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.



Anonymous said...

"Father," I am interested in getting into organized crime when I grow up," said a boy to his father who had his head buried in a newspaper.
"That's nice, son. Private or public sector?"

Anonymous said...

This stupid NEJM "opinion piece" only shows how out of touch and desperate the ABIM really is.

Anonymous said...

Clear evidence of our government bureaucracy run amok is found in the rapidly growing area of certification. Years ago people would get hired for a job, perhaps, but not necessarily after specific training in a vocational school, college, or university, and would then proceed to learn the trade through years of applied work. Trainees or apprentices early in their careers may have been designated as such, but the general public had enough common sense to determine whether someone seemed to know what they were doing and were worth employing for some specific task.

Through the ages systems have developed for the certification of people as experts in their particular trades. Early on these were guilds of successful tradesmen. Later various boards arose to certify and license doctors, pharmacists, and veterinarians. Attorneys are certified as fit to practice through their Bar Associations. There have been a number of factors which have contributed to the development of these certification systems including 1) a rapidly expanding knowledge base in society which has made it impossible for people to know enough to judge for themselves whether the people they want to employ actually know what they claim to know; 2) experts in various fields wanting to preserve the integrity of their profession from people who may try to claim expertise that they do not possess; and 3) governments wanting to protect citizens by providing a mechanism for determining whether people are the experts they claim to be.

In recent years, however, the certification system has become a behemoth with such complexity and momentum that attempting to even slow this monster, let alone begin to reign it in, is becoming a nearly impossible task. A quick search begins to reveal the size of the problem. In any given state the number of certified occupations runs into the hundreds: the state of Washington lists almost five hundred. Certifications run the gamut from accountants to zoologists, and just listing all of these along with their basic requirements could easily fill a book. You can become a certified aircraft fuel distributor, a certified tattoo or body piercing artist, a certified snowmobile dealer, a certified egg dealer, a certified East Asian medicine practitioner, or a certified fur dealer. There are certifications for firearms, fireworks, fire sprinklers, you you can even become a certified fire protection engineer. You even need certifications for your leisure activities: certified martial arts participants, wrestlers, kick boxers, and whitewater river outfitters. You can be a licensed seed dealer, shellfish harvester, waste tire carrier, or taxidermist. And lets only hope that Anthony Weiner found himself a licensed sex offender treatment provider.

Anonymous said...

“So why has this system gotten so out of control?” You may ask “Each of the factors driving these certifications that you listed before appear to be noble goals. Isn’t the whole certification system a good thing?” To answer these questions, we must reexamine the factors driving the system and explore their ‘dark side’. Each of these has what we could generously call a contraposition, or more cynically call their seamy underbelly or ‘dirty little secret’.

Let us start with #1 above. The human knowledge base is rapidly expanding to such an extent that even for your exceptional ‘Renaissance man’ or polymath cannot know everything. Theoretically, it may at one time have been possible for someone to know the sum of human knowledge, and over the years there have been a number of claims of people who in fact did so. These range from Aristotle in ancient Greece to Leonardo da Vinci, Athanasius Kircher, Gottfried Leibniz, Thomas Young, and Max Weber. Of course it is impossible for any of these men to have known everything known to humans in their time, but these well read individuals of high IQ and high capability at least could hold their own on just about any conceivable topic. No one in the last hundred years could make such a claim, and in recent decades just knowing the index has become a challenge. The extent of human knowledge continues to expand at exponential rates. In the future it may be possible for an artificial intelligence to once again know everything, but that is a discussion is for another time.

The problem is that knowledge is expanding at a rate that any system that tries to certify someone as an expert is out of date by the time it is established. Just as software standards run years behind the cutting edge of innovation, and are often useless by the time a standards organization can put them together, the certification tests in rapidly growing fields are hopelessly outdated. In my occupation, cardiology, the science has advanced very rapidly, and old standards of care are often being revised and retooled, if not overturned entirely.

This creates a huge quandary for the people who are making and taking the certification tests. If a newly published study overturns an old way of thinking, and a question about this particular topic appears on the recertification boards, how is a knowledgeable expert to answer? Do you answer the question with the knowledge as it was at the time the board question was likely written, or do you answer with the newer, and (presumably) more correct information in mind? This becomes even more of a conundrum for people who are performing research. These people may have knowledge that is not yet available to the general public, and so they may be forced to answer questions with information they know to be wrong. And the more cutting-edge an expert is, the more difficult this task becomes, and the more that expert may get ‘wrong’ on an outdated recertification board test.

An entire industry has now arisen in order to prepare people for the certification tests. A common theme of these board preparation courses is knowing what the proper ‘board answer’ is, regardless of the state of knowledge in that given field. So we have essentially built a surrealistic alternate reality of ‘meta-truth’ that needs to be studied and mastered in order to pass the board certification tests. And the saddest reality of this alternate universe is that the true experts – the people with the best, actual, cutting edge knowledge – are the ones who have the hardest time with it. The average schmoe who doesn’t keep up with what is really going on in any given field will probably do just fine on the test.

Anonymous said...

“So if it is so hard to figure out who really is an expert in any given field, why do we do it?” you may ask. Well now we get to the dark side of #2 above. Attaining a level of expertise in any field is difficult. It takes time, dedication, and will to become a master of a craft. People who have dedicated their lives to any particular trade tend to become very fond of the art of their work, and they want to defend that trade from outsiders who have not worked as hard as they have. This is a very natural human instinct, and there is not necessarily anything wrong with it.

However, it is not the master of any given profession who feels threatened by interlopers, it is the novice. The person who is least sure of their own ability will feel the most threatened by someone else’s ability to outperform them. And so the certification system tends not to be built by the best people in any given trade, but the worst, because they want to create a back-stop to prevent any others from overtaking their ‘turf’. It is these people who are so uncertain of their own skills that they must find some way, some badge, some stamp-of-approval from above to prove to people that they are worthy of their title. So they create a certification system that gives the illusion of expertise for all of the people who pass the bar. But we know that not all ‘experts’ are equal, and we should not pretend that it is so.

There is an old joke in medicine: What do you call the guy who came last in his class at medical school? Answer: Doctor. Part of the problem with branding everyone who passes the board exam as an ‘expert’ is that now the system can treat all of the doctors as interchangeable widgets. In our current system no doctor is allowed to charge any more for his or her services than anyone else, and the insurance industry and government can choose to pay whatever they like for those services. The doctors just have to shut up to get paid. In a just system, skilled doctors would be able to charge more than unskilled doctors. (Yes, this happens in some very small slivers of the industry such as dermatology and cosmetic surgery where society has determined that it is OK for ‘optional’ medical procedures to be paid for out of the system, but for most of medicine doctors are paid whatever the Medicare system determines to be enough.) If you want to see the best cardiologist in the world, shouldn’t you have to pay a premium? Or do you just want to leave it to chance as to whether you will get to see a top notch doctor versus the latest foreign medical graduate?

Anonymous said...

We are destined for Civil litigation against the ABIM.

Anonymous said...

The worst NEJM editorial ever. Shame on Wachtel and Baron. You will atone for your sins when the ABIM will be decommissioned by the IRS and the DOJ.

Let the indictments and subpoenas begin.

Anonymous said...

Notice how there is no mention about the Mayo Clinic Proceedings manuscript amply showing how useless ABIM MOC is. This is war. Us vs them.

Anonymous said...

We all need to lobby GA Rep Tom Price (an ex surgeon) to dismantle ABIM MOC and use his connections to get the DOJ to investigate the entire ABIM and ABMS.

Anonymous said...

Once Jeff Sessions becomes AG it's curtains for the ABIM. He will take great pride in breaking up this corrupt arrogant organization of ObamaCare politician administrators. Begin with Wachtel Cassel and Baron. Let them bleed as punishment for their sins.

Anonymous said...

Now more than ever.

Art Fougner MD said...

They stab it with their steely knives but they just can't kill the beast.
"Hotel California," Eagles

20/20 Committee said...

There's a profound disconnect from reality at the ABIM. This NEJM entry proves it.

Their elitist executives and officers can no longer recognize reality and have lost the ability to reason carefully and ratiocinate. This is most evident from reading the recent NEJM/ABMS 'AMSCAM INFO-COMMERCIAL' purportedly authored by Drs. Baron and Braddock.

The 'article' drifts with classic ABIM newspeak, which typically says nothing and goes nowhere.

Nothing is convincing or even believable, because of their past research history, which every high school student could recognize as coming from one of ABIM's very dated cheat sheets. This ABMS habit of trying to cheat reality consisting of "making up facts" is founded on premise that can be summed up with ABIM's overriding axiom number one: "It is true if we say so." Axiom number two: "It is even more true if we double-down on it."

Their carefully plotted studies consist of two steps only.

First their communications officers write a paid announcement regarding the necessity of MOC. Step two they put their employee scholars to work making up something that might pass as science, but usually ends up having a disclaimer like, "Well, it is not robust science", but it does fit in with generally accepted notions of "common sense." Christine Cassel is well known for her contributions to "medical science" with just such "sensible" arguments almost always written by someone else.

We have a very basic formal reason also to suspect some other authors wrote this NEJM marketing item on behalf of the ABIM. Ghost-writing is highly likely given the fact the second author, Clarence Braddock, failed to mention that he was financially and politically affiliated with the ABIM as Chairman of the Board of Directors. He has lectured with Baron and served on the ABIM board since 2008, and is compensated by the ABIM for this.

Braddock also lectures on ABIM's Choosing Wisely key clinical components such as "shared decision making" (SDM). SDM is believed to be a clinical imperative for success in the Choosing Wisely paradigm. CW is an ABIM Foundation and ABMS initiative with a wide variety of harmful unintended consequences. We do not understand why a responsible physician would push it on an unsuspecting public.

It is such an embarrassing false statement regarding the NEJM conflicts of interest form. The failure to say yes to lobbying has been another problem that has plagued the ABIM. This is just basic lying about activities one does not wish to disclose to the public.

We believe, Dr. Braddock would not willfully withhold a well known fact from the public. So it must have been written by a very reckless person or an ABIM veteran skilled at misleading the public, thinking nobody would be the wiser. What NEJM reader would even take the time to click on the NEJM conflicts of interest form and read it carefully?

Neither reckless or misleading fits Braddock's profile, so we can conclude Braddock many not have been informed about the article in time to proof or check on conflicts of interest formalities.

20/20 Committee said...

ABIM's disclosure page fails to accurately mention Braddock's board relationship with the Informed Decision Making Foundation. ABIM calls it by the first word in it subtitle name, "Healthwise". He serves on the board of directors. This obscures relationship and history for casual readers. Shared decision making (SDM) is a important component of ABIM's Choosing Wisely Campaign.

This is a significant position and should be on ABIM's conflicts of interest disclosure and on the NEJM form. It relates directly to, not only the evolution of "Choosing Wisely" and informed consent, informed decision making, softening into the neutral shared decision making. Also the grooming/mentorship of physicians into the ABIM's philosophical/ethical/social fold with "sacred" points of view, which is an exclusive process barring differing points of view. The organization should be criticized/admonished for not being more inclusive. Self-appointment by selection and not election is a severe problem by design. Braddock is chair of the compensation committee.

The terms "Healthwise" and "Choosing Wisely" are names that obscure and obfuscate and tend to confuse patients and physicians are not informed/educated on what is happening to them. It is a propaganda that should be labeled as such, born out of social viewpoints and the imposition of them on patients and physicians. This propagandistic tampering with healthcare is wrong. It is wrong to attach labels that one cannot argue with, but mean something else entirely. Healthcare "rationing by ethical arguments" and "rationing by economic/medical arguments" would be more true to reality.

When Braddock was (s)elected to the ABIM board in 2008 his work on "informed decision making" was highlighted. Later his work was highlighted as "shared decision making"

Braddock published on informed decision making in 1999. The term "shared decision" implies "informed decision", but shared decision has a more inclusive ring (with less liability?) and associatively covers more clinical, legal, and ethical issues. Braddock worked on ethical issues related to dying in America for many years. In 2007 dying and "shared decision making" in hospital setting was discussed.

20/20 Committee said...

"Knowing What We Don't Know"

So, given Baron and Braddock's blatant errors on NEJM conflicts of interest form, it is likely a plagiarized piece of classic propaganda written for ABIM's co-captains Baron and Braddock by someone from among the vast teams of ABMS MOC ghostwriters.

I don't know precisely which one, but from the flavor of the writing, it was most likely authored by a former ABIM employee or graduate of the Robert Wood Johnson clinical scholars program.

We cannot rule out the possibly of it being penned by a former 'Pew Charitable Trust' officer. Someone who "worked closely with senior management and the Board of Directors to strategically construct the framework for all marketing and communications initiatives geared to ABIM’s wide spectrum of stakeholders."

Robert Wachter is a good example of the RWJ Foundation school of well-conditioned thinkers and scholars. Strangely he has not written on his corporate-sponsored blog for ages. Lorie Slass is a possible author/co-author who is representative of the "Pew category" of possible moonlighting communications authors. Slass is no longer with ABIM. Both Wachter and Slass, as highly intelligent former officers/employees of the ABIM, have smartly distanced themselves from legal liabilities associated with ABIM's ingrained nerve-wracking work habits involving the necessity for nearly-continuous obfuscation and cover-up.

Slass and Wachter in the past were involved in a lot of classic ABIM misrepresentations of reality utilizing official press releases and professional blog activities. Their writing at one point involved the ABIM's sting operation mentioned by Wes fisher here. Slass and Wachter engaged in mop-up and cover-up media activities, while on the payroll of the ABIM and ABIM Foundations.

These media misrepresentations, as part of Christine Cassel's disinformation campaign, all had the resemblance of authoritative government-like public repudiations and denouncements of a demonized group of carefully-culled and targeted physicians who attended an ABR course. I am speaking of physicians who were all "pronounced guilty" by being immediately sanctions and then sued by ABIM Powerball attorneys for attending an ACGME accredited board prep course, which suddenly fell out of favor with Christine Cassel and her vast network of government and corporate cronies. Some had communications with Dr. Arora. ABIM targeted an old ally threatening to take his house away.

Was it a political or financial attack when the ABIM's A. Benjamin Mannes and C K Cassel closed in on thousands of physicians putting them in the crosshairs of their "Sanctions Panels" and Ballard Spahr's devastating gun sights? With 20/20 vision in the rearview mirror it was a malicious political emasculation of physicians to control them and a very sophisticated form of financial strong-arming that is still going on today in ABIM v. Salas Rushford.!donate/c1ghi

Anonymous said...

anonymous got it so right about the ABIM:
"corrupt arrogant organization of Obamacare politician administrators"

called it Hillarycare and you get even closer to the truth of just how vast this corrupt globalist network extends

AG Sessions can take his pick of who to start with; but if he is smart he will start at the top to save time by hiring a special prosecutor to go after the ringleaders. They will give up their lap dogs in plea bargains.

the network is so pervasive and extensive an SP will need all eight years for his special prosecutor to drain and fill in the quicksand, while his blood hounds drain the swamp.

Unknown said...

I will never forget when I asked the president of osteopathic board of EMERGENCY Medicine when he informed us we will be doing moc because the md's were doing it. He stated it was due to medical mistakes. I asked, "so will we test this to see if it makes a difference or is this just the new 'new' thing?" He answered, "it's just the new 'new' thing." I totally respect his honesty.