/Corporate Medical Director. He also served as Medical Director/Chief Medical Officer of large multispecialty medical groups in Western New York. He has participated in national quality initiatives focused on physician group practice and health maintenance organizations. For more than 10 years, he devoted time to The National Committee for Quality Assurance, including a term as Chairman of the committee charged with accreditation decision-making. Most recently, he was a consultant (emphasis mine) for national and international organizations, including academic medical centers, health systems, community hospitals, medical groups, payers and national physician certification organizations.

Dr. Battaglia received a biochemistry degree from Canisius College, a Jesuit institution in Buffalo, NY. He obtained his medical degree from the University of Rochester School of Medicine and Dentistry. Dr. Battaglia completed his residency through the University of Rochester Primary Care Program in Internal Medicine and also served as Chief Resident."
Maybe PwC's "Unifying Thread" of using (physician) data is the real reason Dr. Battalia promotes "continuous certification" and MOC:
Data is the unifying thread across seven policy areas we highlight here. Privacy, antitrust, tax, regulation of artificial intelligence, and trade are converging around the collection, sharing and security of data.
Physicians subjected to lifelong payments to ABMS member boards for Maintenance of Certification (MOC) and Continuous Certification (CC) should know about Mr. Dr. Battaglia's PwC connection. Just like they should have known about Christine Cassel, MD's connections to Premier, Inc, Kaiser, and CECity, and Dr. Wachter's connections to the The Hospitalist Company and Teamhealth.

When considering patient safety and care quality, a corporate, non-clinical, damage-control medical consultant for a Fortune 500 accounting firm should not be Chief Medical Officer of the American Board of Internal Medicine.

-Wes

Tuesday, January 14, 2020

Visible Cracks

it was a clinic day like all the rest
until it wasn't
she was there with her son and granddaughter
winded
legs swollen "for a month"
afib, fast rate despite cardizem CD 300 mg daily, diabetic meds, norvasc.
EKG with LVH, RBBB, LAFB.
BP 178/84, HR 124
rales
meds to be started, but help?
EMR->no doctor
a nurse practitioner?
4:45 pm-> all gone
see you in two days
no appointments.

i wake too early
staring up
mind swirling
cases ahead
remembering her
and me
alone.

-Wes

Monday, January 13, 2020

The Study We Weren't Supposed to See

Most US physicians are well-acquainted with the American Board if Internal Medicine's (ABIM) breathless claims of ABIM board certification and Maintenance of Certification's benefits. These have included:
  • The Public Expects It
  • Physicians Value It
  • Amount of clinical experience does not necessarily lead to better outcomes or improvement of skills
  • Certification is Associated with Better Care
But what about the harms of constant testing and its affects on physician burnout? Wouldn't it important for the ABIM to mention that their OWN study on 34 subjects, funded by US physician testing fees in the form of grants from the ABIM Foundation and authored (in part) by ABIM staff and consultants, has found that Certification and MOC:
  • "lead to higher measures of depersonalization and emotional exhaustion."
  • "may be an important source of medical errors related to clinical reasoning tasks in practice."
  • yet are considered the "Gold Standard of physician performance."

These are their words, not mine.

Where are these results published on the ABIM or ABIM Foundation website?

Shouldn't U.S. physicians who paid for such poorly conducted/self-promotional "research" be entitled to disclosure of (1) how much granbt money was paid to USUHS, (2) why the funding agency was allowed authorship of this "research," and (3) why the data contained in this work were not disclosed to ABIM diplomates on the ABIM website?

-Wes

Please contribute to help support the legal effort to end Maintenance of Certification nationwide.