Monday, June 24, 2019

Re-Defining Medical Professionalism

In 1999 we were told a new organization was created by the American Board of Internal Medicine (ABIM) to "improve healthcare through the advancement of medical professionalism." That organization then created a workgroup to create a white paper on "medical professionalism co-published simultaneously in the Annals of Internal Medicine and Lancet called "Medical Professionalism in the New Millennium - A Physician Charter."

The President and CEO of the ABIM Foundation has recently begun a speaking tour called "Rebuilding Patient Trust" that started with a Ted talk here in Chicago several weeks ago and now has spread West to the Aspen Ideas Festival. Given this, it is now abundantly clear that the ABIM Foundations' definition of "medical professionalism" needs rebuilding. As a past and future patient, the notion that the head of one of the most trust unworthy organizations in medicine is man-splaining to me how to "rebuild patient trust" is about as creepy as it gets. Visions of catholic priest pedophiles grooming their vulnerable victims comes to mind. Why is this?

Simply, the President and CEO of the ABIM and ABIM Foundation has not proven himself to be a trust-worthy individual. Trust-worthy individuals do not deceptively file tax forms. Trust-worthy individuals that run a 501(c)(3) non-profit organization do not purchase luxury condominiums for themselves. Trust-worthy individuals do not hire felons to serve as test security directors that raid people's homes. Trust-worthy-individuals to not lobby Congress as a 501(c)(3) organization and fail to claim this on tax forms. Trust-worthy individuals do not off-shore physician testing fees to the Cayman Islands. And trust-worthy individuals do not restrict their colleagues right to work because they refuse to succumb to tactics that leverage their false claims to hospitals and insurers to assure their products are purchased.

Patients know better.

Especially this one.

Honesty, transparency, and accountability are the foundations of medical professionalism.

Publicly gaslighting patients as a non-practicing physician in the name of re-establishing "trust" is true medical professionalism's antithesis.

-Wes

Saturday, June 15, 2019

"Nothing Else. Promise!"

From Sermo:
There is no evidence that recertification makes better doctors. All evidence points to a process that merely enriches the boards that impose their wills upon us.

I was one of the first classes to not be "grandfathered". Those who came before me said "Everyone needs to recertify, except us, we're special." But don't worry, they said, it'll just be an open-book, take-home exam every 10 years.

Except then then changed it to a proctored test that I have to drive 2 hours to, taking a full day off work, leaving the night before, and paying an exorbitant amount to be suspected of being a criminal as I show 2 forms of ID, and sign multiple documents stating I am who I say I am, and am video taped while taking the test, and can only use the bathroom during this time with permission.

But that s all! That said. Except it wasn't. We also need you to do a few CMEs. Just a few. Ok 100, alright 200. Better make that 300.

But that's it! Nothing else. Except for these self-assessment exams. You just need to do one. Ok 2. Alright fine, 4. But that's it!

Oh, except for this self-improvement project. Yeah, we need you, over several months, to do an experiment on your patients. No IRB oversight needed. Just pick something, make a change and tell us how much better your clinic is for doing this, ok?

But that's it! Nothing else!

Oh, except the money. Pay each year or we list you as "not current" on your MoC. Pay us, pay us again, and keep on paying us. Lots and lots of money to keep up. And we promise not to add anything else. PROMISE! (fingers crossed behind back).
Legal work takes money. That money is necessary to get past the numerous Motions to Dismiss attempting to throw out the numerous lawsuits recently filed against the ABMS member boards in order to proceed to discovery.

Have you done your part to help?

-Wes

Wednesday, June 12, 2019

More Legal Trouble for ABIM

Last Thursday, US District Judge Katherine Hayden ruled in favor of Jaime Salas Rushford, MD's motion to sever and transfer his counterclaims and third-party complaint against the American Board of Internal Medicine (ABIM) to the District of Puerto Rico.

For those unfamiliar with this case that began in 2014, a brief summary is included in the Opinion (references removed):
ABIM is an Iowa corporation that oversees the board certification process for internal medicine physicians, which includes administering a one-day, computer-based exam given annually on different days at testing centers nationwide and abroad. Salas Rushford resides and practices medicine in Puerto Rico, where he (was) registered to take the 2009 ABIM exam. In preparation, he enrolled in a preparatory course given in New York by Arora Inc., a New Jersey corporation that gives courses to physicians seeking board certification.

In December 2009, ABIM sued Arora (the “ABIM-Arora action”) in the Eastern District of Pennsylvania, alleging that the company “unlawfully obtained ABIM’s secure [e]xamination items by mobilizing course attendees to divulge the contents of the [e]xamination” in violation of federal copyright law. (Am. Bd. of Internal Med. v. Arora, No. 09-05707). That complaint also named John Doe defendants, “a presently unknown number of past and/or present candidates for Board Certification who have complied with [Arora’s] requests…to provide secure, copyrighted [e]xamination content to Arora for further dissemination.” The ABIM-Arora action settled and was dismissed in mid-2010. (June 11, 2010). Non-identical tests are offered through the month of August, which offers early test-takers the opportunity to alert later test-takers about content. To guard against this, ABIM requires that before they take the exam, all candidates must sign a “Pledge of Honesty” whereby they promise “not to disclose, copy, or reproduce any portion of the material contained in the Examination.”

It took ABIM until October 2014 to sue Salas Rushford in this district, alleging in a one count complaint that he was among those John Doe “past candidates” who unlawfully shared exam questions with Arora. Salas Rushford moved to dismiss for lack of personal jurisdiction. Early in 2015, while Salas Rushford’s motion to dismiss was pending in this district, ABIM sued him in the District of Puerto Rico in a parallel action, asserting a copyright infringement claim identical to the one it filed here. In both actions, Salas Rushford filed counterclaims against ABIM and a third-party complaint against the ABIM Individuals alleging malicious breach of contract, commercial disparagement under the Lanham Act, 15 U.S.C. § 1125(a), and tortuous conduct under Article 1802 of the Puerto Rico Civil Code. In these claims Salas Rushford challenged ABIM’s publication on its website that Salas Rushford’s board certification was “suspended” during a disciplinary investigation, as well as the manner in which that investigation and subsequent hearings were conducted. In addition to his motion to dismiss, Salas Rushford moved to stay the action in this district pending the result of the Puerto Rico litigation and for sanctions. In September 2015 this Court denied Salas Rushford’s motions and in the same month, the district court in Puerto Rico dismissed the parallel action without prejudice.

Salas Rushford then moved for judgment on the pleadings on the basis that ABIM’s lawsuit for copyright infringement was barred by the three-year statute of limitations. In March 2017, this Court granted the motion, and dismissed ABIM’s complaint with prejudice. Following that decision, ABIM and the ABIM Individuals (Richard Baron, M.D., Christine K. Cassel, M.D., Lynn O. Langdon, Eric S. Holmboe, M.D., David L. Coleman, M.D., Joan M. Von Feldt, M.D., and Naomi P. O’Grady, M.D.) moved for judgment on the pleadings on Salas Rushford’s counterclaims and third-party complaint, and Salas Rushford moved to sever and transfer them to the District of Puerto Rico. (Magistrate) Judge Waldor granted Salas Rushford’s motion to sever and transfer in the Opinion and Order from which ABIM now appeals.
The 2010 Arora-ABIM case led to this article published the Wall Street Journal. That article claimed as many as "140 physicians" were involved, and mentioned five physicians that the ABIM had just sued. Dr. Christine Cassel, President and CEO of the ABIM at the time was quoted as saying:
"Any high-school kid knows that cheating is unfair," said Dr. Christine Cassel, president and chief executive of the ABIM, who called the sanctions "a message and a deterrent."
What Dr. Cassel had never mentioned were the tactics the ABIM used to bring those charges against the vulnerable Arora course attendees. Furthermore, none of the charges brought by ABIM were ever upheld in court.

No doubt US internists who have been subjected to the strongman tactics used by ABIM sense a bit of schadenfreude knowing the "ABIM Individuals" may be traveling to Puerto Rico to stand trial there, too.

Sadly, their travel and legal fees will be at our expense, too.

-Wes

Monday, June 10, 2019

Plaintiffs Respond to ABPN's Motion to Dismiss

The recently-filed plaintiffs' Opposition to the American Board of Psychiatry and Neurology's (ABPN) Motion to Dismiss concisely summarizes the legal issues with Maintenance of Certification (MOC):
ABPN sells initial certifications to new doctors to demonstrate satisfactory completion of their graduate medical education. ABPN has a 100 percent market share in the market for initial certifications, possessing monopoly (and market) power. ABPN also sells a maintenance of certification product to older psychiatrists and neurologists (“MOC”). According to ABPN, MOC tests something it calls “lifelong learning.” ABPN sold initial certifications for more than sixty years before it began selling MOC. ABPN forces doctors to buy MOC or have their initial certifications terminated, illegally tying its MOC product to its initial certification product in violation of Section 1 of the Sherman Act.

Psychiatrists and neurologists do not want to purchase MOC or would prefer to buy “lifelong learning” products from other providers, but cannot without ABPN terminating their initial certifications subjecting them to substantial economic consequences. In this way, ABPN holds each doctor’s initial certification hostage and controls the maintenance of certification market. Through these and other anticompetitive acts ABPN also has a nearly 100 percent market share in the separate maintenance of certification market. It obtained and continues to maintain its monopoly position in that market in violation of Section 2 of the Sherman Act.
Plain an simple.

Let's hope the truth will set us free.

-Wes

A True Story

From the front line of health care in South Carolina:
It had been a long week of consults and surgeries when he received the call.

"Doctor, why are you behind on MOC®?"

"Really, that's none of your business," he said.

They threatened to take his privileges.

He said, "No you can't because I'm relinquishing them now."

They said, "Wait!..."

He left.
Please help end the abuse.

-Wes

Sunday, June 09, 2019

MOC's End Game: Physician Data Sales

Provider Information Management (actually Physicians Information Management) is the new digital currency being compiled and sold.

ABMS Maintenance of Certification (MOC®), is the means to keep that physician database current.

Meet Phynd Technologies, Inc., a partnership of ABMS Solutions, LLC, Epic Systems Corporation, Amazon Web Services, Drupal, and the non-profit Healthwise, a network of databases used by healthcare organizations to control costs while providing "deeper" patient and consumer engagement with information that they claim, "saves lives."
"Inaccurate provider information puts care, revenue, and reputation at risk.

There is no single source of truth, until Phynd.

Phynd serves as the single source for high-quality provider information:

who they are
where they work
what they do
what qualifications they have."
And let's not forget:
"Referring providers are important.

They’re worth $1 million a year or more to your health system.

You have 10 times as many referring providers as credentialed. Or more.

Your referring provider population is growing much faster than your credentialed population."
MOC® is not about physicians' education, skill, expertise, or knowledge. MOC® is just physician data, credentialed or not, compiled, reformulated, and for sale to the highest bidder.

All done with the blessing and support of our equally-conflicted medical subspecialty societies.

-Wes

Tuesday, June 04, 2019

HRS Hears From Its Members on MOC

From the Heart Rhythm Society online forum by a cardiac electrophysiologist:
After exploring the web of corruption that supports the ABIM and NCQI
(editor's note: actually the NCQA, the National Committee for Quality Assurance), I decided I would take a stand against it and not participate in MOC or re-certify with ABIM. I certified with NBPAS and re-certified with them. I truly believe it’s a great organization. I thought perhaps I could influence the situation and force it closer to a breaking point because I practice in a geographically isolated location and if I’m not here treating patients there will be tremendous expense flying/transporting them to the next closest center hundreds of miles away.

I was able to get my hospital system to accept NBPAS as an alternative board certification...for a time. Until BCBS (who answers to the NCQI  told the hospital they would no longer pay for my services. I explained to the hospital how board members of ABIM sit on the NCQI board and vice versa. How they profit off physicians through their corruption, how the DOJ has taken a position against ABIM, the class action lawsuits and harm the ABIM is causing physicians and patients alike.

Once there was an economic cost to my opposition the hospital system caved. They said they could no longer employ me if I didn’t re-certify with ABIM. I told them fine, I’ll quit and work as an independent physician seeing only CMS patients (CMS does not require board certification). The hospital told me if I quit they’d revoke my privileges and I’d have to move (it’s the only hospital with an EP lab on the peninsula). So this year, for the first time in 15 years, I didn’t attend HRS. I stayed home and clicked meaningless buttons on my screen to collect the 100 hours of MOC points required to be able to take the ABIM recertification exam. I’ll use my CME time to go to the board review course and learn about what gene mutation is associated with LQT type 6 which I’ll never see in my lifetime rather than HRS which changes my practice for the better every year. This is a cost to patients, it’s not quantifiable, but a cost none the less.

I was happy to sacrifice tremendously for this cause because it’s the right thing to do, but in the end I have a family to support. If we stand alone they will shoot us down, if we stand together we may have a chance. It would be nice if HRS would stand with us. If not them then who and if not now then when.
- Name withheld

The time is now. Please contribute: https://www.gofundme.com/practicing-physicians-of-america

Wednesday, May 29, 2019

Medical Societies Side with ABIM at the Expense of Their Members

Yesterday in a coordinated blow, the American College of Cardiology (ACC), Heart Rhythm Society (HRS), Society for Cardiovascular Interventions (SCAI), the Heart Failure Society of America (HFSA), and the American Board of Internal Medicine (ABIM) turned to their marketing muscle, funded in large part by the medical device industry, to issue a joint letter to their respective physician memberships that they stand with the nations' consolidating hospital systems in requiring Maintenance of Certification (MOC) for working physicians:
Dear Member:

We are writing to provide information of interest regarding cardiologists' American Board of Internal Medicine (ABIM) certification status.

On Jan. 1, 2014, ABIM Maintenance of Certification (MOC) requirements changed. In addition to the 10-year assessment requirement, diplomates wanting to maintain their certification are required to complete 100 MOC points every five years. The end of the first five-year period for many diplomates was Dec. 31, 2018.

Early in 2018, ABIM noted that a number of diplomates were at risk of missing the 100-point requirement. ABIM initiated an intense effort to communicate with these diplomates. This resulted in a high percentage of cardiologists across all specialties obtaining enough points to remain certified before ABIM updated its public reporting in February 2019. When looked at through the lens of specific certificates, 94 percent of cardiovascular medicine certificates, 88 percent of electrophysiology certificates, 84 percent of interventional certificates and 100 percent of heart failure certificates were held by diplomates who met the 100-point threshold. Additionally, physicians who had not met their points requirement saw their certification status change to "Not Certified."

The leadership of the four major cardiovascular specialty societies – the American College of Cardiology (ACC), Heart Rhythm Society (HRS), Society for Cardiovascular Angiography and Interventions (SCAI), and Heart Failure Society of America (HFSA) – realized that many cardiologists who had intended to remain certified were somehow unaware of the new process and missed the deadline. Therefore, they initiated a call with the ABIM leadership to discuss opportunities for those cardiologists to bring their certification into good standing.

If you are one of those whose certification status has changed – or if you'd like to confirm what you need to do next – please follow these steps...
This letter was issued despite physicians losing their ability to practice medicine solely because they did not complete "MOC points" before an arbitrary five-year deadline imposed by the ABIM. Physicians across the country are receiving letters from their hospital systems threatening them with "automatic retirement" for allowing their board certification to "expire." Worse still, some of those letters were issued in states where anti-MOC legislation exists, thanks to loopholes conveniently added by hospital lobbyists.

So what do our specialty societies recommend physicians do? Ask the monopoly ring-leader for a letter:
If your hospital, payer or employer credentialing committees have raised concerns, ABIM will work with you to provide a letter that can be shared with them outlining what you need to remedy any temporary loss of certification. To discuss such a letter with ABIM, please see the contact information below.
In other words, pay up, get your MOC points, or shut up and lose your job.

-Wes

Please donate to the GoFundMe page created by Practicing Physicians of America to end this discriminatory educational monopoly and racketeering. It is clear now that state legislation created to outlaw MOC in most states means nothing to our nation's consolidating hospital systems.

Addendum: 29 May 2019 @ 1:18 PM CST - Link to physician letter fixed.

Thursday, May 23, 2019

The Bizarre Week of Pro-MOC Activities

"ABIM is disappointed to learn of a lawsuit filed on behalf of four diplomates. The organization will vigorously defend itself, recognizing that doing so will consume resources far better dedicated to continuous improvement of its programs."

- ABIM blog

What a bizarre week it has been by those who support Maintenance of Certification (MOC). Despite the growing uproar in the working physician community, it is becoming clear that the proponents of MOC are circling their wagons in an effort to go "all-in" on the program.

  1. First came the article by highly conflicted members of the ABMS Vision Commission that was published in JAMA by Christopher C. Colenda, MD, MPH, William J. Scanlon, PhD, Richard E. Hawkins, MD.

    The authors listed the following conflicts of interest:
    "Dr Colenda and Dr Scanlon served as co-chairs on the Continuing Board Certification: Vision for the Future Commission. Dr Colenda is president emeritus of West Virginia University Health System and founder and principal for Christopher C. Colenda, LLC, a firm that provides consulting services to academic health care institutions and organizations, reported receiving personal fees from the Association of American Medical Colleges (AAMC), The Ohio State University, Virginia Tech/Carilion School of Medicine, and Loyola University School of Medicine, and serves as the "of counsel" role with Witt/Kieffer Search, an executive recruiting firm. Dr Hawkins reported receiving personal fees and royalties from Elsevier."
    Of course the authors failed to mention their other significant conflicts. Dr. Colenda was a member of the Board of Directors of the Accreditation Council on Graduate Medical Education (ACGME), the National Board of Medical Examiners (NBME), the American Board of Psychiatry and Neurology (ABPN), the AAMC's Administrative Board of the Council of Deans, Health Systems Governing Council of the American Hospital Association (AHA), and the LCME, where he was chair from 2012-13. Dr. Scanlon served as a "Consultant" to the now-obsolete National Health Policy Forum, a group created to help the government determine how doctors should be paid that was funded (in part) by Blue Cross Blue Shield, the Robert Wood Johnson Foundation, and the Josiah Macy, Jr. Foundation. Both the Robert Wood Johnson Foundation and Josiah Macy Jr. Foundation have donated significant funds ("grants") to the ABIM Foundation to foster the "Choosing Wisely" campaign and "team based" health care delivery. Dr. Hawkins, currently serves as President and CEO of the American Board of Medical Specialties (the owners of the MOC® trademark) and ABMS Solutions, LLC that sells physicians ABMS certification status, updated daily, to third parties.

    God forbid they mention these facts or the editors of JAMA provide professional scrutiny over disclosures.

  2. Second came the plethora of new, costly MOC-preparation materials offered by the American College of Physicians and American Board of Internal Medicine. The business of re-certification is stronger than ever!

  3. Thirdly, the Heart Rhythm Society suddenly became "concerned" that HRS members are losing their ABIM certification. (Who knew?!?) In an announcement to their members after siding with the ABIM and the ACC to create the CMP pathway, they "woke" from their slumber and said:
    "There has been some confusion among members who are not participating in MOC that they should be listed as "Certified, Not Participating in MOC," This has been the case, however, for those last certified in 2014 or later, certification will be forfeited after 5 years of non-participation in MOC. To reiterate, if you certified after 2014 and you have not been participating in MOC, you will be listed by ABIM as "Not Certified" after 5 years. While this has been communicated by ABIM since 2014, we are now seeing the first of our members being negatively impacted by this requirement."
    It's a bit hard to believe that they were unaware of this little right-to-work "problem" with MOC. How did they turn a a blind eye to the many MOC problems as they forged ahead to create the EPSAP educational product for MOC re-certification and the ACC's CMP pathway? Where is their concern over the discrimination against younger physicians certified after the 1990 "grandfather" date? Is another layer of discrimination for those re-certified after 2014 and threatened with losing their certification any different? HRS members on that forum have spoken clearly to the HRS leadership: "Collaborating with corruption is to condone it."

  4. Perhaps the most entertaining thing that appeared this week, however, was an anonymous Twitter account created by an professor at a major academic medical center who serves in a senior leadership position at the American College of Physicians. (Remember, nothing is truly anonymous on the Internet). That account aggressively trolled/baited/harassed anti-MOC working physicians online. Here are a few of the best tweets:
    • "I'm not going to discuss GF (grandfathers). Get over it. What a false flag."

    • Or when responding to concerns about the purchase of a $2.3 million condominium purchased by the ABIM Foundation: "Ignorant comment. Knew you'd go there. That was not corrupt. They used it as a cheaper alternative to hotel stays. Once it went, they had to pay more of your money to house people. Nice job zealots!"

    On and on the tweets went in an unbridled, unprofessional and immature fashion until the account creator was exposed. Then the account went private. As Shakespeare's Hamlet famously said: "The lady doth protest too much, methinks."

  5. Finally, in a Medscape article, the former President of the American College of Cardiology, C. Michael Valentine, MD, suggested that the ACC is prepared to enter the physician certification business by issuing "certificates" for physicians participating in their new Collaborative Maintenance Pathway MOC product:
    "We feel that this gives our members the most options available," said Valentine. "If you decide that you don't want ABIM certification, you can opt out and just do ACCSAP or Cath SAP or EP SAP and we'll then give you a certificate from the College saying that you are engaged in online continuous learning through the College…but that may not be accepted by your hospital or your health system or your payment system. All it says is you're engaged in our SAP program and continuous learning."
    ACC Certification now? Really? For twice the price, too! Never mind that pesky little detail that hospitals and insurers don't currently recognize ACC's CMP without its tie to ABIM's MOC requirements.

It's a shame that the antiMOC battle has come to this, but its really not surprising.

A shift from the corrupt MOC status quo was (and continues to be) inevitable.

-Wes

Friday, May 10, 2019

Grandfathers, Lattes, and the ACC's CMP Pathway

Drs. Kovacs (L), Fisher (C), and Marine (R) discuss MOC and
the ACC/HRS Collaborative Maintenance Pathway (CMP)
at the Heart Rhythm Society's 40th Scientific Sessions
As I head back to Chicago today, I wanted to take a moment and reflect on my experience before, during, and after my opportunity to speak at the Heart Rhythm Society's (HRS) 40th Scientific Sessions in San Francisco yesterday.

Before I do so, I want to thank Tom Deering, MD, President of HRS, for reaching out to me and asking me to share the findings of a small survey I did on working cardiologists and electrophysiologists on the new "Collaborative Maintenance Pathway" (CMP) for "maintenance of certification (MOC)" that the Heart Rhythm Society and the American College of Cardiology have created.

It was clear this session was really an afterthought. It was organized about a month before the scientific meeting after I placed the survey I helped create to gather physician perspectives on the new CMP pathway on the HRS online discussion forum. Dr. Deering ask that I create the title for the talk while the HRS assembled the moderator and speakers.  Ken Ellenbogen, MD, longtime organizer of the HRS Board Review Course held each year in Chicago, was selected as moderator.  Bradley Knight, MD, member of the cardiology committee for the American Board of Internal Medicine (ABIM) was to participate (so I thought), as was Joseph Marine, MD, an EP from Johns Hopkins who helped create the ACC/HRS CMP pathway. It was held on the show room floor at one of those speaking "EPicenter labs" with a computer screen, pretty good sound system, and about 20-30 chairs before the speakers.

Despite the small venue, it was clear the talk was "important" to the ACC leadership. Both C. Michael Valentine, MD and Richard J. Kovacs, MD (out-going and incoming ACC Presidents) were there and warmly welcomed me. In our initial chat together, I learned they were both "grandfathers" to the MOC process but had worked hard to create another way physicians could comply with MOC using their cell phones. I had not met Dr. Marine before, but it was clear he really believed in the MOC process and the CMP program the ACC had created. Dr. Knight, I later came to realize, did not show, likely because of his work with the ABIM and the pending litigation against them.

Dr. Marine kicked off the session with a 15-minute talk describing the CMP program. To his credit, he included the costs circulated by HRS, regarding the program, and was quick to note that the costs really were acceptable, as he showed the relatively high salaries of cardiologists published recently and compared that cost a number of ways, including a comparison that it would only set back participants the equivalent of "2 or 3 lattes a week." It was like a line from the ABMS script.

Then I spoke. Gratefully, I was able to use slides (withheld from me in my discussion at the IL Medical Society) several weeks ago. As I looked around, there were plenty of people standing on the edges and reluctant to take a seat. As my talk progressed, I paused to have those in attendance answer one of the questions. It became clear they were reluctant to do so, but it was clear they sided with the sentiments of the first question - that the ACC should not leverage the sale of their CMP product to our certification. I did not press the audience to answer more questions since I did not want to put anyone on the spot. I continued on reporting the results, limitations, and my final thoughts on MOC in general.

Question and answer time arrived. Dr. Ellenbogen started off and again asked a version of the same hypothetical question Dr. Knight had tweeted earlier - if you had a loved one in another city that needed a cholecystectomy, who would you pick, a doctor who was board certified or someone who was not?" Of course, this question was a straw dog. We are not talking about initial board certification, we were talking about a re-certification product that, unless purchased, invalidates a physician's initial certification. Dr. Ellenbogen then urged one of the ACC Presidents to respond. I would see Dr. Valentine encouraging Dr. Kovacs to step forward, which he somewhat reluctantly did as he complained he really wasn't unprepared. But he sat down and shared the ACC's position: that CMP was a "different" pathway and that doctors have a commitment to show they "keep up."

Then several of the audience members stood up and gave emotion-packed questions of why only select sessions at this meeting are "approved" for CME while other, informative learning (like poster sessions) receive none? "We have to follow rule stipulated by the ACCME," was the (paraphrased) response. On and on it went, back and forth, but NOT participating in some form of MOC was never an option despite my seeming rational lines of logic ("Why grandfathers?", "Why no other country requires "maintenance of certification?", all falling on deaf ears.)

Afterward, I felt like I had just been through a few rounds in a boxing ring but had survived. Everyone left a bit worn, but unscathed.  Ethan J Weiss, MD tweeted from UCSF, "Who won?" I can honestly say that neither side "won." This really was not a debate. MOC continues and at least five antitrust lawsuits against the ABMS or its member boards are filed. But it was clear that working physicians and our little organization, Practicing Physicians of America, are having an impact.

I also came to realize that this battle's far from over.

-Wes

PS: Please consider donating to our efforts to support those trying to end MOC for all subspecialties nationwide.

Thursday, May 09, 2019

HRS Scientific Sessions 2019: Science or Story-Telling?

I had just left the Opening Plenary Session at the 2019 Heart Rhythm Society (HRS) Scientific Sessions in San Francisco and was sitting my cup of coffee when he approached me.

"So, what did you think?"

I wasn't really sure how I should respond, so I was polite and spoke slowly.

"It was nice," I said, waiting to hear what he had to say.

"I thought it was kind of weird. The 'story-telling' theme felt a bit creepy -promotional and like a Ted Talk. I mean, don't get me wrong, I like that guy's podcast and all (Guy Raz from NPR was the keynote speaker), but the 'past, present, future' thing? That kinda left me cold."

"I think they were trying to be 'hip.'  And 40 years is a pretty long time," I said, smiling.

I felt a little more comfortable because I found the message of physician "story-telling" left me flat, too.

For those who weren't in attendance, the theme of the Opening Plenary Session this year was "The Importance of Story-telling."  A cool video of the pioneers of EP was displayed, along with the timeline of when the various EP innovations occurred (this was the best part, IMO).

Then, the lights dimmed just before Tom Deering, MD, the current President of the Heart Rhythm Society came. With lights rising and music playing, he welcomed the nearly 11,000 physicians in attendance this year. He didn't miss a beat (pun intended) as he delivered his message. It was then I saw the two, huge teleprompter screens, scrolling his lines before him. The message took on the look of an informercial. It was surreal. (I'm not sure why I've never noticed this before.) Scientific sessions are being carefully scripted.

The organizer of the Scientific Sessions was then introduced and similarly gave a teleprompter-assisted thank you the various folks who helped with organization of the meeting. Then Mr Guy Raz from NPR was introduced as keynote speaker.

I apologize that I may not be telling the whole story Mr Raz told correctly, but I hope you'll get the general gist of his message.

Mr Raz began his talk with a story of a recent illness and hospitalization he had suffered from a recent episode of cellulitis just before this meeting. Because of his fever to 103, he had missed the fact that he had a very red rash climbing his leg discovered after he presented to his local ER. He was recommended to be admitted for treatment. He was told he would likely be admitted for 48 hours. In his conversations with the ER doctor, as he tried to tactfully explain he really needed to be out of the hospital sooner because he had another speaking engagement for his friend, Jimmy Fallon. He described the excitement the ER doctor had over learning that he knew Jimmy Fallon ad how important the doctor made Mr. Raz feel. Mr Raz then delivered his message: that really, doctors are much more important than NPR hosts that speak on behalf of Jimmy Fallon. After all, they save lives and care for acutely ill patients every day. (Yeah, I thought the same thing: "This is the message?" We never really heard what happened next.)

He then introduced three series of physicians and allied professional leaders at HRS whom he interviewed. It was like a polite, handsome Ebenezer Scrooge interviewing the Ghosts of Electrophysiology Past, Present, and Future in a scripted, "fireside chat" kind of format. (We've seen this format before. It seems very popular right now with corporations.) We heard about the $1 registration fees and the hope that physicians would show up for their first meeting while we reflected on the $1800 registration fee today. We then watched a video for the future where nothing was impossible; the entire interconnected world's health problems, and even catheter ablation, treated from the comfort of your living room provided, of course, you had an iPhone. (Call it "editorial license run amok.")

I wonder: is "the importance of story-telling" really the right message we want conveyed to a room full of gullible young EPs and allied professional there for their first meeting? Or do we want them to see and interact with leaders in science learn critical review without the bright lights and teleprompters?

Lately, what we've seen as patients and physicians is that not all corporate and personal stories are benign. Some can even be harmful. The stories of the measles vaccine. The stories of the promise of flying a plane with computer software alone. The stories of your "value" or "quality of care" as a physician being quantified by  Maintenance of Certification (MOC) testing and the ACC/HRS Collaborative Maintenance Pathway.

Stories, as important as they be at times, can also be spun.

Physicians will get much further if we remember who we are and who we serve and just keep it real.

-Wes

Thursday, May 02, 2019

Physician Plaintiffs Counter ABIM's Motion to Dismiss

Following the Dec 6 2018 filing of a class action antitrust lawsuit against the American Board of Internal Medicine (ABIM) by four internal medicine physicians (that was later amended to include fraud, RICO and unjust enrichment claims), the ABIM filed a motion to dismiss the physicians' Complaint. Much of their argument hinged on the ABIM's supposition that
"... plaintiffs cannot establish that initial certification and MOC are two separate products capable of being tied; plaintiffs’ own allegations demonstrate that initial certification and MOC comprise complementary, continuous components of ABIM’s certification. They are not separate products. For that reason as well, plaintiffs’ claims that ABIM has unlawfully created and maintained monopoly power in violation of Section 2 of the Sherman Act fails. Because they have not met their burden of plausibly alleging the tying of two products, they cannot point to any unlawful (i.e., anticompetitive) conduct.
In defense of their argument, the ABIM attorneys attempted to use two franchise analogies citing Krehl v. Baskin-Robbins Ice Cream Co. and the rejection of a tying claim brought by a Subway franchisee to plead the case that initial certification and MOC are not separate products, but rather one product.

On 30 April 2019, the plaintiffs' opposition to ABIM's Motion to Dismiss was filed. The plaintiffs' attorneys wasted no time countering ABIM's motion to dismiss (starting on page 2 with references removed):
"ABIM relies mostly on franchise cases to argue MOC is not a separate product. Putting aside for the moment that all of the cases it cites were decided on a fully developed factual record at summary judgment or after trial, ABIM’s franchise analogy misses the mark. Physician care is not Baskins Robbins ice cream, and patient treatment is not a Subway sandwich. Hence, the notion that ABIM can force MOC on internists in service of an illusory nationwide standard unilaterally imposed by ABIM offends the free market principles that are the hallmark of medical care in this country. Plain and simple, MOC is a failed and extremely costly product that ABIM, using its undisputed market power, forces internists to buy. Its exploitation of internists is further aggravated because while ABIM deceptively wraps itself in the mantle of self-regulation, it has no legislative, regulatory, or administrative authority at all and answers to no one, and certainly not to the internist community it misleadingly claims to be self-regulating."
Read the whole rebuttal.

-Wes

P.S.: Unless you feel your medical practice is  just a fast food franchise, please support the physician-plaintiffs in this important legal effort to end MOC nationwide for all subspecialties. 

Sunday, April 14, 2019

The Powerful Counterrevolutionaries

There's an amazing thread developing on Doug Farango's Authentic Medicine blog post titled "The AAFP Loves the ABFM and Sleeps Right Alone Side Them." It started with Elizabeth Baxley's "Fact Check" comment suggesting the Family Medicine Certification Longitudinal Assessment (FMCLA) program was not another version of Maintenance of Certification (MOC). Dr. Baxley failed to disclose she served on the American Board of Family Medicine Board of Directors from 2013-2018. Here's the comment from "Steve O'" in response:
April 13, 2019 at 11:04 pm

C’mon. You got to compliment someone for running a shakedown racket, and they got pigeons to pluck who are easily intimidated and got a lot to lose. I like Dr. Baxley’s protest that FMCLA is a different word salad than MOC. She distracts us with irrelevant trivia about the differences.

Here’s what the big picture is. Doctors are worse than nuisances in the new industrial medical chain. They use their accumulated experience and independent principles to decide what to do for the patient. This is – counterrevolutionary behavior. Industrial Pharma makes it, Corporate Pharma distributes it, the Insurance/CME cabal creates the algorithms for every possible treatment. Doctors are the ISIS, the al Qaida of the system. They’ve got to be cleared out at any cost.

Making them memorize the rules and vomit them out on command is what doctors are for. And they should be paid like store clerks. In fact, once the FDA has blessed algorithmic prescribing, Doctor Watson, the driverless car of medicine, will be rolled out. Driverless cars crash. Algorithmically-driven planes have a serious gravity problem. No-brain prescribing will cause countless deaths. But since it’s computers, no more “human error,” right?

You ought to watch the timeline of the Chernobyl disaster. It shows some quite intelligent, experienced and insightful engineers bending to the rules, to avoid getting fired and sent off to Siberia. Only two went to prison for breaking the rules, and a few died. Not a bad outcome, eh? There were at least a dozen times when an engineer couldn’t hold it anymore, and said, “We have to stop this or the plant will blow up!” They were easily shut down by bullying and intimidation. Who can say which possible outcome is better – sticking with the system, or acting like a loose cannon? Mistakes were made – but mistakes happen. Sorry.

That’s the kind of doctors that the machine wants to install in American medicine. Thanks Betsy and Shawn. When the lid comes off, you can always run around like squirrels and say, “Why didn’t anyone let us know?” “It’s not my fault, my support personnel lied to me!” “We were only trying to do the absolute best for patients!” Thanks, comrades.
MOC, FMCLA, CMP, MOCA. The Machine's lucrative alphabet soup.

The physician counterrevolution is growing.

-Wes

Friday, April 12, 2019

Physicians Are Eagles Who Believe They Are Chickens

Chicken or Eagle?
Image by Wes Fisher MD
(Click to enlarge)
There are 800,000 physicians in America and more than 80% believe the Maintenance of Certification process, known as MOC, has no clinical value for patients. For the first time in the history of our profession, physicians have a fighting chance to topple a Goliath-esque organization, the American Board of Medical Specialties (ABMS).

In a 2018 survey conducted by Merritt-Hawkins, 78 percent of physicians said they experience some symptoms of professional burnout. Physician burnout is a public health crisis which threatens the health and well-being of all patients.

A burned-out physician reminds us of the fable about an eagle who believed he was a chicken.

When the eagle was small, he fell from his nest. A chicken farmer found the eagle, brought him to his farm, and raised him in the chicken coop with his chickens. The eagle grew up living like a chicken, doing what chickens do, and believing he was, indeed, a chicken.

One day, a visitor came to the farm and was surprised to see an eagle --considered the king of the sky-- strutting around the chicken coop, pecking at the ground, and acting like a chicken. The farmer explained that this bird was no longer an eagle, instead he was a chicken because he was trained to be a chicken. The man knew there was more to this great bird than “pretending” to be a chicken. He was born an eagle and had the heart of an eagle, and nothing could change that. The man lifted the eagle onto the fence surrounding the chicken coop and said, “Thou art an eagle. Stretch thy wings and fly.” The eagle looked at the man and glanced down at his home among the chickens in the chicken coop where he was comfortable. He jumped down off the fence and did what chickens do.

The farmer shrugged and said, “I told you he is a chicken.” The visitor returned the following day and tried again to convince the farmer and the eagle that he was not a chicken. He took the eagle to the top of the farmhouse and said: “Thou art an eagle. You belong to the sky and not to the earth. Stretch your wings and fly.” The large bird looked at the man and then glanced down at the chicken coop. He jumped onto the roof of the farmhouse and returned to the place where he felt safest.

The visitor asked the farmer to let him try one last time.

The next morning, the visitor returned and took the eagle and the farmer to the foot of a high mountain. They could not see the farm nor the chicken coop from this new place. The man held the eagle on his arm and pointed into the sky where the bright sun beckoned and said: “Thou art an eagle! You belong to the sky and not to the earth. Stretch your wings and fly.” This time the eagle stared skyward into the bright sun, straightened his body, and stretched his powerful wings. His wings moved, slowly at first, then surely and confidently. With the mighty screech of an eagle, he flew.

Because he was an eagle.

This past December 2018, four brave internal medicine physicians --recognizing they are eagles-- filed a lawsuit against the American Board of Internal Medicine, the largest ABMS member board, for harm they endured from the Maintenance of Certification process. Practicing Physicians of America has set up a fund to support our colleagues who are fighting this battle and need the support of fellow physicians.

Merely 1324 physicians, out of 800,000 in the US, have contributed to the legal fight against the onerous MOC process, despite the fact that it is reviled by the majority of doctors. Physicians members of the American Board of Radiology and the American Board of Physical Medicine and Rehabilitation have filed lawsuits of their own regarding violation of anti-trust laws.

Why are so few of our fellow physicians standing up when given the chance?

Unfortunately, physicians often choose consistency over happiness. If you’re used to being abused, ignored, or exploited, it’s strangely comforting to remain in the chicken coop and peck at the ground. These physicians are just like the eagle who believed he was a chicken.

Maybe physicians prefer the devil they know to the devil they don’t know. Maybe physicians are terribly uncomfortable at the prospect of failure. Maybe physicians believe it is better to control failure than be blindsided by it. Physicians are standing on the mountain and being asked to spread their wings and fly. What is stopping us?

The possibilities for the future of our profession are endless if we can win against the American Board of Internal Medicine. If there were ever a time to join the fight, it is now. Surely $100, $200 or even $500 is not too much to contribute to support our talented physician colleagues who have been harmed by MOC.

Now we are asking every physician in America, are you a chicken or are you an eagle?

- Niran Al-Agba, MD and Westby G. Fisher, MD

Drs Niran and Fisher and unpaid board members of Practicing Physicians of America.

Wednesday, April 10, 2019

Schulman: End This Maddening Waste of Time for Rhode Island Doctors

From an opinion piece published earlier by internist Howard Schulman, MD in the Rhode Island Providence Journal:
"I am writing to give the physicians’ perspective on bill H5247/S301 that gives physicians a choice, by medical staff vote, on “maintenance of certification.” (MOC) The organization that sells this certification says it is voluntary, but in fact, for most physicians, is mandatory. Maybe 100 years ago, when this testing began and there was absolutely no supervision of physicians, this “certification” served a purpose.

But that is not the case today. We have the Department of Health, Department of Medical Licensure, malpractice attorneys, the health-insurance companies, the newspapers, social media and the Internet, and hospital credentialing and specialty departments waiting to pounce on any mistake or misstatement we make, never mind ever more informed and empowered patients and families.

Until recently, physicians tolerated the initial certification as just another traditional “hoop” to jump through, but this recent attempt at “maintenance” of certification went overboard. Being a doctor is much more than filling in the dots on a computer screen. We find the huge number of hours of read-a-paragraph and fill-in-the-dot testing a huge waste of time. Physician burn out is already a problem, and this testing is just one more straw on the camel’s back.

* * *

I urge fellow physicians to contact their legislators and the Rhode Island Medical Society to tell them to vote in favor of bill H5247/S0301. I also urge our legislators to talk with their own physicians to understand the negative impact this required maintenance of certification testing has had."
Rhode Island physicians can also help by supporting the litigants who filed a class action lawsuit against the American Board of Internal Medicine because of MOC.

-Wes

Tuesday, April 02, 2019

What Do Working Cardiologists Really Think About the ACC's CMP Pathway?

What do US cardiologists and electrophysiologists REALLY think about the American College of Cardiology's (ACC) heavily-promoted collaboration with the American Board of Internal Medicine (ABIM) to create their "Continuous Maintenance Pathway" (CMP) for continually maintaining their ABIM board certification?

That's a question I wanted to know, so I helped create a quick 5-minute survey on the matter open to US cardiac electrophysiologists, cardiologists, and heart failure specialists.

I hope to have the results compiled by the Heart Rhythm Society in May, 2019.

I look forward to your responses and thoughts. Additional comments regarding the CMP program not covered in the survey can be left in the comments on this blog post.

Thanks-

-Wes

Monday, April 01, 2019

From MOC to CC: Neurosurgeons Fed Hopium

Even the physicians who we trust to do brain surgery can't be trusted to determine their own education or the skills they need to dive into a patient's skull. Instead, the AANS Neurosurgeon says they need is a "paradigm shift" to pay the American Board of Neurological Surgery (ABNS) much higher fees and do meaningless bureaucratic busywork annually:
"Obviously, by moving from a 10-year process to an annual process, there will be increased costs to diplomates in order to comply with the new ABMS directives; however, neurosurgery, as a smaller specialty, benefits from having a Board that is revenue neutral, thrives on volunteerism and has worked hard to keep costs as low as possible. These newborn costs are hopefully offset by the CME credits gained and the increased benefit to our patients gained by maintaining best practice standards."
The Maintenance of Certification (MOC) to Continuous Certification (CC) sleight of hand is being sold to neurosurgeons as "hopium." Thousands of dollars in fees must be paid the the ABNS so that neurosurgeons can "hopefully" offset their costs by the CME credits they receive and feel good those dollars benefit their patients.

Unreal.

Welcome to the fight, neurosurgeons.

-Wes

Wednesday, March 27, 2019

Physician's Week

William Osler

"When schemes are laid in advance, it is surprising how often the circumstances fit in with them."

"To study the phenomenon of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all."

"The philosophies of one age have become the absurdities of the next, and the foolishness of yesterday has become the wisdom of tomorrow."

"Common sense in matters medical is rare, and is usually in inverse ratio to the degree of education."

- William Osler
"Physicians Week" has begun but you might not have known it. I suspect most physicians were busy seeing patients and many didn't stop for lunch, or ate what they brought to work while staring into a computer screen, trying to catch up on patient and staff messages, wiping a bleary-eyed tear from the corner of their post-call eyes, and clicking on hundreds of electronic orders placed by others on their behalf. Such is medicine now: an isolating, mind-numbing, depersonalizing series of clicks. It's hard to get excited about a week devoted to you when you can't get all the finger work done. How far we have traveled from the days of Osler's teachings!

Officially, March 30th marks "National Doctor’s Day" in the United States. National Doctor’s Day was started by Eudora Brown Almond in 1933. The date was chosen to mark the date that Dr. Crawford Long, in 1842, first used ether to anesthetize a patient and painlessly excised a tumor from his neck. Mrs. Almond, the wife of a doctor, wanted to create a day to recognize physicians. She did so by mailing greeting cards to doctors and placing flowers on the graves of deceased doctors. The day was later expanded to "Physicians Week" in March 2017 by Drs. Marion Mass, Kimberly Jackson, and Christina Lang who applied to officially have "Doctor's Day" changed to "Physicians Week."

Healthcare today is more complex than ever before. Our role as working physicians is critical to families, individuals, and their loved ones. It is an incredible privilege and responsibility. Yet, we are faced with new and growing challenges, many caused by greed and "the foolishness of yesterday." Much of the last five years of mine has been spent educating other physicians about this issue on this blog's pages.

Despite these efforts, the American Board of Medical Specialties (ABMS) Maintenance of certification (“MOC™”) requirements and costs continue to grow. They sap our time and resources, making us less available to our patients as we increasingly must "study books without patients." Meanwhile, the organizations behind MOC™ and their substantial resources remain unchecked.

The American Board of Internal Medicine (ABIM), the largest ABMS member board, has recently filed a motion to dismiss the case challenging MOC™ and similar motions are expected in the cases against the American Board of Radiology (ABR) and the American Board of Psychiatry and Neurology (ABPN) in the next month or two. The boards have legions of attorneys lined up to defend their conduct and millions of dollars with which to pay them. Your contributions, thus, remain critical in our fight.

So take a moment and really reflect on Osler's words above.

In honor of National Physicians Week (and National Doctor's Day), I ask you to help me by donating now to get us to the next stage of the lawsuits against MOC™. If you have already given, please consider giving again, as I have done. And please promote our cause to your friends and colleagues. If each one of us can invite just two or three new donors to read about our fight and contribute, we could reach our latest goal, which is to have 1,000 new donors contribute $200 each. These contributions will go directly to continuing our legal fight against MOC™. 100% of your contribution goes toward funding the lawsuits (less third-party credit card processing fees).

Many have had concerns of repercussions to themselves should they contribute. If you wish to keep your participation private, you can designate your contribution as anonymous too. As before, you also have the option to add a “tip” to help GoFundMe maintain its platform. Any “tip” is entirely voluntary, goes directly to GoFundMe, and will not be applied to our goal.

For those wanting to send a check in lieu of using the GoFundMe page, please earmark your check for "Legal Fund" and send it to:

Practicing Physicians of America, Inc.
876 Loop 337, Building 101
New Braunfels, TX 78130

We could not have reached this point without you, and I hope you will continue to help in the fight to take down MOC™ -- for your own benefit and the benefit of your patients.

-Wes

(aka, Westby G. Fisher, MD
Member, Executive Board
Practicing Physicians of America, Inc.)

Sunday, March 24, 2019

Suddenly, Some Specialty Societies Might Be Listening

From the American College of Radiology blog:
"In response to a recent request from the American Board of Medical Specialties (ABMS), the (American College of Radiology) ACR created a work group to comment on a report on the status of (Maintenance of Certification) MOC® across all specialties. That group worked tirelessly over the winter holidays to prepare a detailed comment letter (ed. note: a portion of which is highlighted here):"

(Click to enlarge)
The blog post continues:
"The ACR also signed on to a letter from the Council of Medical Subspecialty Societies (CMSS), which represents approximately 800,000 physicians from 43 medical subspecialty societies.

Both the ACR and CMSS letters call for an immediate moratorium on MOC® until many programmatic deficiencies are corrected.
. . .

These important ACR member issues have recently been amplified by the backdrop of various ABMS member boards coming under intense scrutiny and even legal actions for financial practices, lack of transparency, non-democratically elected leadership, high-stakes non-validated psychometric testing and concerns about monopolistic behavior. The American Board of Radiology (ABR) was named as a defendant in one class action suit and a “co-conspirator” in another.

Our Task Force is studying these issues and preparing to make recommendations to the BOC and CSC at both the ACR 2019 and ACR 2020 annual meetings."
Mind you, these cases have not been brought before the court yet, but there now appears to be a serious level of introspection and concern at the highest level of some specialty societies as to what transpired to get us where we are with "continuous" ABMS Board certification.

Colleagues, now is not the time to back off our funding campaign to support the litigants in this anti-trust battle. In fact, we need more physicians from ALL specialties frustrated with the current MOC® status quo to join us to keep the pressure on ALL of the ABMS member boards.

-Wes

Thursday, March 21, 2019

The Astronomical 10-year Cost of ACC's Continuous Maintenance Pathway

Since the inception of Maintenance of Certification (MOC®) by the American Board of Internal Medicine (ABIM) tied to our initial board certification credential in 1990, the costs of "maintaining" initial certification through "continuous certification" have steadily climbed by way of the threat of invalidating our initial certification credential.

Nothing is different with the new "Continuous Maintenance Pathway" proposed 15 Mar 2019 by the American College of Cardiology (ACC). In fact, the monetary demands are an order of magnitude greater for working heart specialists and cloaked in smooth propaganda published in the Journal of the American College of Cardiology.

To compare apples to apples, it is important to compare 10-year out-of-pocket costs required from physicians participating in MOC®. By way of background, the cost for "Maintenance of Certification" from the ABIM in 2000 was $795 every 10 years.

Here is a breakdown of the costs cardiologists and cardiac electrophysiologists will incur by participating in the "Continuous Maintenance Pathway" proposed by the ACC and the ABIM:

(Click to enlarge)


If you are an ACC member, you get to pay even more to the ACC, despite what their website says.

Here's the breakdown for ACC members:
  • $795 initial ACC membership fee + $150 admin fee x 10 years LESS $400 credit on CMP program every 5 years x 2 = $1495
  • PLUS $1500 every 5 years to ACC for CMP x 2 = $3000
  • PLUS $160 per year to ABIM x 10 years = $1600
  • GRAND TOTAL = $6095 every 10 years of MOC/CMP (or $609.50 / year)
And let's not forget this VERY important adhesion condition for these fees:
(Click to enlarge)
In summary, the ACC's new Continuous Maintenance Pathway is one of the most shameful money grabs from US cardiologists and cardiac electrophysiologists imaginable and represents a remarkable 654% increase in fee payments for MOC® since 2000 for non-ACC members and an incredible $766% increase in fees for ACC members for MOC® since 2000. More importantly, the ACC leverages (ties) CMP to the threat to a physician's ABIM board certification status (and therefore their right to work) and I believe represents a restriction of trade and is in violation of US anti-trust and racketeering laws.

It is truly unbelievable that the ACC and the Heart Rhythm Society would do this to their own membership, but then again, given their prolific financial balance sheets, maybe it's not so unbelievable after all.

-Wes

PS: Please help support the federal antitrust class action lawsuit against the American Board of Internal Medicine by contributing here.

Wednesday, March 20, 2019

ABIM Gives First Public Legal Response to Lawsuit

On 18 March 2019, the American Board of Internal Medicine responded for the first time in opposition to the federal class action lawsuit filed against it by four internists in early December 2018. The 39-page memorandum accompanying their proposed motion to dismiss is re-published here without comment for physicians to read themselves.

Physicians wishing to contribute to the support of the four internists involved in this case are encouraged to donate to this GoFundMe page.

-Wes

Monday, March 18, 2019

The Big Easy: The ACC, HRS, and the ABIM



This weekend, at the American College of Cardiology (ACC) Scientific Sessions in New Orleans, the ACC and the Heart Rhythm Society (HRS) announced their commitment to the American Board of Internal Medicine's (ABIM) continuous certification financial shakedown of US cardiologists and cardiac electrophysiologists. Taking a playbook from the American Medical Association, their leadership has realized the financial milk and honey for their business rests squarely alongside the business interests of US hospitals and the powerful device industry, not the physicians for whom they pretend to advocate.

So they have reached out to their academic colleagues, many of whom are medicine's leading industry thought leaders, teachers, and spokespersons, to create yet another Maintenance of Certification (MOC) testing "pathway" (called the "Continuous Maintenance Pathway" (CMP)). This "pathway" requires purchase of the ACC Self-Assessment Program (ACCSAP) to extract cash from their own colleagues and more vulnerable, younger cardiologists. As always, failure to participate some way with "continuous certification" will always be met with the threat of pulling a cardiologist's credentials to practice medicine if they don't comply. The CMP will only be valid if physicians continuously purchase the ACCSAP study materials. How much will that cost? Well, the ACCSAP used to cost a cool $400 per year and the 2019/2020 prices have yet to be announced, but was promised to be "less than $500 annually").

And why not?

With its Harry Houdini-like balance sheet where over $25 million in assets exactly matches its expenses, we see the value of numbers to the ACC. We also see, like the ABIM, the "value" of a Foundation.

The ACC Foundation has $113,934,622 revenue (and $231,442,569 in assets), over one third of which funds the organization's salaries. The ACC Foundation has also created the ACC Political Action Committee (the ACC-PAC) under the umbrella of the Foundation, "as part of a multi-pronged approach to expand its advocacy program to support incumbent and prospective candidates who are supportive of patient access to care and promotion of quality cardiovascular care."

You are reading that correctly. Leveraged MOC dollars and the fees paid for physician education materials will now be used, in part, for the ACC's support of political candidates.

But if that's not enough, there's this little gem.
In 2018, the Accreditation Council on Graduate Medical Education (ACGME) published a revision of program requirements for accredited internal medicine residency programs. At the same time, the Internal Medicine Board had decided to revisit the procedural requirements for graduating residents, presenting a timely opportunity to make changes to these requirements.
With the announcement yesterday of the CMP physicians will be required to perform two tests, one given by ACC and one given by ABIM EVERY YEAR and much of it for their political gain.

If this new collaboration between the ACC , HRS, and the ABIM sounds problematic to you, you might want to join our effort to end this shakedown of your dollars for political purposes.

-Wes

Saturday, March 16, 2019

Wednesday, March 06, 2019

MOC Legal Battle Broadens to ABPN

Today in the Federal District Court of Northern Illinois, another class action lawsuit on behalf of over 25,000 psychiatrists and neurologists was filed against the American Board of Psychiatry and Neurology (ABPN) by two psychiatrists.

In a script we have seen before, the Plaintiffs brought the action pursuant to the Clayton Antitrust Act, 15 U.S.C. §§ 15 and 26 to recover treble damages, injunctive relief, costs of the suit, and reasonable attorney’s fees arising from violations of Sections 1 and 2 of the Sherman Act (28 U.S.C. §§ 1 and 2). The suit alleges that there is illegal tying of the ABIM’s initial board certification product to its maintenance of certification® (MOC®) product in violation of Section 1 of the Sherman Act and illegal monopolization and monopoly maintenance in violation of Section 2 of the Sherman Act. In addition, the suit alleges that ABPN's conduct has caused it be be unjustly enriched at the expense of the Plaintiffs and the other Class members.

The Complaint details the alleged harms experienced by the Plaintiffs and the numerous changes to ABPN MOC® the Plaintiffs and Class members endured since its implementation. In addition, the Complaint alleges:
"Between 2004 and 2017, after the advent of ABPN MOC, ABPN’s “Program service revenue” account exceeded its “Program service expenses” account by a yearly average of $8,777,319, as reported in its Forms 990 for those years. During that same period of time, ABPN’s “Net assets or fund balances” account skyrocketed 730%, from $16,508,407 to $120,727,606. In other words, at year-end 2017, as ABPN MOC revenue continued to grow, ABPN net assets (assets less liabilities) more than septupled, which included, according to its 2017 Form 990, almost $102 million in cash, savings, and securities."
The Complaint also details allegations of unjust enrichment by the President and CEO of the ABPN, Larry R. Faulkner, MD:
In 2007, he was paid total compensation of $500,726 as Executive Vice President. Dr. Faulkner became ABPN President and CEO in 2009. In 2017, the last year for which data could be located, his total compensation as President and CEO was $2,872,861, including a bonus of $1,884,920.
This lawsuit follows on the heels of two other class action antitrust lawsuits filed against the American Board of Internal Medicine and the American Board of Radiology.

As I've said before, it is critical working physicians see the legal battle against MOC® for what it is: not a campaign against continuing medical education, but rather a campaign against the massive runaway train of economic exploitation, self-enrichment, and micro-management of our professional lives that are now the hallmark of ABMS and its member boards.

I encourage all working physicians donate to our GoFundMe page to help support the next phase of the litigation as ABIM, ABR, and ABPN prepare their responses to the lawsuits.

-Wes

Saturday, March 02, 2019

Maryland Board of Physicians Rejects NBPAS


In November 30, 2018, the National Board of Physicians and Surgeons (NBPAS) and the National Board of Osteopathic Physicians and Surgeons (“NBOPAS”) requested the Maryland Board of Physicians ("Board") formally recognize them as a specialty certification board for continuing certification. Armed with a 17-page letter from the DOJ, they were hopeful, but the outcome of their request they just received from the "Board" was almost predictable:
As a policy matter, board certification or re-certification is not a requirement for licensure. Board certification, however, may be a requirement for employment, hospital privileges, insurance carriers, etc. In that regard, the Board does not believe that it is the appropriate entity to evaluate re-certification or continuing certification boards for approval.

The Board believes, consistent with the DOJ opinion letter, that board certification and the approval of a certifying board for recertification is a business decision to be made by hospitals, insurers, and employers. Even if the Board approved the NBPAS or NBOPAS as a continuing certification board, hospitals, employers, and insurance carriers would still be able to make their own determinations about which boards they choose to recognize for purposes of meeting any eligibility requirements.

Given the inconclusive findings of the MHCC workgroup and the lack of data on quality of care, the Board believes that approval of the NBPAS and NBPOS as a certifying board is premature. The Board will continue to monitor the discussions and research projects regarding maintenance of board certification, including the recommendations from the Continuing Board Certification: Vision for the Future Commission, which are expected to be released in a final report sometime this year.
It is a shame this fight has come to this, but it has. Maybe now the leadership of the National Board of Physicians and Surgeons will recommend their diplomates join our nationwide, multi-specialty legal fight to end "Maintenance of Certification."

-Wes

Addendum: Maybe Maryland joining the Interstate Licensing Compact (with the help of Kaiser Permanente, a fond bedfellow of ABIM's former President and CEO, Christine Cassel, MD), had something to do with this decision.

Why the ACC Threw Cardiologists and EPs Under The MOC® Bus and Why We Let Them

In its latest update with Maintenance of Certification (MOC®), the good ol' boy network of the American College of Cardiology (ACC), Society for Cardiovascular Angiography and Interventions (SCAI), Heart Rhythm Society (HRS), and Heart Failure Society of America (HFSA), announced their commitment to "continuous certification" and MOC® and all its lucrative trappings for US cardiologists and cardiac electrophysiologists.

It seems the authors of this announcement, all older white men without much to lose, just can't get enough of the money associated with locking their younger, more vulnerable colleagues into continuous participation in their expensive board review courses, scientific sessions, self-assessment programs, and pricey study materials. They convened a "Task Force" (or was it a "Committee?") some time ago to study the revenue lost without MOC® verses the money made with MOC®'s leverage on their programs, and it appears they have decided they just can't let go.

So they have a plan.
  1. First, make a lukewarm statement that is supposed to sound opposed to the ABMS Vision Commission, but really says nothing.

  2. Second, to co-brand their own version of "continuous certification" with the American Board of Internal Medicine (ABIM) and call it another name to assure annual payments continue.

They thought hard - really - and recruited lots of their well-respected academic partners and thought leaders in cardiology and EP - to create their own ABIM MOC® pathway called the "Collaborative Maintenance Pathway." (You can't make this stuff up.)

As if cardiologists are deaf, dumb, and blind.

But cardiologists and electrophysiologists have to be honest: we live with the reality that our skills and intellect are uniquely valuable to hospital and health care systems. Without us, they'd die. And now that 75% of cardiologists are employed by hospitals, hospitals need us just as we need them.

The ACC, tied irrevocably to the good fortunes of the Medical Industrial Complex and the realities of managed care data collection, knows this.

So they sugar-coat their decision to side with "continuous certification" as a "commitment to lifelong learning" instead of what it really is, an adhesion contract with the ABIM and the ACC, SCAI, HRS, and HFSA for their lifelong funding at our expense.

In effect, the ACC is saying "Cardiologists and EP's - get over it - you have no choice but to be the breadwinners for US hospitals and health care systems. We scratch their backs so they can scratch ours, so you have to pay up."

Ooops, I just said the unspeakable.

I can hear it now:

"But we are beneficent, selfless 'care providers' who do the work, take call, and save lives at 3 AM when we're dead tired, not just the funding vehicles for US hospitals! We are the good guys, need to keep up with the latest advances, and deserve what we get! How can you dare say such a thing?!?"

Because, deep down inside, it's the truth.

A growing tension is exacerbated by the ACC siding with the corrupt ABMS MOC® program: cardiologists serving hospitals' best interests verses cardiologists serving their patients' best interests. Certainly no one will argue with the benefit to a patient for stenting an occluded coronary at 3AM - it's the magic of what we do and why we do it. But there is also a growing conflict of interest that develops when we must live in fear of losing our credentials (and our jobs) because we don't participate in MOC® and MOC® is tied to our ability to make a living only at hospitals: that tie makes us beholden to our employer before our patient.

It has been revealing to be a student of MOC®'s evolution over the years. I believe there is are complicated psychological and economic principles at play with MOC® (or "continuous" certification).

First, MOC® forces the doctors to split. Psychologic splitting is commonly used to justify unreasonable behavior. Why else would highly intelligent people put up with the now highly public political, financial, and monopoly-making activities of the ABIM? Perhaps its because by participating in MOC®, we can remain the "good guy" in a guideline-directed decision making world of medicine while the ABIM can remain the "bad guy." No need to consider the realities involved with their conflicts of interests. By continuing to participate in MOC® (or it's latest "continuous" iteration, doctors don't have to worry themselves with the nasty details of the high cost of medicine, the waterfalls in the front lobby, and the big screen TV's in every patient's room. We are "just" the beneficent doctors working within the "guidelines." So we "keep up" with our education and those "guidelines" (thanks to the ACC and their "Collaborative Maintenance Pathway") to impress our patients (and truth-be-known somewhere deep inside, ourselves) by promoting this "board certified" marketing accolade and not dealing with its unpleasant realities.

Secondly, MOC® influences the "behavioral economics" of physicians in perverted ways. As an example, behavioral economics states that even if a doctor wants to lose weight and sets his mind on eating healthy food going forward, his end behavior will be subject to cognitive bias, emotions, and social influences. What is a bigger cognitive bias and social "influencer" than the fear of losing your credentials or ability to receive insurance payments because of lack of participation in MOC®?

So the next time you wonder why the GoFundMe page to fight Maintenance of Certification has been fairly slow to reach its ultimate goal, I believe this is why.

Many doctors are putting up with the MOC® charade because they are afraid of losing their job if they speak out and are not completely honest about the MOC®'s role in maintaining healthcare's costly financial status quo.

Perhaps it's time we be honest with ourselves. Who ultimately loses with MOC®'s perpetuation?

Not just younger, more economically vulnerable physicians, but our patients, too.

-Wes

Wednesday, February 27, 2019

Doctors Take the MOC® Stick: Legal Avalanche Unfolds

Working doctors have made their dissatisfaction with the American Board of Medical Specialties' (ABMS) time-limited certification known for years. They have tried to reason with the American Board of Internal Medicine (ABIM). They have exposed the corruption for all to see. They have gone to Washington DC. They have presented these findings to the leadership of the American Medical Association, ABMS, American College of Physicians, and the AMA House of Delegates. They have tried to get meaningful legislation passed at the state level for years. They created their own competing non-profit "board" to offer an alternative to the time-limited credential. They contacted major medical journal editors about the lack of proper disclosure of financial conflicts of interest. They tried to publish an article documenting the harms caused by MOC® (and called "very important" by one reviewer) was repeatedly suppressed from publication. They contacted the Internal Revenue Service. Then they gave one last "Hail Mary" pass to the ABMS by submitting survey results organized by that alternate board from 21,000 physicians to the ABMS Vision Commission, all to no avail.

MOC® (or some bizarre, fractionated form of MOC® rebranded as "continuous certification") continues with all its lucrative trappings.

Now a new, tactic is unfolding to end ABMS time-limited certification nationwide: litigation.

A new free-to-join non-profit was created, run by a multi-specialty group of working physicians from across the nation (disclosure: I'm a co-founder). They created a GoFundMe page to fund anti-MOC litigation that has already raised over $200,000 and is supported by over 1000 physicians (and growing).

In light of the ABMS boards ignoring working physicians' demands to end MOC®, or even allow a meaningful alternative to MOC®, physicians across specialty boards have felt empowered to initiate litigation against time-limited certification. Rather than thinking of this as doctors suing other doctors, it is more accurate to say that this is doctors taking a collective stand against insulated, self-elected, answer-to-no-one bureaucratic bodies; organizations that hide behind humanistic slogans while churning billions of hidden dollars for themselves.

The recent litigation timeline:
  • 6 December 2018 - The first class action anti-trust lawsuit against the ABIM - the largest ABMS member board - is filed.

  • 23 January 2019 - The ABIM suit is amended to include racketeering and unjust enrichment claims.

  • 26 Feb 2019 - Yesterday, another class action antitrust suit  on behalf of approximately 25,000 US radiologists was filed in federal district court in Chicago against the American Board of Radiology.
How many more ABMS member boards will be sued?

ABMS and its member boards may claim to be nothing less than "a selfless ministry" in the service of medicine and that these lawsuits are frivolous, irresponsible, or even unprofessional. Nothing could be further from the truth. Those on the front lines of patient care fully understand the time and cost involved. But you can be sure of this: litigation was not the frontline physicians' first option. Far from it. All other less time-consuming and expensive alternatives have already been exhausted.

To paraphrase Theodore Roosevelt, justice consists not in being neutral between right and wrong, but upholding the right against the wrong. All working physicians should climb off the sidelines and join this fight to end the unproven MOC® and "continuous certification" programs and recognize the legal battle against MOC® for what it is: not a campaign against continuing medical education, but rather a campaign against the massive runaway train of economic exploitation, self-enrichment, and micro-management of our professional lives that are now the hallmark of ABMS and its member boards.

-Wes

Addendum 6 Mar 2019 - The MOC® legal battle now includes the American Board of Psychiatry and Neurology, too.