Saturday, December 17, 2016

Physician Burnout and MOC: Treating the Cause, Not the Symptoms

This brilliant essay appeared in Practical Neurology Nov/Dec 2016 issue by Paul G. Mathew, MD, FAAN, FAHS. Dr. Mathew is on staff in the Department of Neurology and is Director of Continuing Medical Education at the Brigham and Women’s Hospital, John R. Graham Headache Center, and staff neurologist at Harvard Vanguard Medical Associates and the Cambridge Health Alliance. He  also serves as the neurology representative on the volunteer advisory board of the National Board of Physicians and Surgeons. 

Here's a brief example:


As a volunteer board member of NBPAS (no compensation or honorarium as opposed to the salaries of ABMS board members, which can range from $300,000 to greater than $800,000), I have often wondered why private payers require MOC when Medicare does not require board certification or MOC. The answer is quite disturbing. Private payers actually participate in certification, which is issued by the National Committee of Quality Assurance (NCQA). Margaret E. O’Kane is the founder and president of the NCQA, and she is also a member of the ABMS Board of Directors. The NCQA requires private payers to require physicians to participate in MOC in order to be NCQA certified. Thus, anyone contracting with a private payer will require MOC. In the conflicted case of Ms. O’Kane, she profits from the NCQA requiring private payers to require physicians to participate in MOC, and then she profits again from her ABMS position when said physicians must pay to comply with MOC requirements.

Read the whole thing.

Dr. Mathew will be giving Neurology Grand Rounds at Michigan State University/Sparrow entitled "Maintenance of Certification: Reform or Reboot?" on 13 Jan 2017 from 07:30-08:30 AM EST. All are welcome to attend.


Friday, December 16, 2016

Philadelphia Medicine Magazine's ABIM Issue

An entire issue of Philadelphia Medicine magazine devoted to the American Board of Internal Medicine (ABIM), (pdf  here) and the ABIM wouldn't respond other than to say:
"We do not feel that this format appropriately presents the variety of viewpoints about MOC."

The magazine attempted to invite Richard Baron, MD to give the ABIM's side of the story but he declined. This speaks volumes.


Wednesday, December 14, 2016

ABMS/ABIM MOC Controversy: 2016 Year-in-Review

It's hard to believe that another year has come and gone since my 2015 update on the ABMS/ABIM Maintenanence of Certification controversy. I thought it would be important to maintain this chronological annual review of the ABIM and their conspiring organizations to keep physicians and the public apprised of the situation unfolding. Here is the timeline of the major developments regarding the ABIM MOC controversy for the past year so far:*

  • 12 Jan 2016 - All ABIM archived webpages published after 1 Jan 2014 are removed from the internet archive Wayback Machine at

  • 13 Jan 2016 - More evidence for improper research practices used at ABIM surface on the ABIM website as physicians are asked to "update their profile" so the ABIM can research ways to "improve health care." ABIM diplomates are not informed on the research being conducted nor have they been given informed consent about the research activities being conducted.

  • 21 Jan 2016 - ABIM Foundation publicly discloses for the first time $56 million in transfers (unverified) from ABIM since 1990.

  • 26 January 2016 - Robert Wachter, MD, former Chairman of the Board of the ABIM and its Foundation, publishes a New York Times opinion piece entitled "How Measurement Fails Doctors and Teachers" and suggests "the secret of quality is love." With the article, Wachter  fails to disclose his own conflicts with the "measurement industry" at the ABIM and ABIM Foundation and the stock earnings he received from IPC Hospitalist Company (later acquired by TeamHealth) that is under federal investigation for overbilling Medicare.

  • 16 Feb 2016 - The website goes live to support the legal defense and countersuit of Jamie Salas-Rushford, MD, a Puerto Rican physician sanctioned and then sued by the ABIM in 2012 for allegedly disclosing ABIM test questions to Rajender Arora, MD, the creator of the now defunct ACGME-accreditied Arora Board Review courses as he studied for his certification examination. Numerous sanction letters and court documents against Dr. Salas Rushford appear online.

  • 8 March 2016 - The peer-reviewed journal article, "Medical Specialty Certification in the US - A False Idol?" is published.

  • 11 March 2016 - Like the practicing physicians' anti-MOC activities underway, medical students push back against another unneccessary and expensive testing requirement: the National Board of Medical Examiners' Step 2 CS requirement.

  • 12 March 2016 - The sworn testimony of Rajender Arora, MD of the ABIM's raid on his home by Federal Marshals appears online and offers remarkable details of the operation ABIM used to gain access to hundreds of review course attendees' personal information and email accounts.

  • 1 April 2016 - Robert Wachter's industry-sponsored blog, Wachter's World, disappears from the internet. Recall that Wachter's company, IPC The Hospitalist Company, for which he served as director and received 3,995 shares of stock valued between $50.68 and $58.50 per share, was sued by the Department of Justice for was overbilling federal insurance providers. The company was later acquired by TeamHealth 23 Nov 2015 for $80.25 a share, netting him and his University, the University of California, San Francisco (with whom he had a sharing agreement with), a comfortable profit.

  • 26 April 2016 - Oklahoma passes comprehensive anti-ABMS MOC legislation and ABMS responds.

  • 10 May 2016 - More changes to the ABIM MOC program to be implemented 1 Jan 2018 that includes more frequent testing are announced.

  • 12 May 2016 - Public disclosure of American College of Physician's Executive Vice President Steven E. Weinberger, MD's upcoming retirement appears.

  • 13 May 2016 - ABIM posts June 30, 2015 Form 990s. ABIM Foundation reports correct year and state of incorporation after six years of inaccurate reporting.

  • 20 May 2016 - The ABIM Foundation moves $6.5 million of diplomate testing fees offshore to the Cayman Islands in fiscal year 2015.

  • 9 June 2016 - The dark story of ABIM's felonious "Director of Investigations" and the strongman tactics used by the organization against economically vulnerable physicians is reported.

  • 14 June 2016 - Scott Shapiro, MD, Bonnie Weiner, MD, Charles Cutler, MD, myself, and Mr. Charles P. Kroll appear before the AMA House of Delegates meeting in Chicago to deliver our evidence supporting financial and professional mismanagement at the ABIM that culminated in the Pennsylvania Medical Society issuing a formal "vote of no confidence" against the ABIM.

  • 16 June 2016 - The AMA membership presses for an immediate end to MOC.

  • 2 July 2016 - Expanding investigations of other member boards of the American Board of Pediatrics reveals retired President and CEO of the American Board of Pediatrics, James A. Stockman, III, MD earned $793,438 working just eight hours a work-week as an "advisor."

  • 10 July 2016 - ABIM Foundation sells its controversial luxury downtown Philaelphia condominium at an estimated $1.2 million loss.

  • 21 July 2016 - The untold story of three ABIM-sanctioned physicians appears that chronicals the humiliation, ethics course requirements, and a $5000 check one of them had to pay ABIM to reinstate their certification.

  • 2 August 2016 - Several doctors of osteopathy file a class action lawsuit against the American Osteopathic Association seeking to recover millions of dollars in annual membership fees that the doctors allege they have been forced to pay for years to the organization to maintain their certification.

  • 4 August 2016 - ABIM Foundation shifts from defining and promoting "medical professionalism" to "co-creating" health care.

  • 5 August 2016 - Medical Economics publishes MOC promotional piece by Richard Baron, MD, President and CEO of the ABIM, then asks for a physician rebuttal via its Twitter feed. After writing the rebuttal at their request, Medical Economics refuses to publish it. The rebuttal is published on these pages and received over 10,000 page views within 48 hours.

  • 24 September 2016 - Retirement plan and change in audit firm disclosed publicly for the first time: value of ABIM's 100% employer funded Retirement Plan now exceeds combined value of ABIM and Foundation accumulated since 1936 (ABIM) and 1989 (Foundation).

  • 28 September 2016 - My 22-minute talk on "Why MOC is Broken and How to Fix It,  delivered at the AAPS meeting in Oklahoma City, appears (video).

  • 16 October 2016 - How the major medical journals, including JAMA and the New England Journal of Medicine, shield ABMS authors' conflicts of interest via IRS Form 990 tax filings and do not report these conflicts (and their own conflicts with the program) in their journals.

  • 16 October 2016 - The California Medial Society holds a debate between Lois Margaret Nora, MD, JD, CEO of the American Board of Medical Specialties and Paul Teirstein, MD, the unpaid President and CEO of the National Board of Physician and Surgeons. Attempts to shorten Teirstein's talk by the moderators are shouted down and Teirstein delivers his 14-minute talk and then receives a standing ovation (video).

  • 27 October 2016 - Press release announcing the retirement of ABMS President and CEO, Margaret Lois Nora, MD, JD appears.

  • 28 October 2016 - Mayo Clinic Proceedings publishes a survey on MOC with editorial commentary by James C. Puffer, MD, the President of the American Board of Family Medicine (ABFM), yet fails to disclose the ABFM's financial conflicts with MOC that includes running ABFM Realty, LLC, a firm that manages a $4.2 million office building purchased with ABFM diplomate testing fees in 2012.

  • 11 November 2016 - ABIM certification scoring methods that changed pass rate cut-offs are disclosed.

  • 14 November 2016 - Resolution 607 re: request for independent ABIM audit, passes in AMA House of Delegates.

  • 21 November 2016 - Letter from the American Board of Anesthesia threatening to report a physicians' certification status as "Not Participating in MOCA" if he does not pay for and complete their MOCA-Minute program by 21 December 2016 appears. (The impact on the physicians' ability to receive payment from insurers if this occurs is not mentioned).

  • 1 December 2016 - New England Journal of Medicine publishes "Knowing What We Don't Know - Improving Maintenance of Certification" by Richard Baron, MD and Clarence H. Braddock, III, MD, MPH, both employees of the American Board of Internal Medicine, and fails to allow comments or rebuttal, and (once again) fails to disclose the Journal's conflict of interest with the program.

  • 2 Deceember 2016 - The American College of Cardiology sends an email to all of its members announcing their collaboration with Part IV of MOC program and their approval as a Portfolio Program Sponsor by ABMS.

  • 16 Deceember 2016 - Philadelphia Medicine magazine publishes issue dedicated to ABIM. ABIM declines to contribute, stating "We do not feel that this format appropriately presents the variety of viewpoints about MOC." (PDF of entire issue available here.)


*Additional updates to this timeline with be made for the remainder of December as needed or if other newsworthy events were missed.

Saturday, December 03, 2016

Chicago's Cold December Game Plan

In June 2016, "Chicago" had a problem. A small renegade group of doctors had uncovered some dirty secrets about the Chicago-based American Medical Association's (AMA) subordinate organizations, the Philadelphia-based American Board of Internal Medicine (ABIM) and its Chicago-based mothership, the American Board of Medical Specialties (ABMS). Action was needed. It would have to be invisible to the lay public. It would take a slick, well-coordinated game plan. It would also take some money. People don't mess with The Chicago Machine.

The major players assembled in the room to get some background on the problem. They'd have to understand the depth and breadth of what was known before they could structure a counter-offensive using every option at their disposal: ties to leadership at medical journals, public relations groups, finely-tuned email lists, and buy-in from like-minded medical societies who needed the AMA's political clout on Capital Hill - the works.

There they were, all the major players in one room, looking less than happy to be there to hear me (of all people) and my colleagues who were rattled to our core at what had transpired in the bureaucratic House of Medicine for all these years.

The room took a while to fill at first, but as time for the presentations approached, they were standing room only. The early attendees looked a bit worried. Those arriving later appeared less concerned for time and money were on their side. Many of the dignitaries were introduced to me by Charles Cutler, MD, from the Pennsylvania Medical Society who had invited a few of us to attend: the President of the Board of the American Medical Association (AMA), the Executive Vice President of the American College of Physicians (ACP), members of some of the medical national medical societies. All in one room to hear me and Mr. Charles Kroll, a certified public account, give our little talks (seen here and here).

They listened intently. They asked no questions. They needed to think. Poor Lois Margaret Nora, MD tried to come to the microphone to defend her actions feebly. It was clear to them she was a liability. More senior veterans at this game would have to step in.

It was a time to marshall the considerable resources of Chicago's medical establishment's senior spin experts: the American Medical Association and their collaborators at the Accreditation Council of Graduate Medical Education. They knew they could do this. After all, it had been done before when Thomas Brem, MD testified before Congress 30 April 1969 after he was paid from "Special Account No. 4" maintained by tobacco lobbyists. (See US District Court for the District of Columbia, United States of America v. Phillip Morris USA, Inc, et al., Case 1:99-cv-02496-GK Filed 8/17/06. Page 174 of 1683. Available at: ) We are beginning to see telltale signs of a similar well-coordinated plan to forward a separate, non-patient care agenda against the practicing physicians who had grown restless.

First, the leadership recognized that change was needed. Dr. Steve Weinberger, Executive Vice President of the PhiladelphiaChicago-based ACP had heard enough and wisely wanted out. He could see the writing on the wall and had given plenty of time, energy and effort to the ACP. He announced his retirement. Lois Margaret Nora, MD, JD wanted to stay on but knew she couldn't. She, too, announced her retirement but was asked to stay on until the end of 2017 to help "smooth" the transition. Or to be a fall guy. (This is Chicago, remember.)

Second, a "go live" date had to be set. 1 December 2016, just before the new US President took office, would be perfect.

Third, an article would have to appear in the New England Journal of Medicine without an accompanying rebuttal article reaffirming the importance of MOC and how hard the ABIM are working to modify it. This article would serve as the "starting gun" for all that was to occur next. In turn, Richard Baron, MD would serve, once again, as sacrificial lamb and receive a "special fee" above and beyond $800,000-a-year ABIM salary in return for "publishing" the article (see the article's disclosures). Perhaps this was because Dr. Baron and Braddock didn't write a substantial part of the it, we can't be sure. Practicing physicians would be appalled by the piece containing many non-scientific assertions. It didn't matter. They liked the use of the example where anyone can become an ordained minister online to justify ABIM's unproven maintenance of certification program as a "solid," and "valuable" standard. No one would dare comment that the ABIM's secret, black-box antiquated questions (held secret behind a thin veil of threats of prosecution for leaking those "secrets") were any more "solid" or "valuable" than those "internet based" ministry credentials. Especially if the New England Journal of Medicine didn't allow comments. Furthermore, Baron and Braddock's must make board certification sound as though it was "always" supposed to be time-limited. No one must know that Walter Bierring, MD, the unpaid organizer and first officer of the ABIM never intended the test to become a mark of adequacy to practice medicine rather than an optional sign of excellence. (See: Bierring WL. The American Board of Internal Medicine. Ann Intern Med 1937 10(12):1746-1751.) Denis M. O’Day, MD and Mary R. Ladden, BA's peer-reviewed article on the history of board certification, published the criteria of the American Board of Medical Specialties member boards that stated their voluntary nature and the requirement their tests and programs NOT be tied to the ability of a physician to practice. And practicing physicians certainly should not know about the first recertification test, taken by internists on 26 October 1974,  recommended that "no one should lose their primary certification as a result of the examination."(Meskaukas JA and Webster JD, The American Board of Internal Medicine Recertification Examination: Process and Results. Ann Intern Med 1975 82: 577-581). To provide cover to these facts, Drs. Baron and Braddock must use ABIM's usual strongman tactics and threaten "escalating consequences for unsatisfactory performance over time" in their piece. And so it was.

Fourth, that evening after the New England Journal of Medicine article appears and people have a chance to digest it, a mass email must be sent to all members of the American College of Physicians announcing their "new pilot MOC program" in coordination with the American College of Cardiology (ACC) and the ABIM that promised to "ease the burden and increase the relevance" of the ABIM MOC process. Specific details like time frame, cost, and methods must not be disclosed, however.

Fifth, more pressure must be applied. The AMA and the Committee of Medical Subspecialty Societies (based in Chicago) will coordinate with the American College of Cardiology to use the ACC's considerable financial and political clout to re-introduce the previously-suspended Part IV "Practice Improvement and Safety Modules" via an email to its members the following day. After all, it took a lot of lobbying to assure Part IV of the ABIM MOC program was woven into the new physician "value-based" payment scheme called the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). For their help, the ACC should be granted "Program Sponsor" status of the ABMS Multi-Specialty Portfolio Approval Program. The message to lowly physicians MUST be: "Participate in MOC or don't get paid, sucker!"

It all seemed like such a good idea at the time. Those pitiful physicians wouldn't stand a chance. The Chicago Machine was in charge. It would be easy to roll over those quiet, unassuming doctors with this plan once and for all!

And then the unimaginable happened. An unanticipated Presidential candidate won the election. Like BREXIT, the medical political establishment were caught completely off guard. None of them could imagine it happening. And even though larger and larger numbers of doctors weren't buying the propaganda of the Affordable Care Act (ACA) and MOC any longer, the AMA, heavily invested in the ACA construct, stuck to their plan to strong-arm physicians with these MOC "modifications" anyway.

Practicing doctors and their patients have been waking up to what the medical establishment have done to the middle class and the practice of medicine in America. We've been slow to catch on thanks to the realities and time required for this thing called patient care, but the reality is profound.

Thanks to Maintenance of Certification, practicing doctors are not so easily fooled any longer and with a new sheriff in town, the Machine might just have to go to an alternate Plan B in January 2017 or face some serious consequences.


Thursday, December 01, 2016

Knowing What We Don't Know

This week, Richard Baron, MD and Clarence H. Braddock, III, MD, MPH, both paid staff of the independent and unaccountable American Board of Internal Medicine (ABIM), received more (free?) advertising space in the New England Journal of Medicine to publish their perspective piece entitled "Knowing What We Don't Know - Improving Maintenance of Certification." While my readers are welcome to read the piece, rest assured there is nothing new there except more unsubstantiated excuses to prop up this expensive, wasteful, and corrupt enterprise.

I believe these authors should be very clear that physicians are quite aware of "Knowing What They Don't Know" about Maintenance of Certification (MOC), the ABIM, their collaborators at the American Board of Medical Specialties.

Here's what we don't know:

1) Who wants Maintenance of Certification so badly that Drs Baron and Braddock are allowed to publish their promotional piece in the New England Journal of Medicine after US physicians have overwhelmingly voted to end MOC immediately in the June 2016 AMA House of Delegates meeting? We can hypothesize many possibilities:

  • The New England Journal of Medicine itself, who stands to profit from their Knowledge+ educational product for MOC preparation.

  • The ACGME and its many members like the ABMS member boards, the AMA, the American Hospital Association (AHA), and Association of American Medical Colleges (AAMC) who stand to profit directly from the program and or by the anticompetitive practices it creates.

  • The multibillion dollar physician testing industry (Pearson, Prometric, etc.)

  • The major players in the US medical insurance industry (Blue Cross Blue Shield, Unitedhealthcare, Aetna, Cigna, etc.) who want to reduce their costs for expensive experienced physicians in lieu of physicians extenders, using the "National Committee on Quality Assurance" as their scapegoat?

  • Or perhaps, it's all of the above?

2) Why did the ABIM feel it could funnel $55 million of diplomate testing fees from 1989 to 1999 to fund its secretly-created (and undisclosed until 1999) ABIM Foundation?

3) Why has the IRS not investigated the repeated ABIM Foundation Form 990 tax fraud regarding the date and state of its Foundation's origin and the non-disclosed lobbying activities?

4) Why has the ABIM Foundation moved over $6.5 million of diplomate test fees offshore to the Cayman Islands in 2014?

5) Why were lawyers from ABIM's legal team, Ballard Spahr, and Ariel Benjamin Mannes (their two-time convicted felonious "Director of Investigations") allowed to accompany Federal Marshals during a home raid of two physicians homes that had developed an ACGME-accredited board review course? What agreement (monetary or otherwise) exists between the Dr. Rajender Arora (the director of the course) and the ABIM?

6) Why has the antitrust case filed by the Association of American Physicians and Surgeons against the ABIM, originally filed in New Jersey and then moved to the United States District Court for the Northern District of Illinois (Docket No. 1:14-CV-2705) on 4/23/2013, languished unaddressed in the Northern Illinois court docket since 7 Jan 2015?

These are just a few of the things practicing US physicians "Know What We Don't Know."

Rest assured, we won't rest until we find out and bring the corrupt MOC program to an end.