Monday, July 27, 2020

Physician Plaintiffs File Reply Brief Against ABIM

The four Internal Medicine physician Plaintiffs-Appellants filed their latest Reply Brief in the class action lawsuit against the American Board of internal Medicine (ABIM) today. That reply brief summarized the alleged tying arrangement of ABIM board certification to "Maintenance of Certification (MOC)":
"ABIM’s monopoly power over certifications is undisputed. Certifications are an economic necessity for a successful medical practice. From 1936 to today ABIM certifications have assessed one thing: postgraduate medical education. 

Realizing that only so much in certification fees can be extracted from new residency graduates, MOC allows ABIM not only to charge internists a one-time certification fee at the outset of their practice, but to force internists to purchase MOC by revoking their “initial” certifications if they do not, requiring them to pay inflated MOC fees throughout their entire decades-long careers. The two products are separate because, in ABIM’s own words, MOC “means something different” from certifications and “speaks to the question of whether or not an internist is staying current.” (¶ 53). MOC’s true purpose, however, is to create a lucrative revenue stream for ABIM, resulting in hundreds of millions of dollars in new fees. (¶ 65). 

There are other products—not sold by ABIM—that help internists stay current, including continuing medical education products (“CME”). (¶ 54 (“MOC serves substantially the same function as CME”)).1 

MOC is ABIM’s fourth attempt to sell a product distinct from certifications to help keep internists current. Thousands of internists bought three previous voluntary MOC products separately from their certifications as part of ABIM’s Continuous Professional Development Program (“CPD”). (¶ 25). “Grandfathers” today also purchase MOC separately from their certifications. (¶ 35). Purchases by internists of MOC, CME, and other non-ABIM CPD products to stay current, demonstrate distinct demand for those products separate from the demand for certifications. ABIM’s earlier versions of MOC failed to generate the hoped-for revenue because ABIM did not revoke certifications of internists who did not buy them. That ABIM’s voluntary products were unsuccessful reflected internists’ preferences to buy products from others to stay current. (¶ 55). ABIM ensured, however, that MOC succeeded by tying it to “initial” certifications and making it mandatory. (emphasis mine) Plaintiffs’ claims do not threaten ABIM “standards” any more than ABIM’s earlier voluntary MOC products did. Plaintiffs ask only that ABIM’s illegal tie be severed and that MOC once again be voluntary."
In addition, the filed brief explains the basis of the RICO claims made by the physician Plaintiff-Appellants against the ABIM: 
"After ABIM was unable to generate hoped-for fees from its first three voluntary MOC products sold as part of its CPD Program, it realized it must force internists to buy MOC. ABIM did so by revoking the certifications of internists who did not buy MOC. In furtherance of its scheme, ABIM waged a campaign of fraudulent misrepresentations to deceive the public, including but not limited to hospitals and related entities, insurance companies, medical corporations and other employers, and the media, that MOC, among other things, benefits physicians, patients and the public and improves patient outcomes. As a result, ABIM has collected hundreds of millions of dollars in MOC fees under false pretenses."

Finally, in regard to the unjust enrichment claim dismissed by the earlier District Court judge:
"The district court’s sole rationale for dismissing Plaintiffs’ unjust enrichment claims is its conclusion that ABIM “did not ‘force’ Plaintiffs to purchase MOC.” A-41. ABIM similarly repeats its argument that internists “chose” to “pursue and maintain their certifications.” ABIM Br. 54. Plaintiffs have already debunked this argument, and clearly allege “forcing” notwithstanding the erroneous conclusions and arguments of the district court and ABIM. 
ABIM points out that certifications are not required for licensure. But it does not deny certifications are required for admitting privileges, insurance, and other requirements of a successful medical practice, and accordingly are an economic necessity. Finally, the district court opinion in In re Avandia Mtkg., No. 2007-MDL-1871, 2013 U.S. Dist. LEXIS 152726 (E.D. Pa. Oct. 22, 2013), does not support ABIM, as the unjust enrichment claim there failed for several reasons not pertinent here, most importantly because, unlike MOC, the purchases were voluntary. See ABIM Br. 55-56."
With this filing, it is clear that the class action lawsuit filed by working physicians against the ABIM is far from over. Read the whole Reply Brief here

-Wes

To support the physician plaintiffs in this ongoing lawsuit, consider contributing to their GoFundMe page.

Friday, July 17, 2020

ABMS Board Certifications: One Product or Two?

It is the question at the crux of the antitrust cases against the ABMS member boards: Is board certification one product that has merely been updated or does board certification contain more than one product? If more than one product, is the second product tied, or leveraged, to force the purchase of the second product?

Let me be the first to admit I am not a lawyer, much less an expert on antitrust legal issues. (That is stating the obvious.) But I am a physician who has felt first-hand the squeeze applied to my bank account and psyche by the monopoly power enjoyed by the American Board of Medical Specialties (ABMS) and their member boards over the many years I have had to endure their repeated testing.  

For most US physicians, board certification is anything but voluntary as the ABMS and their member boards suggest. The history of board certification did NOT require MOC when hospital credentials, insurance panel participation, and malpractice coverage began requiring the lifetime credential before 1990. Only AFTER the 1990 change in "rules" imposed by ABIM that their certification was suddenly "time limited," did physicians become trapped and had to purchase MOC. For this reason, I know if I do not repeatedly "re-certify" by paying the ABIM their fees and performing their continuing professional development programs (however they have been morphed over the years) I could lose my ability to work as a physician - the profession I have practiced for over thirty years.

It is that nauseating "squeeze" that has lead a number of physicians to file suit against these powerful (and we now have learned, highly financially conflicted) tax-exempt US specialty "medical boards." Personal luxury condominiums with chauffeur-driven town cars, off-shore retirement accounts, first-class and spousal travel to resort meeting locations offered to a few lucky and highly-marketed physician "experts" has kept the process going for years at the expense of their less well-to-do and politically connected colleagues. 

Maintaining this monopoly has come at a huge direct cost to working physicians. The cost of hiring felonious "test security" personnellobbying Congress, hospitals, and the insurance industry has seen the costs for "re-certifying" mushroom over 654-766% in the last twenty years.

Since the onset of the coronavirus pandemic, with the exception of a video chat on Fox News by Richard Baron, MD, the President and CEO of the American Board of Internal Medicine (ABIM), the medical boards have largely gone underground. Instead, they are content with letting their 400+ lawyers work to preserve their fiefdom by arguing  that board certification is one "voluntary" product.

Where Does the Precedent-setting ABIM Antitrust Lawsuit Stand?

In December 2018, the ABIM was sued by four internal medicine physicians who claimed the ABIM engaged in illegal antitrust activities. That lawsuit was later amended to include racketeering and unjust enrichment claims. But that lawsuit was never tried because a senior district court judge sided with the ABIM on September 26, 2019 that initial certification and Maintenance of Certification are one product, "ABIM certification:"
"Internists are not buying “initial certification” or “maintenance of certification,” but rather ABIM certification. This is made clear by hospitals and other medical service providers requiring ABIM certification, in general. This fundamental misconception about the nature of the entire certification product offered by ABIM undercuts Plaintiffs’ arguments."
With that decision, the plaintiff's antitrust claims were dismissed with prejudice, but the racketeering and unjust enrichment claims were dismissed without prejudice.  So the plaintiffs appealed the district judge's ruling to the Appellate Court level on 4 May 2020 and argued the judge ruled erroneously:
"Plaintiffs allege: internists differentiate between certifications and MOC; ABIM has always sold them separately; ABIM treats the two products as separate; ABIM bills and accounts for certifications and MOC separately; and other vendors sell CPD (continuous professional development) products like MOC that keep internists current without selling certifications. Case: 20-1007 Document: 22-1 Page: 21 Date Filed: 05/04/2020 13 The district court ignored these allegations and erroneously concluded that certification and MOC are one product. A-29. In doing so it arrogated to itself determination of the ultimate factual issue, improperly weighed facts, resolved inferences against Plaintiffs, and considered “facts” asserted by ABIM outside the Complaint, all of which are improper on a motion to dismiss. See Flora v. County of Luzerne, 776 F.3d 169, 175 (3d Cir. 2015); Kedra v. Schroeter, 876 F.3d 424, 433 (3d Cir. 2017) ; Sweda v. Univ. of Pa., 923 F.3d 320, 326 (3d Cir. 2019)."  
In response, the ABIM has argued otherwise in their recently filed brief:
"The district court properly dismissed plaintiffs’ Section 1 tying claim because plaintiffs failed to plead factual allegations plausibly demonstrating that MOC and initial board certification are separate products capable of being tied. The district court considered each of plaintiffs’ factual allegations and, drawing upon the case law and common sense, rejected plaintiffs’ argument that MOC and initial board certification should be considered separate products. Instead, the court concluded that plaintiffs’ allegations make clear that there is no demand for MOC separate and apart from the demand for board certification. ABIM offers a single certification program for internists to demonstrate their excellence. That program includes initial certification and MOC. As plaintiffs acknowledge, ABIM is entitled to set its own standards in determining who qualifies for its recognition." 
But the ABIM conveniently never mention the grandfather issue in their brief - that is, the discriminatory practice of exempting older physicians certified before 1990 from having to perform MOC. Instead, they claim in this brief that "ABIM has always sold MOC together with Initial Certification." Senior physicians like myself know nothing could be further from the truth. 

The Plaintiff's response to the ABIM's brief is due July 27, 2020. If the opposition to motion to dismiss the lawsuit against the American Board of Radiology (another ABMS member board also sued for antitrust violations) is any indication, holes in the ABIM's argument that initial certification and MOC are a  "single product" could soon surface and lead to the Plaintiffs finally getting their day in court.

We can only hope.

-Wes

P.S.: Physicians wanting to support the Plaintiffs in their David-vs-Goliath effort are encouraged to contribute to the GoFundMe campaign created on their behalf.

Thursday, July 16, 2020

MOC and the Racist Origins of Grandfathering

From Paul G. Mathew, MD via Facebook: 

A hearing was held yesterday by the Rhode Island State Legislature's House Finance Committee regarding H7171 Article 20 on Healthcare Reform. One of the topics of discussion was the Interstate Compact, which will allow physicians to practice medicine across state lines. This will be especially helpful in providing tele-health services to areas of need. One major concern is that the compact is written in such a way that a physician is defined as someone who is compliant with the American Board of Medical Specialties Maintenance (ABMS) of Maintenance of Certification (MOC) Programs. The American Medical Association (AMA) has passed numerous resolutions that MOC compliance should not be a requirement to practice medicine (https://assets.ama-assn.org/sub/meeting/documents/i16-resolution-309.pdf). This would be the first time that obtaining a medical license would require a physician to pay this non-profit private monopoly for a product that is expensive, time consuming, and has little evidence that it improves patient care.
 
MOC serves to increase the cost of healthcare, reduce patient access to healthcare, and contribute to physician burnout. As recently as May 28, 2020, the AMA has taken a public position that compulsory MOC participation contributes to physician burnout (https://www.ama-assn.org/practice-management/physician-health/12-factors-drive-physician-burnout). In addition, MOC compliance is discriminatory based on age, race, and gender, as time-unlimited certificate holders (grandfathered physicians) are excluded from participation, and are 80% white and 70% male (https://www.aamc.org/system/files/reports/1/factsandfigures2010.pdf).
 
The term “Grandfathering” has racist origins as the term was used in an effort to limit people of color from voting. As such, it should not be used by name or in discriminatory practice. (https://www.npr.org/sections/codeswitch/2013/10/21/239081586/the-racial-history-of-the-grandfather-clause). Granting one group of physicians elite status of this nature is particularly concerning given our society's current focus on systemic racism and gender discrimination. The danger here is that if the Interstate Compact is successful, national rather than state medical licensure may be on the horizon, which should not be tied to MOC compliance.
 
As Director of Legislative Affairs of the National Board of Physicians and Surgeons (NBPAS.org), I submitted testimony requesting that NBPAS also be recognized as a re-certifying entity. Physicians must have a choice in board re-certification providers between evidence based (CME) NBPAS re-certification or MOC based ABMS re-certification. I hope that my physician colleagues will join me in voicing our concerns to the leadership of our societies and policymakers that MOC compliance should not be required for practice, and in the case of the Interstate Compact, should not be a requirement for licensure.

View more about MOC, its harms, and inherent racial and gender discrimination here.

-Wes
 

Wednesday, July 01, 2020

Will the History of US Physician Board Certification Sink MOC?

In the closely followed Siva v American Board of Radiology (ABR) antitrust case (1:19-cv-01407), the Plaintiff recently filed an Opposition to Dismiss the First Amended Complaint (FAC) earlier this week. At issue in this case is whether intial certification and MOC are a single product or two separate tied products. In this newest legal docket entry, the Plaintiff added additional arguments from a recently decided Viamedia, Inc. v. Comcast Corp. antitrust tying opinion recently decided in the Seventh Circuit Court that demonstrates the importance of the history of US Board Certification is to the tying claim made by the Plaintiff:
ABR also virtually ignores the new Sherman Act, Section 2 tying opinion, Viamedia, Inc. v. Comcast Corp., 951 F.3d 429 (7th Cir. 2020), in which the Seventh Circuit reversed summary judgment for defendant, rejecting the same single product arguments ABR makes here. First, Viamedia holds that whether there is separate demand must be assessed before the tie is imposed, and not after. Viamedia, 951 F.3d at 469 (“the market must be ‘assessed at the pre-contract rather than post-contract stage’”) (quoting Philip E. Areeda & Herbert Hovenkamp, Antitrust Law: An Analysis of Antitrust Principles and Their Application, ¶ 1802d6, at 89 (4th Ed. 2018) (“Areeda & Hovenkamp”)).

This guts both premises of ABR’s single product theory: (1) that certifications should be analyzed post-MOC, with MOC viewed as a component of a “multi-stage” process (ABR at 8), rather than before ABR imposed its tie forcing radiologists to buy MOC or have their certifications revoked; and (2) as to MOC, “the relevant inquiry” is whether there currently is conflated demand for a single CPD product (MOC) and certifications as a result of ABR’s tie (id.), rather than inquiring whether there was separate demand by radiologists for CPD products before ABR tied certifications and MOC. See Viamedia, 951 F.3d at 469 (consumers “viewed the services as separate prior into entering into their present [tying] contracts with Comcast”). The Viamedia imperative to assess demand before the tie makes perfect sense because focusing on demand after the tie is forced on consumers inevitably rewards the defendant who has already successfully reduced competition, the very goal of the illegal tie. Viamedia makes clear that a defendant like ABR who forces consumers to purchase a tied product, cannot then parlay its own coercion into evidence of lack of separate demand for a product that the victimized consumers would not otherwise purchase, exactly what ABR argues here. (ABR at 8-9, 11).
Additionally, the new brief suggests the adhesion contract physicians must sign when enrolling in MOC (or one of its Continuous Professional Development (CPD) successors) are irrelevant to the antitrust issues being decided by the court:
ABR argues repeatedly that Dr. Siva “knew” from “the outset” based on a “contract” that MOC was tied to certifications. (ABR at 3-4, 10, 11). In doing so, ABR misrepresents information and documents about MOC that Dr. Siva received “after he purchased his certification.” (¶ 255; emphasis added).7 Dr. Siva alleges that neither his application for certification nor the certificate itself referred to “initial” certification or to MOC. (¶¶ 250, 252- 253). (emphasis mine) The FAC also alleges no contract obligating radiologists to buy MOC; nor does any such contract exist. Radiologists are forced to buy MOC because if they do not, ABR revokes their certifications, without which a successful medical career is impossible.

At any rate, ABR’s argument is a diversion. Awareness that a tie exists when the tying product is bought does not make the tie any less coercive. Radiologists’ knowledge of ABR’s monopoly power and leverage cannot absolve ABR of its illegal tie.
There is no question the heat is being turned up of the American Board of Radiology and this new legal precedent set by Viamedia prioritizes the importance of the history and original intent of board certification (that is, of assuring adequate residency training) is an important factor in establishing the illegal product tie that ABR has leveraged with MOC against its diplomates for their financial benefit.

ABR has approximately three weeks to respond to these latest arguments.

-Wes

PS: Physicians wishing to help the ongoing legal efforts to end MOC for all subspecialties are encouraged to contribute to the GoFundMe page created to support the plaintiffs.

Monday, June 08, 2020

How MOC is Contributing to the Demise of Physicians

Dr. Torie S. Sepah, MD on the KevinMD blog:

Now, one could argue, what’s $500 a year to a physician? Well, it adds up to $5,000 in ten years, at which time I’ll shell out another several grand to take the recertification exam.  Contrary to popular belief, physicians aren’t exactly rolling in the dough. In fact, 8 out of 10 physicians under 40 carry over $150,000 in medical school debt.  It all adds up: the medical license fee, the DEA fee, the specialty association fee.  Is this extra $5,000 really necessary, and if so, what is it for?

Here’s what it is not being used for, to protect what our board certification stands for.

My board certification in psychiatry doesn’t mean much these days because NPs and PAs are also board certified in psychiatry without attending a medical school, completing an ACGME residency program, passing the three-part oral exam in order to become eligible for the written exam in psychiatry, and of course not participating in MOC or taking our rigorous written exam every ten years.

To make sure that the world knows they are board-certified, they often embroider it on their white coats. And now, in 24 states, they can practice medicine independently with board certification in a specialty like psychiatry.

More physicians are waking to multitude of harms caused by Maintenance of Certification (MOC).

This is why multiple antitrust lawsuits have been filed against the ABMS member boards. Right now, the American Board of Radiology has filed a Motion to Dismiss the first amended complaint filed in the lawsuit against them. They argue that MOC and initial certification are all one product (certification) and therefore the anti-trust claim filed has no merit. As physicians, we know better. The detailed 79-page amended complaint explains the differences of initial certification from all other "continuous professional development products" (like CME, MOC, "continuous certification" and NBPAS recertification) and explains why ABR's contention that MOC and initial certification are one product is wrong on many levels. We'll see if the judge in that case feels the physician plaintiff has sufficiently argued his case to move this case to discovery.

The American Board of Internal Medicine also had the original District Court lawsuit dismissed. But that first-pass lawsuit has now been appealed to the Third Appellate Court. That appeal adds lots of new evidence supporting the differences between initial certification and the "continuous professional development" program that is MOC and the ABIM's monopoly control, racketeering, and unjust enrichment that has followed as a result. The ABIM response to that filing is currently due July 6th.  

Our own medical boards have repeatedly poked a sleeping bear with MOC payment and testing requirements. Those requirements have harmed physicians and limited access of care to patients. While this is not an easy path to find justice, the best victories are those that are hard fought with lasting and meaningful results.

-Wes


Tuesday, May 05, 2020

Appeal Filed in Physicians' Ongoing Lawsuit Against ABIM

"ABIM has created a lucrative new revenue source by forcing internists to buy MOC. The new MOC revenue has not been used in the interests of the internist community, but to serve the economic interests of ABIM management, including overly generous compensation, ABIM’s lavish pension plan, and purchase of a $2.3 million condominium used by ABIM management."

- From the Brief of Plaintiffs-Appellants filed yesterday
It was almost six years ago the story of ABIM's $2.3 million condominium was told. It was a tale of corruption, greed, and the laundering of physician testing fees to create the ABIM Foundation using the smokescreen of repeated physician testing called Maintenance of Certification (MOC®) as a mark of a physician's "professionalism." Working physicians, however, knew better. They felt first-hand the financial and emotional toll this ever-changing program caused. MOC® was always about the money, but most physicians were too afraid to speak up lest they lose their jobs. Today MOC® remains a story of adhesion contracts to force payments to the numerous conflicted interests of the medical publishing, credentialing, device, pharmaceutical, and hospital supply line industries in exchange for the physician data it generates.

The irony of Richard Baron, MD, President and CEO of the ABIM and ABIM Foundation discussing disinformation on Fox News from the comfort of his own home is lost on few US physicians. So is the irony that the insurance industry is poised to make a windfall on the unaffordable insurance law they helped author.

These conflicts have come at a very stiff price for many United States physicians, nurses, and medical technicians who toil on the front lines without sufficient personal protective equipment (PPE) today. MOC® and the data entry it required fed Group Purchase Organizations and the insurance industry the data they needed to squeeze the suppliers of materials and the suppliers of care. As Siddhartha Mukherjee, MD, DPhil explained in his recent New Yorker article, its all a game of assuring a sizable profit margins for these the little-known supply line organizations who receive kickbacks in return for their efforts:
“Hospitals typically don’t order masks as individual buyers,” he told me. He spoke deliberately, with the slightest Texan drawl. Instead, they negotiate contracts as members of a Group Purchasing Organization—representing hundreds or thousands of hospitals—and, as Bowen explained, the G.P.O. always “chooses the cheapest bid.”
Yesterday the Brief of Plaintiffs-Appellants was filed in the 3rd Circuit Court of Appeals against the American Board of Internal Medicine (ABIM) regarding MOC®. In that Brief, the physician plaintiffs argue that the earlier District Court erred in dismissing (1) the anti-trust tying claims with prejudice, (2) the monopolization claims, (3) the racketeering claims, and (4) the unjust enrichment claims made by the plaintiffs concerning MOC. The details of the clearly-written 78-page brief argue why.

As health care workers struggle to cope with our current US supply line shortcomings, the US physician MOC® story takes on new meaning. Now more than ever, US physicians deserve their day in court concerning the exploitation they have endured because of MOC®.

If this case finally proceeds to discovery, we might just find the real truth about MOC® after all.

-Wes

P.S.: Working physicians are encouraged to contribute the the GoFundMe page supporting the physician plaintiffs in this ongoing case.

Sunday, April 26, 2020

Two ER Physicians Lend Their Opinion on Reopening the Economy

Addendum: YouTube brought down the videos included in this blog post because they claimed it violated their terms of use. I found that very disturbing that non-anonymous US physicians were silenced during these unprecedented times. I believe we should promote (and not silence) legitimate, respectful, critical debate. Whether right or wrong (and certainly many of the facts delivered have been thoroughly debunked by others) their viewpoint opened peoples' eyes.

Because nothing is erased on the internet, readers will find links to the videos on a different platform below the YouTube video placeholders.
"Typically you quarantine the sick. When someone has measles you quarantine them. We’ve never seen where we quarantine the healthy."

"We’ve tested over 4 million… which gives us a 19.6% positive out of those who are tested for COVID-19. So if this is a typical extrapolation 328 million people times 19.6 is 64 million. That’s a significant amount of people with COVID; it’s similar to the flu. If you study the numbers in 2017 and 2018 we had 50 to 60 million with the flu. And we had a similar death rate in the deaths the United States were 43,545—similar to the flu of 2017-2018. We always have between 37,000 and 60,000 deaths in the United States, every single year. No pandemic talk. No shelter-in-place. No shutting down businesses…"

Dr. Daniel W. Erickson of Bakersfield, California, is a former emergency-room physician who co-owns, with his partner Dr. Artin Massih, Accelerated Urgent Care in Bakersfield, CA north of Los Angeles. They conducted a press conference regarding their opinions about reopening the economy and withstood many challenging questions by a hostile press. I encourage my interested readers to watch the entire hour-long press conference:





Addendum: Links to the above videos can be found here:

Part 1: https://vimeo.com/412698864

Part 2: https://vimeo.com/412699764
In a follow-up ABC news piece it is also interesting to note, "Dr. Erickson also claimed that state health department officials also agreed with his statements about reopening. 23ABC News reached out to the state to see if officials agree with Dr. Erickson about reopening and they have no(t) responded back."

We should acknowledge these physicians test patients and have a vested interest in doing so. Whether testing will ever really clear the way toward reopening the economy is debatable in my opinion, given that every test has false negative and false positive results. Yet testing is the popular narrative now.

As we sit in our living rooms staring at Netflix as the economy begins to creak forward, perhaps we should ask ourselves when we're told our salvation will occur after we test billions of people worldwide (which will never happen, in my opinion), who stands to benefit? Likewise, who benefits by promoting more fear and the isolation/distancing narrative?

-Wes

Saturday, April 18, 2020

Rethinking the COVID-19 "Pandemic"


The front page headline of the Wall Street Journal this morning read: "Stocks Rally in Face of Downturn."

Why?

Perhaps they know something we don't? Or have we been too manipulated by fear to look critically at what has just happened thanks to a little-known RNA virus?

I realize that most of the blog posts here lately have been critical of the American Board of Medical Specialties and their 24 subsidiary medical specialty boards, in large part because they rely on rote memorization of trivial facts as a means of gauging physician "quality" and "professionalism" (as they have deemed to "redefine" the term in their 2002 widely-published self-written white paper). Clinical experience gained only after years of complicated and uncertain patient interactions has always been immaterial to these rent-seeking data-collecting medical specialty member boards. But what I'm focusing on now is something much more important for the practicing physician that can't be measured by a standardized test: the ability to think critically in the face of the unknown. After all, most new patient encounters require the ability to assimilate vast amounts of information and distill it clinically for the benefits of an individual patient that has an infinite number of possible clinical co-founders.

We have to remember that 27-year old journalists and younger brilliant physician sycophants of the computerized test, as much as they may mean well, can be easily manipulated by political, economic, and social agendas that have been engrained in our society for years. As clinical physicians, is our job to listen to politicians and economists and those young physicians, or to think critically about an incredibly complicated non-linear (and non-exponential) biologic event that has just swept the world and resulted in the shuttering of so many economies and left over 22 million unemployed in the United States alone?

In the beginning of this evolving WHO-defined pandemic, the world were enamored with mathematical models from economists and pundits based in complicated assumptions - most of which were (quite frankly) guesses and never truly gauged to existing well-known viral illnesses like seasonal influenza. The World Health Organization (WHO) proclaimed early on that this new coronavirus had an incredibly high 3.4% mortality rate. New phrases were quickly introduced into our daily vernacular by the mainstream and social media like"flattening the curve," and "social distancing" as images of refrigerator trucks to house the dead were pushed to our cell phones. But that mortality statistic, we're now finding, was markedly overblown.

Perhaps more important is the way this virus has managed to seek out and impact the most medically vulnerable of our populations: those in close living environments or the socially disadvantaged with serious preexisting medical conditions like obesity, diabetes, lung disease, heart disease, cancers, and blood dycrasias. The elderly in particular, have been remarkably vulnerable to succumbing to COVID-19, in large part because they carry these preconditions far more frequently than younger patients. Health care workers, too, see a skewed population that can seem overwhelming at such a time since we are subjected to an unknown pathogen with an uncertain transmission, prevalence, and unknown lethality. We see the people dying and our bias is reinforced: this must be something BIG.

So how do we gain perspective and reliable data? Do we turn to mainstream media, or print scientific journals that are slow to react and limited in their scope, or do we turn to each other knowing each of us is struggling with the same unknowns? Or maybe that, too, is complicated.

Fortunately, thanks in large part to the internet, the world is quite literally, our oyster. It is time as one British pathologist John Lee has appropriately suggested, that we begin to examine the evidence with "skepticism and vigorous debate." The COVID-19 death toll, and how it relates to our more typical seasonal flu that often impacts hospitals, is far from clear. There is nuance involved in proclaiming a death rate when those dying from a virus are intermingled with those dying with a virus.

Clinical physicians should begin to critically question our national narrative, given these recently updated facts regarding the COVID-19 pandemic from a Swiss physician, each of which are carefully referenced. Look them over. Carefully. Perhaps putting the current situation in perspective from other parts of the world will be more helpful to our patients and their economic and psychologic strife than  taking remarkably expensive and unproven computerized tests created by unaccountable bureaucrats that mean absolutely nothing.

-Wes

Image above from: Lee, J. "How to understand - and report - figures from "COVID Deaths."

Friday, April 17, 2020

COVID-19: A Way Forward

Since the beginning of the coronavirus pandemic and the ongoing Personal Protective Equipment (PPE) shortages I have quietly wondered, "Where is the American Medical Association (AMA)?" Why weren't health care workers and their patients the FIRST consideration of the AMA rather than the making of CPT codes? Is it because the words "physician" and "patient" do not appear in their mission statement?

With an estimated 22 million people currently unemployed in the United States and with states making plans to reopen their economies, a medically cogent path forward out of this pandemic is desperately needed.

It is with that background that I had the opportunity to read this opinion piece by Paul Kempen, MD, PhD that I took the liberty of republishing here. Admittedly, there are no perfect answers right now, but we all need to do our part to bring some semblance of normalcy to our lives again since this situation is likely to continue for some time (I have taken the liberty of making minor edits and have added a few hyperlinks for clarity):

Personal Health is a Personal Responsibility to Enable National Health

Paul Kempen, MD, PhD

"It really amazes me as a physician and health care expert, that while the government and general population expect doctors, nurses - yes, ALL hospital health care workers (HCW) down to the janitor - to go to work every day to care for severely and clearly infected patients, the expectation that the general population cannot even perform daily tasks in low risk environments seems severely misplaced. Being out of doors has even been declared “illegal” in some places. We have seen the country “closed for business” and production capabilities, lives and personal welfare, decimated. If all HCWs are able to work in clearly infected environments, why are citizens unable to protect themselves in low risk environments? Why are there not clear and effective educational and production mechanisms for ensuring regular daily living activities promoted in all media at this time? I have NEVER seen a public educational clip on HOW to correctly wear a mask but have repeatedly seen “experts” without and improperly wearing masks. Are factories and businesses still (really) unable to provide PPE and distancing between workers? WHY? If we can put a man on the moon, we cannot provide education and PPE?

Of course, the lack of Personal Protective Equipment (PPE) has been the serious issue. Government/CDC/WHO “Expert Action” has been unable to address to date the singular outstanding shortage of N95 masks, gowns, and hand disinfectant, or provided accurate and specific instruction/education on personal protective measures. Instead, concentrating on ventilator production (to treat disease) and “testing” to identify infections remains “the answer”. In medicine, we typically test to identify infection based on symptoms - as a healthy, negative tested individual is not protected by the test (due to false negatives) and can become infected by those providing tests to hundreds per hour.

These deflective and reassuring measures apparently resulted politically from “overstated need” by “hot spot Governors” looking for “quick answers” and sound-bytes. Even our CDC “health care experts” got it wrong (or was this merely political decisions): CDC statements initially recommended that civilians should NOT wear masks (because of the shortage), when clearly, masks are the single most important protection against air-born, respiratory infection dissemination. The first thing I personally did when I heard of COVID in January was to order ten N95 masks. Even today, 4/16/2020, three months after the first diagnosed infections were reported in January, this country still does not have enough N95 masks for every citizen. Why? Sending in Navy Hospital ships to NY and LA flies in the face of “Carnival line contagion” episodes: After admitting only 40 patients, the USNS Comfort was infected. The USS Mercy was similarly infected. Will it be also “quarantined”? The medical personnel would have been better utilized on land based stations - but that big red “X” would have not been able to provide the political statement and reassurance in NY harbor.

We have been through infectious hysteria before: The HIV epidemic in the 1980s, which led to important “universal precautions” for self-protection. The SARS (2003) and MERS (2012) Corona infections occurred and should have led to testing and treatment mechanisms decades ago. Flu epidemics occur every year and kill 30-60,000 people-just like COVID and our lessons here should be applied for all future flu seasons-which are coming. Needed measures now include production and education to enable return to economic stability - the ONE essential of any country “at War”:

Instead of forcibly pulling citizens without masks off of a subway train, the CDC and government experts should have ramped up N95 mask production in January to insure at a minimum, one N95 mask per citizen per week. (Editor's note: To be fair, hind sight is aways 20/20) Make N95 masks universally available at no cost to everyone now, including child sizes. They can be disinfected repeatedly by baking at 180 degrees F for 30 minutes. This should NOT require 30 days for each state to insure production for each member of state’s society. (This is much cheaper than $1,200 checks for every tax payer!) Educational commercials should appear hourly and instruct ALL citizens how to wear masks appropriately, the difference in mask types and identify mask type abilities to protect you. Mandating everyone appearing on television to be wearing appropriate masks correctly, as examples to foster compliance, is as possible as legally forcing everyone on an airplane to undergo instruction on how to fasten a seat belt in 2020.

Surgical and home-made masks catch (only most) personal, exhaled droplets and protect to a limited degree those around you. N95 masks will, when correctly worn, eliminate 95% of particles in your INHALED air from reaching you if worn correctly. HCW are “fitted” for N95 masks when hired under OSHA mandates, that is, specifically instructed in proper use. Civilians need this instruction also.

Cut your beard off, shave daily to maximize N95 mask “fit” and effectiveness. Wear masks at all times when not alone and do not touch your face unless immediately after hand washing. Wash your hands frequently (whenever possible contamination occurs), shower and change clothing daily to reduce personal contamination.

If you show signs of infection, contact your doctor for definitive advice and wear at minimum a surgical mask at all times while avoiding others. DO NOT go to hospitals or drive through testing sites if healthy - these sites are high risk areas and those testing hundreds of civilians per hour may well be a significant vector for transmission from infected to those heathy. The tests require invading your body and with unknown hygiene - i.e. out there on the streets where there is no ability to wash hands between individual tests (and I am sure they do not change PPE between each person, given the shortage).

Testing, currently unavailable and with unknown reliability, should be reserved for those with probable/known infection and done in facilities with hand washing between individual tests, unless self testing kits become readily available and are dropped off/mailed in bio-infection labeled and protective packaging (which seems unlikely or reliably possible for general populations).

In addition, we should be testing ALL deaths for COVID presence, instead of declaring all deaths automatically as COVID, as appears to be the current methodology. This is needed to yield REAL numbers.

Insure production of ALL treatment/prophylaxis drugs in sufficient quantities and allow doctors the ability to practice prevention, prophylaxis and treatment tailored to the individual patient and their wishes with all available products - including “compassionate” and “off label” prescriptions.

Serious COVID infections occur in under 5% of all infections. Healthy children and young adults appear resilient. Release this mostly-healthy “herd” now, or when the “surge” is over and create the “herd immunity”. In any “war” the young and healthy are sent to fight and maintain the economy, but please, also provide the needed weapons to them (masks and sanitizers). They will volunteer! Perhaps this group is resilient because they are self-immunized by yearly non-lethal common cold coronavirus encounters which account for 20% all yearly colds creating crossover immunization/disease mitigation.

It is time we all recognize your health is YOUR responsibility. Quit smoking, overeating, passing “joints” and crack pipes and other high risk behaviors. The “opiate epidemic” suddenly disappeared from the news with the COVID19 emergence but it is not gone! As a nation, we must insure our economy and production to maintain wartime abilities. Not just tanks and jets, but drugs, testing, ventilators and PPE should have national priority for “in-country” self-sustaining production. Most drugs marketed in the USA are made from Chinese imported materials at this time. This must change. We must take charge of ourselves and our national security in war and disease. We must stop the media and government hysteria and work with facts, real facts, and not politically motivated reassurances made in the moment as acts of reassurance. Restart the economy to provide PPE and drugs tomorrow for all who need them.

In 1933, the worst year of the Great Depression, President Franklin Roosevelt stated in his inaugural address: “So first of all, let me assert my belief that the only thing we need to fear is fear itself - nameless, unreasoning, unjustified terror, which paralyzes needed efforts to convert retreat into advance.”

This was great advice then and seems especially pertinent on 4/16/2020 before we create another modern great depression. If we are at war, we need our economy to provide for the common good and protection of life, liberty and the pursuit of happiness. The media must be used to serve the people and not continue to create paralyzing terror."
I welcome thoughtful comments to this piece.

-Wes

Tuesday, April 14, 2020

MOC's Irrelevancy To Public Unmasked In Time of Crisis

With the collapse of testing center availability, travel bans, and growing physician clinical demands, the American Board of Medical Specialties' lucrative Maintenance of Certification® program recently proved how unnecessary it was to the public's wellbeing as each of the member boards followed the ABMS's announcement shuddering its entire Spring examination schedule and many maintenance of certification and continuous certification exercises for all medical subspecialties.

The American Board of Family Medicine, which enjoys the richest balance sheet of any ABMS member board with assets of over $137 million dollars, seems to have a hard time letting go however. The ABFM released this multi-page tortuous statement, portion of which is published below:
Changes to Certification Deadlines

At this time, ABFM has made the following accommodations to the deadlines for your continuous certification participation:

All Diplomates with a three-year stage ending in 2020 will have a one-year extension on completing all stage requirements.

For Diplomates participating in FMCLA, the Quarter 1 deadline has already been extended through June 15, 2020; we anticipate extending completion guidelines further for subsequent quarters. For first year participants, we will adjust the meaningful participation guidelines.

Any Diplomate in Year 10 of their certification cycle who opted for the one-day examination will have an additional year to meet their examination requirement.

Any board-eligible family physician with an eligibility end date in 2020, or anyone participating in the Re-Entry process with an end date in 2020, will have an additional year to obtain their certification.

Any Diplomate who also holds a Certificate of Added Qualification with an examination deadline in 2020 will have the option for an additional year to complete the examination requirement.

For those facing financial hardship as the result of the pandemic, we will establish a method for delaying 2020 payments. This will take a short time to be implemented online, but once available, Diplomates will find information about this in their Physician Portfolio.

These extensions do not prevent anyone with a 2020 deadline from staying on the current timeline. Certification activities will be accessible for anyone who wants to use them.


Certification Stage Activity Requirements

We are continuing our efforts to improve our current Knowledge Self-Assessments (KSA) and will begin to support learning on COVID-19 as evidence becomes more available.

Specifically related to the Performance Improvement (PI) requirement, we will be providing a mechanism to meet the PI requirement by telling us about the unprecedented and rapid changes that you had to make in the ways that you deliver care, regardless of practice type or scope.

An extension has been granted to the first quarter deadline for anyone who is utilizing Continuous Knowledge Self-Assessment (CKSA) as part of their certification activities. The deadline to complete your current quarter 25-question set has been extended from March 31 to June 15, 2020. As the experience of the pandemic evolves, further extensions may be needed.

Any Diplomate who had planned to participate in a Group KSA that has been canceled or postponed can still do the activity online in their ABFM Physician Portfolio. The same certification points and CME credit will be applied as if it was done in a group setting.

Seriously?

Let's keep the magnitude of what frontline doctors are doing today in the care of patients during the COVID-19 pandemic, shall we? The above gibberish should be simplified to the following:

"Any ABFM diplomate caring for patients between 1 Feb 2020 and 1 July 2020 and holding a valid medical license to practice medicine while risking their lives and the lives of their loved ones on behalf of their patients during the COVD-19 pandemic has hereby demonstrated all the skills, professionalism, fortitude, and leadership required to establish themselves as a physician in good standing for a lifetime and will receive lifetime certification from the American Board of Family Medicine without restriction. Self-selected continuing medical education for ongoing education, as required by their respective state licensing boards, will be all that is required of these exceptional physician professionals thereafter.""

Instead, the American Board of Family Medicine seems hellbent on proving just how irrelevant, greedy, insensitive, and distracting they are to the care of our patients in this time of unprecedented physical, psychological, and economic need.

-Wes

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.