Monday, March 03, 2014

When Regulators Pay for Peer-review

The ongoing controversy among US physicians over newly-implemented "Maintenance of Certification (MOC)" requirements created by the private organization, the American Board of Medical Specialties (ABMS) and its 24 subsidiary subspecialty boards has breached another ethical front: paying for peer-reviewed publications in support of their expensive and proprietary MOC process.

In the Fall of 2013, the ABMS single-handedly funded an entire supplement devoted to the MOC process in the Journal of Continuing Education in the Health Professions. This journal is published quarterly by the Alliance of Continuing Education in the Health Professions, the Society for Academic Continuing Medical Education, and the Council on CME of the Association for Hospital Medical Education. Not surprisingly, the articles published were uniformly favorable about the MOC process despite evidence to the contrary. The American Medical Association (who also stands to benefit from the process politically) was quick to provide a free link to the full pdf of the supplement from its AMA Wire news bulletin.

Interestingly, the literature review of the MOC process performed by Lipner et al. (page S20 of the supplement) admitted the limitations of their review:
"First, we did not consider certification by other entities other than ABMS boards; these results may not generalize to other certification bodies. Second, we did not use a formal system to judge the quality of the methodology used in the studies. Third, a meta-analysis to compared effect sizes across different data types was not done; designs were extremely diverse, and it may not be possible with the information available."
Given these limitations, the "value" of the MOC process, based on the data, is totally subjective. Despite these glaring limitations, the article concludes:
The main goal of certification is physician accountability to the public (editor: note that the "patient" and "doctor" are not mentioned). We have shown that a substantial body of evidence supports the value of certification and MOC in meeting that goal but the evidence is not unequivocal. In response, the ABMS have begun to enhance their programs to be more authentic and relevant to practice while maintaining their rigor and continuing to study the program's validity."
If the way the ABMS "enhances" the value of its proprietary MOC process is to pay for peer-reviewed publications that ignore the serious limitations mentioned by the authors themselves, then those directly impacted by the MOC process (like myself) have an obligation to question the validity and ethics of the ABMS's self-promotional practice.

I welcome the ABMS's response regarding their practice of paying for publications in support of the MOC process in the comment section of this blog.



Anonymous said...

The ACC supports the MOC wholeheartedly. The current president of the ACC, John Harold, is a tremendous supporter of the intensified MOC requirements. He is also part of the ABIM that unilaterally jammed these changes down the throats of physicians. The ACC stands to benefit by having cardiologists come to the national meeting to obtain MOC points.
These people are corrupt to the core with their own self interests and conflicts.

Anonymous said...

Wes: This is only one aspect of the low moral s exhibited by the ABMS crew. They continue to author papers while declaring "no conflicts of interest" while the papers are clear advertisements for MOC program. It is time that all MOC related articles be declared advertisements and paid by the ABMS and affiliates as exactly that! Their corporate mission is no different from that of a drug or device corporation. The only difference from a NON=profit to a for profit corporation is as follows:
For profits provide a service to make money, non-profits make money to provide a service. The ABMS has over $400 million in IRS declared assets-indicating significant profits over the years! Any non-profit paying the execs more than a typical doctor salary in that profession should graduate to for profit and pay taxes. Any non-profit with gross earnings exceeding $1 million a year similarly should pay taxes.

Anonymous said...

As always, good info and analysis. Is this a surprise ? For years the AMA, and to some extent, the sub-speciality societies have :a) been in bed with driving a revenue objective- screw the docs- as with AMA; 2) or, reactive to the 'cr_p' that comes from Washington &/or AMA-- seemingly always after the fact; 3) sat by the sidelines as ACA, Pfizer , AMA, AARP, GE, etc,,,, "helped " create the present medical system disaster. Too strong ? Perhaps? Look at the new codes ! Jeez ! Talk to med school students & recent grads. Check out affects of the medical device tax ( loss of jobs + worse= loss of needed technologies).
Physicians have the power, if they wish to use it. Patients who are educated will rise to supporting theses causes.
Sorry for the rant. Know too many patients and doctors who are being 'medically-micro managed' - and, not in the progress direction.
NOW, is the time to speak up and organize --- this is a crucial election year. Hopefully, physicians ( and ,patients) will take part !

Paul Kempen said...

The credentialing developments described by the OP of this thread are not surprising. Indeed, the natural history of any bureaucratic entity must include the generation of rules, procedures, restrictions, forms, fees, investigations, penalties, and educational material which shows how vital the respective entity is for the nation, civilization, etc. These productions are the lifeblood of the entity, since its first duty and task is to survive and expand its power. And its resistance to attrition and extinction can be as intense and extended as that of a biological organism fighting to survive. A very telling example is the Board of Tea Tasters: it took 20 years of bipartisan efforts spanning four administrations to finally close it down, after 99 years of existence and millions of tea brews, collections of samples, reports, stats, and permissions/restrictions of tea importation.
However, what we must observe with regard to our Medical Boards and Institutions is that our own profession has begot them. One hundred years ago, the Hippocratic “hypocracy” (leadership of hypocrites) of our allopathic forerunners decided to get the competition of homeopaths, naturopaths, and others out of business by resorting to the police powers of the governments. Medical Licensing was born, not as a private credentialing and certification agency, but as a general patent grant of exclusive economic rights, contrary to the US Constitution and to the British pro-market revolution initiated by the 1624 Statute of Monopolies, but very much in keeping with the burgeoning crony capitalism that swept the 20th century, introducing socialism through the back door of the progressivist movement and the figment of government-business cooperation, the American version of fascism.
The sea change that followed in medical ethics was not immediately apparent, as the medical hypocracy alleged its continued commitment to the patient-centered Hippocratic values, even as behind the scenes it allowed vast inroads of the coercive-collectivistic values of a Platonic type of medical ethic. As you might recall, 24 centuries ago, in The Republic, Plato advanced the concept that the physician's allegiance is to himself and the other holders of power, not to the patient: “The business of the physician, in the strict sense, is not to make a profit but to exercise his power over the patient's body.” And Plato clearly explained, “This then is the kind of medical and judicial provision for which you will legislate in your state. It will provide treatment for those of your citizens whose physical and psychological constitution is good; as for the others, it will leave the unhealthy to die, and those whose psychological constitution is incurably corrupt it will put to death.”
It is of course high time for us to re-evaluate the sordid achievements of the politically and bureaucratically based Medical Licensing that we live and practice under today. Far from being crazy, its standards and procedures only reflect the natural course and propensities of this century old arrangement.
To put it more allegorically, no pact with the devil can portend the eternal life and perpetual happiness that the deceiver promised in order to get the agreement signed.