Wednesday, June 29, 2016

On Brexit and Maintenance of Certification

The degree to which this was a vote that was directed against the British elite is vital to understand. Politicians, business leaders, and intellectuals were all seen as having lost their right to control the system. The elites had contempt for their values - for the nationalism and their interests. This is not a new phenomenon in Europe, but it is one that the EU had thought it had banished. This is not a British phenomenon by any means. This is something that is sweeping Europe and China. It is also present in the U.S., in the figure of Donald Trump, whose entire strategy is to attack the Democratic and Republican leadership and the elite who have contempt for the nationalism and moral principles of those beneath them. It is the general process the West is undergoing, and it came to London (Thursday).

George Friedman, Geopolitical Futures

Could what has happened in London parallel what is simultaneously happening to Organized Medicine in the United States? Cracks have formed in the foundation that American physicians have trusted for years: the Accreditation Council on Graduate Medical Education (ACGME), the American Board of Medical Specialties' (ABMS), American Board of Internal Medicine, the American Medial Association, and our many of our specialty societies. Practicing physicians are looking with a new lens at "politicians, business leaders and intellectuals" who were once trusted to protect the practice of medicine and the physician-patient relationship.

Can our current byzantine system of unelected, unaccountable, non-profit health care organizations "lose their right to control" our health care system - a roughly $3.0 trillion dollar sector or 17% segment of the entire US gross national product? Will they endure under this new level of scrutiny and demand for transparency from those on the front line of health care delivery? How will these structures pivot?

How much tax fraud must occur, how many laws must be broken, how many physician personal liberties must be tossed aside before practicing physicians and their patients demand change?

You can feel the ground shaking.

The silence is deafening.


Friday, June 24, 2016

Heart Rhythm Society Waffles on MOC

On Thursday (yesterday), I received this notice from the Heart Rhythm Society (HRS) concerning their stance on the American Board of Medical Specialty's (ABMS) Maintenance of Certification (MOC) referendum at the recent AMA House of Delegates meeting held in Chicago:
"The American Medical Association (AMA) House of Delegates recently approved resolutions addressing concerns about the American Board of Medical Specialties' (ABMS) MOC program at its annual meeting.

The resolutions are consistent with the HRS concerns and commitment to advocate for changes to the Maintenance of Certification (MOC) program. HRS currently has a representative in the AMA House of Delegates. To ensure that HRS maintains its seat at the AMA House of Delegates, the Society must demonstrate that 20 percent of the Society’s U.S. physician members are also members of the AMA.

The AMA also approved the commissioning of a study that will evaluate the impact of MOC and Maintenance of Licensure requirements on physicians. This study addresses the heart of the debate and HRS looks forward to the results of this important study."
I found this notice puzzling.

While the Heart Rhythm Society states the resolutions "are consistent with the HRS concerns and commitment for changes to the MOC program," it appears they do not understand that the House of Delegates overwhemingly resolved to end Maintenence of Certification immediately:
"RESOLVED, That our American Medical Association call for the immediate end of any mandatory, secured recertifying examination by the American Board of Medical Specialties (ABMS) or other certifying organizations as part of the recertification process for all those specialties that still require a secure, high-stakes recertification examination."
This does not mean changing the ABMS MOC program, it means ending it.

This does not mean studying the ABMS MOC program, it means ending it.

And this certainly does not mean supporting the AMA with our dues when they fail to act in the practicing physicians' best interests either.

Look, it is now abundantly clear that the ABIM did many, many illegal and self-serving activities with our diplomat fees for (at least) the past 27 years. And when they were caught red-handed with their hand lodged in the practicing physician's personal liberty and financial cookie jar, they tried (and continue to try) to cover it up. What they've done is illegal in many fronts. This is not acceptable and none of us need to "change" MOC or perform "another study" on MOC (funded by our dues) to sweep these actions under the rug. MOC just needs to end immediately.

I worry that the HRS leadership doesn't understand how angry practicing physicians are about what has transpired behind our backs as we've struggled to do the yeoman's work of patient care.

Here's the deal:  if the HRS wants my dues for another year going forward, move to end MOC now. Put your actions where our money is. Otherwise, I'll save my hard-earned assets for other things besides supporting groups who don't support those of us on the front line of health care who obey the law and prefer to manage our profession ethically and transparently, rather than through political channels using threats and intimidation as their modus operandi.


Wednesday, June 22, 2016

ABIM's Bedfellows

Right now, the Center for Medicare and Medicaid Services (CMS) has a comment period that extends through 27 Jun 2016 regarding MACRA, the new payment scheme created by the health care industry, to pay physicians on the front line of health care. I encourage every physicians to voice their  opinion about this plan,

Before you do, however, I'd like to remind you of the recent indifference by the AMA regarding the House of Delegates overwhelming vote to end Maintenance of Certification last Monday.  Needless to say, there's a reason why.

Remember those conflicts of interest with Christine Cassel, MD, former President and CEO of the American Board of Internal Medicine (ABIM) and, later, the National Quality Forum, the ABIM, and ABMS?  Remember the huge splash the announcement of those conflicts had when her conflicts were disclosed by Propublica, and Dr. Cassel quickly relinquished her ties to Premier and Kaiser Health Plan and Hospitals? Remember how Christine Cassel, MD pocketed a cool $230,000 ($100,000 of which was in Premier securities) just before Premier, Inc purchased CECity for $400 million?

Here's the image on the front page of the CECity website:

(Click to enlarge)
Look at all of the friends of the ABIM who welcome CECity's services: Johns Hopkins Medicine, the American Osteopathic Association (AOA), Merck, the American Medical Association (AMA), Aetna, The American College of Physicians (ACP), Premier, the ABIM, NextGen, Athenahealth, and Optum. These are just a few of ABIM's corporate bedfellows. The AMA has no interest in what doctors really want or need.  The AMA has no interest in ethics or what's best for patients.

The AMA and the ABIM only have interest in what's best for the AMA and the ABIM.

This is why the ABIM wants physicians to do Maintenance of Certification and enter all their demographic and survey data into the ABIM's database. It has nothing to do with maintaining physician skills but has everything to do with medicine's new digital party.

This is why physicians must act collectively to stop the tax fraud, violations of research ethics, and abuse of our civil rights that has occurred at the ABIM and the ABMS. Because like it or not, you're paying to have your right to practice medicine independently corrupted by these organizations that stand to earn billions from your work while being simultaneously coerced into paying ABIM's fees.


Monday, June 20, 2016

Pennsylvania Medical Society Explains Their Vote of No Confidence Against the ABIM

The Pennsylvania Medical Society just sent this letter to all Pennsylvania physicians explaining their rationale for issuing a "vote of no confidence" against the American Board of Internal Medicine (ABIM):
The Pennsylvania Medical Society (PAMED) believes that continual professional development, lifelong learning, and providing quality patient care based on the best science and evidence to guide medical decision-making is the fundamental cornerstone of what it means to be a physician.

For two years, PAMED leadership has had numerous meetings with senior management at the American Board of Internal Medicine (ABIM) with the purpose of representing our members' high levels of dissatisfaction with the ABIM Maintenance of Certification (MOC) program. Early in this process, we concluded that the reason ABIM leadership was so out of touch with practicing physicians was because nearly every member of the ABIM's board is not involved in the full-time practice of seeing patients. We attempted to work collaboratively with ABIM's leadership to help them better understand that their punitive process is needlessly time-consuming and takes physicians away from their patients. We demonstrated to them that their process is exorbitantly and unnecessarily expensive compared to other continuing medical education activities through which medical knowledge and excellence in patient care can be maintained and demonstrated. Most importantly, we clearly expressed to the ABIM that the content and available medical resources of their secure, high-stakes computer exams bear little to no relevance to the care we render to our patients in our offices and hospitals.

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 others 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 that the ABIM's motivation for their recertification process was primarily driven by little more than financial mismanagement.

If true, what makes these actions so deplorable to physicians is that it was perpetuated on all of us by our colleagues whom we mistakenly believed were part of our medical family. In response to the overwhelming pressure being placed on their leadership, the ABIM has begun a public relations campaign with a barrage of emails and blog posts to create an illusion that they have the ability and the desire to correct this problem. As our PAMED Board reviews these emails, we believe that the ABIM's motivation and ultimate program will continue to have as their cornerstone the creation of as financially lucrative a position as possible for their Board and their misguided foundation.

It is for all of these reasons that I announced at the American Medical Association's (AMA) Annual Meeting last week in Chicago that the Board of the Pennsylvania Medical Society has voted a position of NO CONFIDENCE in the leadership of the Board of the American Board of Internal Medicine. We believe that their current leadership is not capable of reforming the process in an academically meaningful and fiscally responsible way. ABIM leadership has issued an apology for instituting their January 2014 MOC program. The ABIM has admitted that all three aspects of the program were improperly designed and deeply flawed. Millions of dollars were spent by the ABIM in preparation for this program. It can be argued that the January 2014 MOC program was the most expensive mistake in the history of medical education.

In keeping with the consensus of PAMED members and physicians across the country who are embittered with the practices of ABIM, we call for the immediate replacement of the entire ABIM Board and leadership with new leadership, representative of physicians actively participating in the full-time practice of clinical medicine. In the absence of this happening in a timely manner, we plan on calling on ALL specialty boards and societies to listen to their members and to work to remove the MOC process from ABIM oversight. Our PAMED Board is committed to aggressively advocating for all physicians on this important issue. We hope to see more meaningful progress in the coming weeks. We will explore every avenue to bring about meaningful MOC reform and will plan on keeping all PAMED members informed on any progress made in our efforts. Most sincerely,

Scott Shapiro, MD, FACC, FCPP
PAMED President
I hope other state medical societies across the country issue similar statements in the weeks ahead.


Saturday, June 18, 2016

Video: The Gory Details of ABIM Maintenance of Certification

The Pennsylvania Medical Society posted the presentations made at the AMA House of Delegates Meeting at the Hyatt Regency Chicago on 13 Jun 2016 this morning (please see that link for all of the presentations made).

I post just two of those presentations here for your review.  First, the finances of the ABIM and ABIM Foundation that prompted the creation of Maintenance of Certification, as told by certified public accountant, Charles P. Kroll (27 min) (Slides here):

Next, my presentation on how Maintenance of Certification has affected practicing US physicians and their patients (22 min) (slides here):

Spend some time to review these videos and and inform yourself when you get a chance. Then work with your state medical societies and hospitals to end this onerous and corrupt physician program.


It's Time to End the MOC® Brand

After Monday's resounding AMA resolution calling for an end to Maintenance of Certification®, it is time to end, once and for all, the MOC® brand held by the American Board of Medical Specialties (ABMS).

Maintenance of Certification® remains as a failed social justice experiment foisted on unsuspecting and vulnerable practicing US physicians by the American Board of Internal Medicine (ABIM) and the ABMS solely for the dual purposes of financial and political gain. Multiple studies have demonstrated MOC's inability to improve patient care or quality while wasting valuable time and physicians resources to fund this illegal experimentation.  After secretly lifting at least $55 million in diplomate fees to form the ABIM Foundation, MOC® has become the poster child for financial malfeasance, corporate cronyism, conflicts of interest, and fraud.  In all my years of practicing medicine, I have never seen such an egregious violation of medical ethics levied on practicing physicians by some of our own.

Yet MOC lives on in the hearts and minds of the AMA and affiliates of the Accreditation Council for Graduate Medical Education (ACGME). From the AMA press release after Monday's passage of the anti-MOC® resolution, it seems the AMA still thinks MOC® is a good idea:
Asking the American Board of Medical Specialties to encourage its member boards to review their MOC policies regarding the requirements for maintaining underlying primary or initial specialty board certification in addition to subspecialty board certification to allow physicians the option to focus on MOC activities most relevant to their practices
At the same time in an apparent attempt to render MOC® life support, the Accreditation Council for Continuing Medical Education (ACCME) has recently begun co-branding CME with MOC®.  They've even produced a new logo (they call it a "badge" - seen above) for sympathetic training organizations and medical schools to download. It all amounts to brainwashing our youngest and most vulnerable physician professionals that the behavior demonstrated by the ABIM and the ABMS should not only be condoned but promoted.

Practicing physicians have spoken loud and clear about their feelings about the ABMS/ABIM MOC® program.  It's time to end it, all of it, and expunge this horror story from the practice of medicine.


Tuesday, June 14, 2016

AMA House of Delegates MOC Session Recap

It was a beautiful day in Chicago yesterday: sunny, not too humid. I left home early. The sun had risen some time ago and could be seen reflecting off the lake to the front of the downtown skyscrapers highlighting every detail of their construction. Lake Shore Drive is magnificent this time of day. I parked, as many must do each day, down in the basement of a nearby parking garage, making the "early bird special" parking fee of $16 when your arrive before 8 AM.


(Click to enlarge)
I entered the Hyatt and saw a large meeting room across the foyer with a "Southeastern Delegate Meeting" sign outside the huge room. Lots of people with the representative state name on a card in front of them and a man in a bright kelly green jacket sitting next to the speaker stand who looked like a preppy leprechaun: the "Vice Chair." Heh.

I had to find registration at the Hyatt Regency Chicago: no easy task for someone who's never attended the AMA House of Delegates meeting, but approached what must have been a senior delegate adorned with his AMA badge with multi-colored tags draped some 14" beneath it highlighted by political stickers and little metal badges (I learned later you got some of these after contributing to various political action committees). He was cordial and helped direct me to the subterranean registration desk in the East Tower.

There were delightful ladies more than willing to help. "Are you a delegate?" they asked. "No, just a speaker." They gave me a registration card and I filled it out and was promptly handed a badge of my own with a lonely gray "speaker" badge dangling below.

"Don't listen to a thing he says, he's a doctor," someone said behind me. I turned around to find Charles Kroll, who has also just arrived, waiting to register.  I hadn't seen him for two years since we started to work together on the ABIM story. He grabbed his badge and we headed upstairs. I called David Winchester, MD, a delightful young cardiologist that I was introduced to via Twitter  (cardiologist and Florida delegate) and he joined me and Mr. Kroll for coffee.

AMA House of Delegates MOC Meeting
(Click to enlarge)
Next, I called Charles Cutler, MD from the Pennsylvania Medical Society who met us in the lobby of the East Tower. We headed to the meeting room and he introduced me to numerous people: Steven E. Weinberger, MD of the American College of Physicians (Executive VP and Chief Executive of the ACP), Stephen R. Permut, MD, JD, (Chair of the Board of Trustees of the AMA), and newly-elected Board Member of the American Board of Internal Medicine (ABIM), Yul Enjes, MD, among others. Only later did I realize Lois Margaret Nora, MD, President, and Chairman of the American Board of Medical Specialties (ABMS) was there, too, among many others (seated in the back, far right). Many stood in the back of the room despite available chairs in the front of the room (some things never change).

As luck would have it just before we began, the projector bulb blew shortly after it was turned on so another projector had to be retrieved. Meanwhile, the videographer had set up and was ready to go, but we had to remain seated as we spoke to use the available microphones. Once the new projector was secured, we were ready to begin.

Mr. Kroll went first (slides at link, video here) and explained his background as a forensic accountant specializing in health care and non-profits to the audience. He began discussing his educational background, credentials, prior experience with other non-profit shenannigans in Minnesota (Alina/Medica scandal) and his experience working with the attorney general there. He then explained how he stumbled across the ABIM story (a former article by Linda Girgis, MD asking if ABIM was "extorting" physicians). He pulled the ABIM's financials and immediately found discrepancies and outlined many of his findings to the audience. You could see heads shaking with disbelief. He kept it simple and understandable.  It was devastating. He then told the story how he contacted a mainstream media outlet who requested the last twelve years of audited financials from the ABIM and how the ABIM refused to produce all but the last year, and only if they met in persons to review them together. Evidently, the reporter politely declined and then requested these financials from the PA Attorney's Office (who never responded).  Only after a request was made to the press secretary of the PA Governor's office were the last two years' of audited financials produced. Mr. Kroll, who had these full financials in his possession, then noted that when the ABIM published them, they failed to publish six key parts of those financials on its website. Only after he disclosed this fact in an article in MedCityNews, did the ABIM recant and post the full financials. Finally, we concluded with a description of the meeting he help with the Iowa Attorney General's office and the recommendations he made regarding actions the Iowa AG could impose on the ABIM and their Foundation.

I was next.

In my presentation (a rather large Powerpoint presentation can be downloaded here, video here), I discussed my background, the background of how Board certification, how the philosophy of lifetime certification morphed to time-limited based on the ABIM's assertion that older physicians lost their skills over time, but then pointed to the paradox of the "grandfathering" of physicians and the inherent age discrimination against our most vulnerable physicians with that policy change. I also explained patient's definition of the excellent physician vs the ABIM's definition, and reviewed the costs in terms of out-of pocket costs and time involved (detracting from patient care). I also touched on the creation of the ABIM Foundation and the transfer of funds from the ABIM to the Foundation for "research" and showed the webpage asking for physician data for more "research" without informed consent and disclosure to physicians who were serving as study subjects in violation of the Belmont Report. With the purchase of the ABIM condominium, perhaps they were performing investment research instead, I suggested. I then summarized much of what has transpired with the ABIM and asked the important question, "How did it get this way?" and why I thought it happened. Finally, I summarized the disturbing code of silence that has surrounded the ABIM controversy by using the "Little Red Hen" allegory. The only people who will fix this mess is practicing physicians, starting with a full investigation of the responsible parties.

Next up was Bonnie Weiner, MD, board member of the National Board of Physicians and Surgeons ( who gave an update of their efforts to create a more credible board credential for assuring continuing medical education. She expressed concern that future modifications to MOC will result in making one wasteful test taken once every ten years into many worthless tests over the same time period. She summarized the philosophy and finances of the and explained that she could no longer serve as an interventional cardiology program director because she refused to perform MOC for that credential. (So much for "voluntary" certification!) She noted over 30 hospitals now accept NBPAS as an alternative to and emphasized the need to have competition in the credentialing market.

With the last presentation by Scott Shapiro, MD, President of the Pennsylvania Medical Society, a shot was fired across the bow of the ABIM. Dr. Shapiro announced that the PA Medical Society was publicly announcing  their "vote of no confidence" against the ABIM and approved funds to evaluate legal options against the ABIM:
Today, at the AMA Annual Meeting in Chicago, our Pennsylvania Medical Society Delegation convened a national discussion panel to present their research findings, insights, and recommendations regarding the failures of the American Board of Internal Medicine and the MOC process. The discussion regarding the actions, finances and possible historical motivations for the ABIM actions was eye-opening and alarming.

Notably, during the conference, we announced that our PAMED Board of Trustees—after reviewing the available data and recent ABIM actions—voted and are now issuing a statement of no confidence in the ABIM's Board and leadership.

We also announced that, earlier this year, our PAMED Board approved the necessary funding to move forward with obtaining a legal opinion into whether PAMED would have standing to file a lawsuit against the ABIM. We hired a firm and recently received their opinion that not only would we have standing but they found potential legal claims consistent with our concerns that could be filed in a lawsuit against the ABIM.

Physician leaders from many other states have inquired about how their state can join PAMED's efforts. We look forward to these and other strategic conversations in the near future.

You could have heard a pin drop.

After his announcements (and I probably missed a few key words), the floor was open for question and answer. Lots of people asked questions respectfully. Many were in support. Some were disappointed that there was not a more broad perspective of the opposite arguments for MOC on the panel. One physician with lots of tags on his chest approach the microphone saying," I learned a lot today in this session. Most of all I learned that I'm really glad I never became an internist." (He was an anesthesiologist). The room burst into laughter. He then went on to express his like of anesthesia's "MOCA minute" initiative but never disclosed if he had conflicts with the program or how much it cost. (By now, Dr. Nora from the ABMS had joined the question and answer line.)

It had to be difficult for Dr. Nora to enter this room, but I respected the fact that she came to the microphone to point out her views.  Unfortunately, rather than mentioning anything about the corruption we had just uncovered, Dr. Nora seemed upset that I had been inaccurate with my portrayal of where the ABMS gets their money (I am paraphrasing here). She also commented that we have been given a privilege to self-regulate and that we should consider carefully what we are doing. I then asked her a question as she walked away. She turned to answer. My question was this: "Have you ever studied what happens the physicians that you fail and what happens to their patients in turn?"  She stated she didn't "understand" my question and then proceeded to redirect to another topic before turning to walk away. Perhaps there will be an audio feed soon of this interaction. It wasn't one of our chief regulator's best moments.

Other questions kept coming, with many shifting to "what's next?"  Unfortunately the session went 30 minutes over and another meeting needed the room.

Finally, it was over.

I would like to take this moment to thank Charles Cutler, MD of the Pennsylvania Medical Society for his invitation to speak in this important venue. I am glad I could meet the players in this saga firsthand. There's no excuse for delaying any longer. Everyone knows the problems. Illegal stuff has occurred.

I can only hope those responsible take meaningful and serious steps to resolve the financial malfeasance, corruption, cronyism, and lack of accountability that has been ongoing at the ABIM (and other affiliated member boards of the ABMS hierarchy) for so long.  Otherwise, it's going to get very ugly very quickly.

Practicing physicians across the US have had enough of the ABMS MOC requirement shenanigans.


AHA House of Delegates MOC Session Speakers, June 13, 2016
(L to R: Scott Shapiro, MD, Bonnie Weiner, MD, Charles Cutler, MD,
Wes Fisher, MD, and Mr. Charles P. Kroll)

P.S.: I will post a link to the videos of the sessions as soon as they become available.

Monday, June 13, 2016

Dr. Wes Speaks At the AMA House of Delegates Meeting on MOC

This morning I will be speaking at the AMA House of Delegates Meeting in downtown Chicago at the Hyatt Regency Hotel, 151 Upper East Wacker Drive, Columbus Room E-F at 09:00 AM CST to encourage the abandonment of ABMS MOC re-certification for other alternatives.

For those unable to make the talk, you can download the full Powerpoint presentation here.