Ending MOC Nationwide

Continuing education for physicians is important (and we've been doing it all our lives on our own), but when working physicians' right to care for their patients is threatened by unaccountable non-profit testing organizations that have serious undisclosed conflicts of interest, we will take action.

 -Wes



P.S.: Patients, doctors: want to help? You can still donate.

On Trust

Elizabeth A. McGlynn, PhD, immediate past chair of the ABIM Foundation and Vice President for Kaiser Permanente Research and Executive Director of the Kaiser Permanente Center for Effectiveness and Safety Research (CESR) with Richard Baron, MD, President and CEO of the American Board of Internal Medicine,  at the 2018 ABIM Foundation Forum on "(Re-)Building Trust"

Recently, the ABIM Foundation hosted a webinar entitled "(Re-)Building Trust." Oh, the irony. The fact they need to have such a conference is telling of the dire straights the staid and outdated medical credentialing complex has become.

As physicians who funded the ABIM Foundation, why do we fund such nonsense?  The American Board of Internal Medicine has never sufficiently explained why this organization felt compelled to use over $78 million of physician testing fees to create the ABIM Foundation or how and why it uses that money. Is it really to fund such conferences?  Or might conferences like this really be a distraction for the real reason the ABIM Foundation was created: their retirement fund. By the way, whatever happened to those funds shipped off to the Cayman Islands? Why will we lose our privileges at hospitals or insurance payments if we don't pay into this scheme? And why is the ABIM Foundation colluding with Kaiser Permanente directors? What does Kaiser get for this relationship?

If physicians trusted the ABIM, we would not have to ask such questions and the ABIM Foundation would not have to hold conferences on "re-building" trust.

Three years ago, Richard Baron, MD issued the now infamous: "We got it wrong" mea culpa press release when the 2014 iterations of Maintenance of Certification (MOC) foisted on US physicians resulted in a powerful working physician backlash. Lots of soft-shoe, "listening," and MOC program changes have occurred since then. But in reality four years later, little has changed other than parsing our payments into annual aliquots rather than a single lump sum every-10-year payment. The growth of fees is back on schedule, climbing an incredible 276% in the past 18 years.  Even the ridiculous Part IV of MOC is back as before.

It is hard to trust any business, especially a nonprofit organization when they ignore the customer.

We should not lose sight that physicians are the customer of ABIM, not patients. We pay for their medical accolade and the paper certificate that ABIM issues when we successfully complete our initial Board certification and (now) subsequent MOC requirements.

There are many within the US medical board credentialing system who feel otherwise; for them, they are there to serve "the public." Yet this deflection is little more than a propaganda message created to justify their use of our money for their political and financial purposes.

When we see our funds continuing to be wasted at Las Vegas convention venues for American Board of Medical Specialties meetings with their "stakeholders" we realize that this old-school attitude of colleague disrespect and self-importance is endemic to the entire US medical board certification and medical credentialing industry. Hard to re-establish trust with overt demonstrations such as these.

-Wes

PS: Wonder what you can do to change things?  Donate here and get a free book at the same time! We're 78% of the way there!

Enough is Enough

It is 8:30PM CST on the 23rd of May, 2018.

The American Board of Internal Medicine (ABIM) has still not posted their financials from fiscal year 2017, due May 15th, 2018 after an extension is granted by the Internal Revenue Service, on their website. I wouldn't be surprised if they're insolvent, or close to it.

Maintenance of certification (MOC™) is expensive, costing physicians over $23,000 every 10 years in fees, travel, and time from work. Doctors are sick and tired of being manipulated and coerced into playing the continuous certification game created by the non-profit ABIM that has never been independently proven to improve patient safety, care quality, or patient outcomes after a doctor's initial board certification. Doctors are especially sick and tired of these unaccountable member boards of the American Board of Medical Specialties (ABMS) mandating busy work that, if not performed, would limit our ability to maintain our hospital credentials, receive insurance payments, or even obtain state licensure.

We are also sick and tired of being ethnographic research subjects and "HIPAA Business Associates" for the member boards of the ABMS so our data can be bought and sold while board members and officers of the ABMS member boards enjoy their multi-million dollar condominiums with chauffeur-driven BMW town cars, office buildings, first class and spousal air travel, Cayman Island retirement funds, and health club memberships all on our hard-earned nickel.

The conflicts of interest created by MOC spread far and wide: BCBS, CECity/Premier, PearsonVue, ABMS Solutions, LLC, IPC The Hospitalist Group, National Committee on Quality Assurance, American College of Physicians, Wolters Kluwer, Reed Elsevier, UCSF, Massachusetts Medical Society, the AMA, AHA, CMSS, among others.

The financial orgy within the bureaucratic halls of the ACGME has been going on for years at the expense of hard-working doctors. MOC fees alone have mushroomed 244% from 2000-2014 to fund these shenanigans. Numerous doctors are burning out, or quitting altogether, to avoid the ruse. It must come to an end. The integrity of our profession demands nothing less.

Please join me in this GoFundMe crowdfunding drive by Practicing Physicians of America to end MOC™ nationwide for all subspecialties. The specifics of the campaign's purpose are outlined in the campaign's "story" on the GoFundMe page. Please give generously.

It's time to stand up for what's right.

Enough is enough.

-Wes

Too Little Too Late: The ABIM Foundation Sells Its Condo

It was a story that broke on this blog nearly two years ago when the American Board of Internal Medicine (ABIM) Foundation was putting their luxury condominium, complete with a chauffeur-driven Mercedes S-Class town car that was purchased with physician certification and re-certification fees, up for sale.

Over 550 days later, we find the notorious ABIM Foundation condominium was finally sold on 6/21/2016 for $1,650,000 representing an up-front cash loss of $650,000.

But let's not forget the other associated fees required to sell a condo:

Real estate commission (6%): ($99,000)
Transfer Tax as buyer (2%) (2007): $46,000
Transfer Tax as seller (2%) (2016): $33,000
Title insurance: $10,000
Other fees: deed preparation, attorney fees, recording fees, etc. $10,000.
Furniture expense: $56,267


And then there's the annual condo fees, cable, phone, electric, cleaning, etc., that came to $41,000-$50,000 annually (approximately $450,000 over 9 years) (Source: Richard Baron, MD, President and CEO of the ABIM and ABIM Foundation)

All told, ABIM took $2,356,267 million of ABIM diplomat's cash and lost at least $1,265,267 on our behalf.

So much for "Choosing Wisely®."

But let's face it, incurring a financial loss on an "investment" is not necessarily illegal. After all, any of us could have made a horrible investment decision.  Rest assured we'll soon hear the ABIM trying to justify their real estate loss because they would have lost this money anyway if they had to pay hotel costs for all of their out-of-town guests and programmers from India eager for a cheap place to stay.

But we should ask ourselves now with the sale of this condominium, what was illegal at the ABIM Foundation? Anything?

Tax Fraud

First, recall that Dr. Baron claimed in my communications with him that much of the condominium expenses they claimed on their tax forms as program service expenses was actually a depreciation expense they lumped into the "program services expenses" of the condominium. Yet the ABIM and their accountants never claimed depreciation under the separate line item on their federal IRS Form 990 for this expense.

Honest mistake?

Unlikely. After all, other tax filing discrepancies with the ABIM Foundation have occurred repeatedly and systematically over many years. Any credible accounting audit should have disclosed most of them.

For instance, surely someone at the ABIM knew the difference between the two states of Iowa and Pennsylvania, didn't they? So why was the ABIM Foundation domicile claimed as Iowa for years when, in fact, it was domiciled in Pennsylvania but never disclosed? And isn't it striking that the ABIM Foundation was claimed for years as being formed in 1999 until this blog disclosed that it was actually created in 1989, some ten years earlier? Only in its most recent tax filings has that little "oversight" miraculously been corrected without explanation to the Internal Revenue Service.

And why didn't the ABIM disclose that it was lobbying Congress on its tax forms when it had been doing so for years? Was this merely a mistake? Or was it because the ABIM and their Foundation would have opened themselves up to closer scrutiny and lost their tax-exempt status if they had?

Unethical Research Practices

Finally, we have to ask ourselves just what kind of research on physicians for the betterment of health care requires a $2.3 million condominium? After all, the ABIM Foundation has always heavily touted their research work and publications.

Some may argue there wasn't "research" being conducted at the ABIM Foundation but rather "quality assurance" or "Quality Improvement" exercises performed there. If so, then why did the ABIM Foundation promote it's pioneering research by using the term at least five times on a single web page in May of 2007?

Archived Screen May 2007 - ABIM Foundation
(Click image to enlarge)

We also find that the ABIM funded "various research projects" at its Foundation in the fiscal year 2008 with the transfer of $6,000,000 of ABIM diplomat fees:

Evidence of ABIM Funding "research projects" at the ABIM Foundation
for $6 million in Fiscal Year 2008
(Click image to enlarge)

There is no escaping the fact that this was a very serious effort at conducting "research" on physicians.

Or not.

Was the whole "research" story told by the ABIM and ABIM Foundation just a front for other activities? I wish to bring my reader's attention that the ABIM Foundation no longer has the word "research" appear anywhere on its website. Instead, there are only words like "Medical Professionalism Charter," "Initiatives," "Grants" and "Choosing Wisely®." The cover-up continues.

Credentialing of physicians involves human testing. As such, it appears the ABIM Foundation unilaterally decided to perform research on physicians without informed consent, without an impartial Investigational Review Board, and without a clear research hypothesis, method, or analysis of the harms they might cause.

"Research" conducted in such a manner is dangerous for many reasons and some of the most egregious examples of dangerous research have happened in government agencies or when the individual or collective social beliefs or dogma were imposed on others as justification for "research."

The Nuremberg Doctrine which rose from the World War II war crimes is very clear in its requirements for human subject research, especially as it pertains to proper consent. From my recently conducted bi-annual CITI Training:

"The voluntary consent of the human subject is absolutely essential.

This means that the person involved should have the legal capacity to give consent; should be so situated as to be able to exercise free power of choice, without the intervention of any element of force, fraud, deceit, duress, over-reaching, or other ulterior form of constraint or coercion; and should have sufficient knowledge and comprehension of the elements the subject matter involved, as to enable him to make an understanding and enlightened decision. This latter element requires that, before the acceptance of an affirmative decision by the experimental subject, there should be made known to him the nature, duration, and purpose of the experiment; the method and means it is to be conducted; all inconveniences and hazards reasonably to be expected; and the effects upon his health or person, which may possibly come from his participation in the experiment.

The duty and responsibility for ascertaining the quality of the consent rests upon each individual who initiates, directs, or engages in the experiment. It is a personal duty and responsibility which may not be delegated to another with impunity."

It goes without saying that human subject research that involves real estate investment strategies to fund research on practicing physicians is unethical (at least) and likely highly illegal. As we have seen, the MOC recertification program can cause significant harm to physicians, their patients, and their families, especially when this credential is tied to physician employment and remuneration. Worse still, the average failure rate of the unproven "Maintenance of Certification" re-certification metric has averaged 13.2% over the past 10 years with wide year-to-year volatility in pass rates using an inconsistent metric. Was the impact of funneling money from the ABIM to the ABIM Foundation for the ABIM Foundation's "research" really that harmful?

Absolutely.

But this story isn't about a condominium or its sale, is it? It's about the wholesale sell-out by some in Organized Medicine that have systematically and repeatedly turned their back on their fellow practicing physicians and the doctor-patient relationship for their own political and financial benefit. For this story is not just restricted to the ABIM or its Foundation. This story extends to all member organizations of the Accreditation Council for Graduate Medical Education (ACGME) that tie the ABMS Board certification credential to medical training program directors, lab certifications, and a host of other regulatory traps, too. So it should come as a surprise to no one that we find more recently that each of these organizations appears to have been complicit with the ABIM Foundation moving funds derived from practicing physicians' "research" fees offshore.

In the end, the entire American Board of Medical Specialties' Maintenance of Certification® story has alway been about making money for their coffers at the expense of practicing physicians, irrespective of the specialty.

Always has been and always will be.

It's NEVER been about "Choosing Wisely®."

-Wes

Pennsylvania Medical Society Spearheads Effort to End MOC Nationwide

Recently, the Pennsylvania Medical Society sent this letter to the executive vice presidents of all US state medical societies and many specialty societies regarding their vote of no confidence regarding the ABMS Maintenance of Certification® (MOC®) program and the current leadership at ABIM, stating specifically:

"... We believe that their current leadership is not capable of reforming the process in a timely, academically meaningful, and fiscally responsible way.

In keeping with the consensus of our members and physicians across the country, we call for the immediate replacement of the entire ABIM Board of Directors and leadership with new leadership, representative of physicians actively participating in the full-time practice of clinical medicine. The undersigned organizations would further offer to assist the ABIM and any of the ABIM subspecialties with the formation and transition to a new Board that is representative of and accountable to the physicians whom they will certify. ..."

For those interested in learning more or who's state is ready to sign on can email Dr. Scott Shapiro, President of the PA Medical Society at stat@pamedsoc.org‎ for more information.

Please forward a copy of this letter to all of your practicing physician colleagues (irrespective of specialty) and ask each of them to contact the leadership of their respective state medical societies and specialty societies to urge them to co-sign this letter and work with the PA Medical Society to end the corrupt ABMS MOC® re-certification requirement.

Only through aggressive, meaningful, nationwide collective action against this needless, unaccountable, expensive, and coercive ABMS re-certification program will practicing physicians restore sanity to our own life-long continuing medical education process.

Thank you-

-Wes

A copy of the letter to circulate to your colleagues can be downloaded here.

Maintenance of Certification: Medicine's House of Cards

Background

In 1986 after struggling for years to secure a growing stream of revenue, the American Board of Internal Medicine (ABIM), a 501(c)(3) non-profit physician testing agency originally domiciled in Iowa and now located in Philadelphia, PA, unilaterally decided to make its once voluntary and lifelong Board certification credential time-limited. In 1986, the prospect of implementing universal healthcare (Hillarycare) loomed on the political landscape so there was a growing sentiment within the ABIM that its role should shift from determining a physician's excellence to practice medicine to assuring a physician's practice adequacy. By making this strategic philosophic change, the ABIM assured itself a new and virtually limitless revenue stream for years to come on a promise they knew how to determine such a metric.

There was only one problem: how does one define physician excellence?

Excellence in medicine is not easily defined. Is physician excellence defined by patience, empathy, intellect, experience, surgical dexterity, technical skills, or some combination of these things? Or might it be judged on something else entirely? Might the qualities of excellence from a general internist be very different from those of a specialist in internal medicine?

Such important questions did not concern the leadership at the ABIM. They were convinced that not only was it possible to define methods for measuring excellence, they would blaze the trail for this endeavor. To assist them, the leadership of the ABIM co-opted the nation's brightest scholars, lured by first-class airfares, the nation's most luxurious hotels, and elegant wine selections at dinner, to create more challenging and clever test questions for practicing physicians. None of these scholars complained.  Many were honored to provide such a service; it was a great gig for those lucky enough to escape the mundane work of actually caring for patients while being wowed by the lavish creature comforts afforded to them.

On the other hand, working physicians on the front line of health care were caught completely off-guard by the unexpected unilateral "re-certification" rule change developed in December 1986 and ultimately implemented by the ABIM in 1990. Practicing physicians, accustomed to a lifetime of testing and unaccustomed to strongman tactics and political pandering that threatened  "uncertain consequences" if they did not participate, never questioned the rationale for the rule change. For most doctors, the change was seen as just another test they needed to pass to keep working despite never being independently shown to improve patient care or outcomes.

That is, of course, until practicing physicians slowly awakened to the gravity of the ABIM's rule change if they failed re-certification: there was a very real possibility that they might find themselves no longer "Board certified" and could lose their license to practice medicine, hospital admitting privileges, or ability to receive insurance payments. They were cleverly trapped. What choice did they have other than to participate?

Empowered by the significant additional revenues garnered by re-certification and a politically lackadaisical physician workforce, the leadership of the ABIM and the American Board of Medical Specialties (ABMS), along with the many friends they secretly lobbied on Capitol Hill, were asked to deliver even more for their undisclosed corporate clientele: Premier, Inc., CECity, Kaiser Foundation Health Plans and Hospitals, the IPC The Hospitalist Company and their close-held relationships with the Center for Medicare and Medicaid Services (CMS). The leadership at the ABIM decided to expand their definition of physician "excellence" to include the concept of "medical professionalism." This way, a health care cost-saving imperative could be levied on physicians, too.

But medical professionalism, like medical excellence, was not easily defined. Like pornography, the leadership at the ABIM just knew it when they saw it.

Never deterred, the ABIM convened a "writing group" funded by $59,618,428 in assets the ABIM had secretly funneled from unsuspecting ABIM diplomats' board certification and re-certification fees from 1989 to June 30, 1999 to the secret "American Board of Internal Medicine Foundation." (Author's note: In my opinion, the amount taken from practicing physicians may have been considerably more since the ABIM paid large fees to a high-risk investment firm, 1838 Investment Advisors, LLC that lost 74% of its value before it was quietly shut down. Only after an IRS name change was the undisclosed "ABIM Foundation" finally revealed to the public and practicing physicians in 1999. I believe the origination date and domicile of the Foundation was repeatedly misrepresented to the IRS from fiscal year 2009 to as late as the 2013 IRS Form 990 to obscure its origin. To the best of my knowledge and belief after piecing together available tax forms, the leadership and board of the ABIM authorized $80,278,428 to be taken from diplomats' testing fees to fund the ABIM Foundation in the form of contributions and grants from 1989 through 2007.)

After several years of meetings with members of sympathetic U.S. and European professional societies and leadership from the Robert Wood Johnson Foundation, the writing group from the ABIM Foundation achieved their goal. They published their missive entitled "Medical Professionalism in the New Millennium" in 2002 as a non-peer reviewed white paper in the Annals of Internal Medicine and Lancet with the help of sympathetic editors. Not surprisingly, many of the creators of this document have since left medicine to join the lucrative ranks of the insurance and retail pharmaceutical industry like Wellpoint and CVS.

Thanks to their growing avarice and their undisclosed political and health care policy activities, none of the leadership or board members of the ABIM found fault with the purchase of a $2.3 million condominium complete with a chauffeur-driven Mercedes S class town car in December 2007. According to Richard Baron, MD, such an "investment" was the norm for tax-exempt non-profit 501(c)(3) corporations. (The condominium expenses totaled $850,340 from December 2007 through June 30, 2013 (FY 2008: $42,522, FY 2009: $164,460, FY 2010: 161,957, FY 2011: $165,982, FY 2012: $161,980, FY 2013: $153,439)). In the email I received from him regarding this discrepency, Dr. Baron claimed that many of these "condo expenses" included the depreciation expense for the condominium, yet depreciation for the condominium was never claimed on any ABIM Foundation IRS Form 990 tax form until this fact was disclosed on these pages.

As the requirements to participate in Maintenance of Certification (MOC) mandated by the American Board of Medical Specialties (ABMS) grew, many physicians found the requirements little more than onerous busy-work exercises that distracted from patient care. Many practicing physicians elected to stall or not participate. For these reasons, the pressure on the ABIM to market the ABMS MOC recertification program and to protect their monopoly on the program increased. Many specialty societies, hungry for cash as physician participation at national scientific sessions waned, were increasingly happy to help the ABIM market MOC because of the revenue it generated for them.

ABIM's Director of Investigations

In 2008, it appears the ABIM hired a "Director of Investigations" to investigate physicians or individuals who they suspected might be stealing secrets from their proprietary certification process and disrupting their monopoly.  A unique individual had surfaced that year that promised a return on their investment.  He was perfect: someone with deep ties to law enforcement and surveillance techniques who had created a niche for himself in test security. He was comfortable collaborating with various law-enforcement organizations like the U.S. Postal Inspection Service and the FBI. His self-generated LinkedIn webpage (Author's addendum 9 June 2016 @ 20:00 PM CST: LinkedIn page has been brought down. Earlier partial copy can be viewed here or his Infragard info page should suffice. *** Author's Addendum: July 4, 2016: Mannes' LinkedIn page brought back up) impressive so few would question his integrity. But while this individual seemed perfectly amicable and credit-worthy on the surface, he held a more concerning past that the ABIM may have known but chose to ignore. Perhaps this is why his position and true background has never been formerly disclosed to physicians or the public. He appeared on the scene quietly at first with a press release concerning the existence of "phony boards" in AMA Medical News. A similar press release remains on the ABIM website. As others reportedly tried to capitalize on the board certification money pipeline, another warning of a fraudulent board scheme was circulated by the Connecticut Attorney General's office a short time later. In fact, according to my review of available Form 990 tax forms, this individual and the salary he receives from the ABIM has never been disclosed by the ABIM, yet he freely promotes his position at the ABIM with the movie and test security industries.

It was becoming abundantly clear: the ABIM meant business when it came to protecting their physician testing empire.

Teaching to the Test

With the exponential growth of information in health care, "knowing what to know" to pass a re-certification examination became more important than ever to practicing physicians. Not only were the insurance company and pharmaceutical company pre-authorizations adding to physicians' workload, certification requirements to remain employed were as well. By 2009, the demand for Board review courses that promised successful re-certification pass rates had skyrocketed. Because the stakes were so high and the content of the examination often obtuse, many physicians recognized that they could no longer just rely on their experience to pass the examination. Board review courses became a necessary pre-requisite for many to pass because hints and tips of what content to study were always provided, irrespective of which organization or individual offered them.

As the stakes for certification and re-certification grew, word spread that a doctor, Rajender K. Arora, MD was running an "Unusual Board Review" course that used content remarkably similar to study questions on the ABIM certifying examinations. They had heard he got most of his study materials  from physicians that had already taken the test. Pass rates and course ratings from attendees of Arora's course were good. Many medical schools and hospitals, eager to report high board certification pass rates for their physicians to remain ACGME credentialed, recommended their residents and physicians attend this course. After all, the Arora Board Review had received ACGME accreditation.

But for the ABIM (and for their affiliated professional societies like the American College of Physicians that earn handsome returns from board review materials) who felt their databank of re-used test questions might become compromised and less valuable, something had to be done.

The Raid

So the ABIM tapped the skills of their "Director of Investigations." According to the original complaint of a suit filed under seal by the ABIM, an employee of the ABIM was tapped to attend (see items 43 and 48) and audiotape at least one of Arora's courses. The ABIM has retained this audiotape in their possession (partial transcripts of the recordings made by ABIM are included here, here, and here). It appears this evidence was used to help secure an ex parte Temporary Restraining Order and Seizure and Impoundment Order issued against Rajender K. Arora, MD, Anise Kachadourian, MD, and another 50 unnamed "John Doe's" in 2009. The complaint was filed "under seal" (not disclosed to the public initially). Only three names (other than the ABIM's counsel) appear on that order that supplied the judge with the evidence the ABIM had acquired: Christine Cassel, MD (President and CEO of the ABIM), Rebecca Baranowski (Senior Clinical Content Manager for the ABIM), and A. Benjamin Mannes (Director of Investigations for the ABIM). On the basis of the evidence obtained by the undisclosed ABIM employee (s), US Marshals executed a writ to seize materials from Dr. Arora's residence including copies of computer hard drives, backup tapes, Dr. Arora's cell phone as well as 36 boxes of course materials.

But what the Director of Investigations, A. Benjamin Mannes, (aka "Ariel Benjamin Mannes") likely failed to disclose to the judge (and still has never been fully disclosed in my own earlier personal email communications with him, other US physicians, or the public) is that Mr. Mannes carries two felony convictions. These convictions were issued Dec 13, 2005. According to District of Columbia felony conviction #006438 found on the DC Court Cases Online search web page, Mr. Ariel Benjamin Mannes, a former DC police officer released from the DC police force in 2003 after targeting a journalist who wrote a satire on dirty DC cops, was later convicted on charges of (1) impersonating a DC police officer and (2) carrying an unregistered firearm in 2005 after working as a bouncer "keeping the piece" (details at this link) at a local D.C. nightclub to supplement is income while working for the TSA, Railroad division. As a result of the night club incident, Mr. Mannes was released from the TSA in late 2007 just before apparently joining the ABIM. He lost his appeal of these convictions Oct 21, 2008 less than two months before he appeared (backup pdf of the webpage here) in the press as the "director of test security" for the ABIM.

This revelation is not a minor concern for practicing physicians and the public. Certainly using convicted felons for security jobs is not news. But the irony that a felon would be hired to tract the elusive physician thought to be cheating as they studied for a credentialing examination is lost on few.

Many other important questions remain. Did the ABIM call the police before initiating their investigation or use Mr. Mannes, a confirmed expert at intimidation, as a "law enforcement officer" to establish probable cause for the search and seizure at Dr. Arora's residence? What policy and process does the ABIM have to assure due process of physicians accused of cheating? Why was a press release issued before due process occurred? Why is his salary and position of someone this instrumental to physician "investigations" and intimidation not disclosed on ABIM tax forms or elsewhere? How much did (and does) Mr. Mannes earn for his "services" at the ABIM? Would the 139 physicians who were either sued, sanctioned, or vilified in the mainstream media for "cheating" without due process have had a very different outcome if Mr. Mannes' past history been brought to light? How many other of the "50 John Doe's" does the ABIM intend to sue based on Mr. Mannes' "investigation" work and how much will this cost practicing physicians?  With whom did Mr. Mannes collaborate in law enforcement? Did Mr. Mannes' access to law enforcement assets allow him to track physician email addresses? What did he disclose to them and what did they disclose to him? Were the physicians struggling to remain credentialed to practice medicine after the ABIM's abrupt unilateral and highly lucrative certification rule change at fault or was the leadership and board members of the ABIM who instigated this attack on their character using a convicted felon? Who at the ABIM directed an "employee" to attend and secretly audiotape the Arora Board Review courses?  Should attendees of Dr. Arora's course have been informed they were being audiotaped or did the ends justify the means? Were physicians' Fourth Amendment Constitutional rights violated because a law enforcement officer was not used to obtain the search and seizure order on Dr. Arora's residence? Was evidence manipulated? What right to privacy are physicians entitled that study for their MOC re-certification examination? Do physicians have a right to know that attendance at a board review course could be used against them if they mention question content they heard from others?

Considering the millions of dollars involved, the myriad of conflicts of interest, and use of a felon for Board certification and re-certification "investigations," who cheated whom in 2009?

Sadly, these concerns have not disqualified Mr. Mannes and the ABIM's former prosecuting attorney from ABIM's law firm, Marc Jacob Weinstein (with whom Mannes collaborated and who helped bring the original legal complaint against Dr. Arora in 2009) from serving leadership roles (or as employees) of the test security firm, Caveon and marketing their expertise to the Association of Inspectors General or test security conferences (page 19) as late as November, 2015. It is also concerning that Mr. Mannes' background allows him to serve as Governor on the Board of Directors of Philadelphia InfraGard. (For those unfamiliar, "InfraGard is a partnership between the FBI and the private sector created after the 9/11 terrorist attacks that is an association of people from businesses, academic institutions, state and local law enforcement agencies, and other participants dedicated to sharing information and intelligence to prevent hostile acts against the U.S." Doctors should note that Philadelphia InfraGard lists its address as the same address as the FBI in Philadelphia.)

I believe Christine Cassel, MD, who was President and CEO of the ABIM at the time, bears much of the responsibility for the actions and direction of the organization during her tenure. The day after publishing the ABIM press release about the ABIM's actions and the appearance of a simultaneous article in the Wall Street Journal on the matter, Dr. Cassel published a column on the KevinMD blog 10 Jun 2010 entitled "ABIM responds to doctors sharing board certification questions." The original link to the redacted Arora emails that the ABIM claimed formed the basis of their suits against physicians has since been removed. (I retrieved the emails from the internet archive here). In her column, Dr. Cassel explained: "through these actions we are taking, we are reassuring patients and the public that the can continue to trust the process and, and (sic) physicians can continue to trust that it is a fair and rigorous assessment of their medical knowledge and judgment." In retrospect, I believe Dr. Cassel had good reason to use strongman tactics and a convicted felon against more vulnerable physicians: to insist the income generated by physician re-certification be protected. In her 11-year history as President and CEO, to the best of my knowledge, she earned at least $10.88 million dollars, with nearly $9 million of that amount from fees paid diplomats of the ABIM. Dr. Cassel, who it appears was pivotal in organizing the raid on these physicians' residences for her financial and political benefit, was a member of the President's Council of Advisors on Science and Technology (PCAST) at the time and remains there today. PCAST is an advisory group of the nation’s leading scientists and engineers who directly advise the President of the United States and the Executive Office of the President. Not surprisingly, Dr. Cassel who ironically describes herself a "leading expert in geriatric medicine, medical ethics, and quality of care," does not participate in Maintenance of Certification despite being a founding member of the Institute of Medicine and the former President and CEO of the National Quality Forum that determines quality metrics for the nation's hospitals on behalf of the Center for Medicare and Medicaid Services. Given her long-standing conflicts of interest with Kaiser Foundation Healthcare and Hospitals, is there any wonder why she was appointed as Planning Dean for the newly-announced Kaiser Permanente School of Medicine as of March 1, 2016? What message will her history of intimidation and questionable ethics send to Kaiser's future medical students?

ABIM's Ongoing Legal Actions

Currently, the ABIM is involved in another suit they brought against Arora Board Review attendee, Jaime Salas Rushford, MD from Puerto Rico. According to the letter sent to Dr. Salas Rushford on May 8, 2012, the ABIM was "conducting an investigation into the practices of Arora Board Review and its customers." According to the letter, the ABIM traced emails they obtained from Dr. Arora's computers and on the basis of their discovery "determined to indefinitely revoke your certification and will notify the Medical Board in every jurisdiction in which you are licensed" without due process. Given what we now know about the practices of the ABIM and their "Director of Investigations," is there any surprise that  Dr. Salas Rushford is having difficulty obtaining documents from the ABIM for his defense and for his countersuit against them? The foot-dragging and excuses made by the ABIM, including the possibility that Dr. Salas Rushford will make the settlement arrangement between Dr. Arora and the ABIM publicly available on his website, suggests the ABIM cut a special deal with Dr. Arora whom they never sued. What was that arrangement? Why has this not been disclosed publicly? How many other physician email addresses obtained from the Arora Board Review course computers does the ABIM still plan to track down and sue? How many millions of dollars have been squandered by the ABIM in legal attacks upon physicians attempting to fulfill the ABIM's unilaterally mandated re-certification requirements?

Most of all: how much more is the ABIM hiding?

It is difficult to imagine a more Kafkaesque twist to US medicine's professional regulatory system.  At least six physicians were sued as a result of the ABIM's raid on Arora's residence and 134 more sanctioned, resulting in untold professional ridicule, anxiety, embarrassment, and potential loss of their ability to practice medicine. No doubt their patients suffered, too. To add insult to injury, Ms. Lynn Langdon, then the Chief Operating Officer of the ABIM and a non-physician staff member of the ABIM who earned $681,152 in FY 2012 ($297,646 as a "bonus and incentive compensation"), sent thousands of "letters of concern" to other physicians who attended the Arora Board Review course and reportedly keeps those letters on file. Richard Baron, MD, the current President and CEO of the ABIM, earned $61,216 as Chair of the Directors at the time of the audiotaping of the Arora Board Review course and was surely was aware of the raid as well. Like the McCarthy era, it appears we have a system of regulators that will stop at nothing to intimidate and blackball physicians to assure funding of their regulatory cartel.

It is time for the public and our professional societies to know the truth. I believe, given these facts, that the ABMS MOC program (and any iteration that it might morph into) has no place in US medicine and should be abandoned immediately. I also believe the Wall Street Journal that published its earlier story in 2009 with the headline suggesting physicians "cheated" should publish a retraction and provide a follow-up investigation of the ABIM with these facts in mind to set the record straight.  After all, the simultaneous release of the Wall Street Journal story the same day the ABIM press release was issued, coupled with the fact that physicians' names appeared in the article that did not appear in the press release, suggests the Journal was tipped to the story by the ABIM who sought to profit from their actions. To the best of my knowledge at this time, no physician that was sued by the ABIM as a result of the Arora raid has paid a dime in penalties to the ABIM for copyright infringement for attending the Arora course. Yet how much harm was experienced by the 139 physicians who were sued or sanctioned by the ABIM on the basis of the irresponsible actions of the ABIM and their felonious "Director of Investigations?" I know of at least one physician who received the ABIM's "letter of concern" has been unable to re-certify in any subspecialty since that letter was issued.

Moving Forward

It is time for a full investigation of the ABIM and its practices by the Department of Justice, Internal Revenue Service, or the Federal Trade Commission. Are the tactics, that have been used by the ABIM typical of a non-profit 501(c)(3) organization granted tax-exempt status? It will take time and resources to do so, but the public and practicing US physicians deserve to know the truth of all that has transpired and continues to transpire with our nation's physician regulatory system. Without such an investigation, it is hard to see how the ABIM or the ABMS will ever regain the trust of physicians or the public. Clearly, the status quo is unacceptable. If the ABIM and ABMS structure are to survive, bylaws must be changed to insist that an elected board will lead each subspecialty society in lieu of the appointed ones and membership of each organization must decouple themselves from the government and corporate interests that financially benefit the current system.  A full independent financial audit as far back as 1986 as well with full disclosure of tax filing discrepancies is especially needed.  Professional societies and academic journals who conspired with the ABIM and continue to support the ABMS MOC program for their financial benefit need a similar shake-up as well.

Physicians want to care for patients, we do not need unaccountable henchmen and bureaucrats hell-bent on their own power and profits to do our job. It will be up to each of us to demand that hospital systems and insurance companies no longer require ABMS specialty board "maintenance of certification" as an exclusive requirement for licensure, hospital admitting privileges, academic appointments, or insurance panel participation. If they do, it will be up to each of us to demand justice.


"It ain't what you don't know that gets you into trouble.
           It's what you know for sure that just ain't so."

- Mark Twain

(borrowed shamelessly from the opening quote of "The Big Short")
-Wes


References:

Dr. Wes blog: The Maintenance of Certification Controversy 2015 - The Year in Review 
Dr. Wes blog: The Business of  Testing Physicians

Image references: 
https://www.thrillist.com/culture/best-frank-underwood-quotes-house-of-cards-funny-and-witty-lines
http://houseofcardsquotes.tumblr.com/post/77137104455
http://www.scoopwhoop.com/world/hoc-quotes/

Behind the Curtain

On Monday morning (13 June 2016), I will enter "Crystal City" and speak to the men and women behind the curtain at the AMA House of Delegates Meeting here in Chicago. Today begins the first day of registration and the meeting carries through Wednesday morning. They have devoted a tiny 1.5 hours of time to speak on MOC beginning on Monday, 13 June 2013 at 9AM, Columbus Room EF, at the Hyatt Regency Chicago, 151 Upper East Wacker Drive, Chicago.  I will be joined by Charles Culter, MD of the Pennsylvania Medical Society and Mr. Charles Kroll, the forensic accountant from Minnesota with whom I have worked closely to dissect the IRS tax forms of the ABIM and ABIM Foundation. I have only 15 minutes to talk, but there will be a 30-minute question and answer session following.  I understand the session will be videotaped.

As I sit here this morning and try to collect my thoughts, it is clear that I cannot possibly cover all of the corruption that I can uncovered on these pages with the ABIM and with MOC, but what I know is that there are many who still don't know about my work and the far-reaching implications it has, not just for the ABIM, but for the entire ABMS re-certification industry and colluding members of the ACGME that have enjoyed their high salaries and health club memberships on the backs of our re-certification and membership fees.

Practicing physicians across the US and around the world are a world divided from the bureaucratic administrative members of the AMA. They are keenly aware that the AMA has not had their backs in the recent years. My hope is to educate and inform, not throw flames, but because the depth and breadth of the corruption and conflicts of interest with MOC have been so dire, it is time the delegates  at the AMA and the world at large be informed.

At noon today (CST) I will publish my latest work on the MOC debacle that has involved years of research and investigation. Many new revelations are exposed.  This piece will form the foundation for my remarks at the AMA House of Delegates meeting on Monday.  Be sure to check back here then.

Me?  I'll be doing cases and will moderate comments on my blog when I can.  Consequently, posting comments may be delayed until I can get to them.

Thanks for your understanding.

-Wes

Medical Specialty Certification in the US - A False Idol?

For the first time, the history of the ABMS/ABIM board re-certification corruption scandal has reached a peer reviewed medical journal, the Journal of Interventional Cardiac Electrophysiology. I hope practicing physicians here (and others worldwide) take time to read the history and evolution of board certification in the US reviewed in the article and to review the associated references. 

I would like to thank my co-author, Edward J. Schloss, MD (Twitter: @EJSMD) for his contributions to this work and the many helpful editorial suggestions made by the JICE reviewers.

It is time we reconsider the ABMS "Maintenance of Certification" (MOC) program. It is also time to have an independent audit of the financials from 1989 to 2016 from the American Board of Internal Medicine and its Foundation, including full disclosure of the many financial conflicts of interest within the American Board of Internal Medicine (ABIM), the ABIM Foundation, and each of the 24-member boards that comprise the American Board of Medical Specialties. Finally, a full investigation of misleading tax filings and lobbying disclosures of the ABIM as a public tax-exempt 501(c)(3) corporation by the IRS and Department of Justice is long overdue in light of these revelations.

-Wes

Reference:
Fisher WG and Schloss EJ. Medical Specialty Certification in the United States - A False Idol? J Interventional Cardiac Electrophysiology doi: 10.1007/s10840-016-0119-4 Mar 8, 2016.

Holding the ABIM Accountable

I ask my readers to indulge me as I provide some background about the strongman tactics used by the American Board of Internal Medicine (ABIM) to protect their board certification monopoly.

It started with a press release sent by the ABIM dated 9 June 2010, resulting in a story by Katherine Hobson making national headlines in the Wall Street Journal entitled "Medical Board Says MDs Cheated." Ms. Hobson also cross-posted her story on the Wall Street Journal's Health Care blog which she helped moderate at the time.

With this article, the public learned that five physicians, Monica Mukherjee of Washington, D.C.; Anastassia Todor of Aurora, CO.; Pedam Salehi of Los Angeles, CA; Sarah Von Muller of Tulsa, OK and Frederick Oni of Warner Robins, GA were sued by the ABIM "for what it deemed were ethical breaches involving the disclosure of test questions—which aren't supposed to be repeated, copied or reproduced." Another 134 physicians were "sanctioned" by having their Board certification revoked for at least a year, and thousands more were sent "letters of reprimand." Labeled as an "unprecedented action," the sanctions were "immediate" and resulted in the revocation of these physicians' Board certification for at least a year or more without trial. Hiding behind the legalistic  "Pledge of Honesty" that physicians have no choice but to sign when they enroll in the ABIM certification program, Dr. Christine Cassel, president and chief executive of the ABIM at the time, called the sanctions "a message and a deterrent."

It's was also an unprecedented strongman tactic by a self-appointed and unaccountable non-profit corporation. Should the entire unaccountable American Board of Medical Specialties and their 24-member boards be allowed to  intimidate, threaten, and professionally destroy physicians to protect their financial stranglehold on their own version of professional certification?

To those in their isolated executive perches, it seems they feel they can. And so, the story does not end there.

Using undisclosed methods and personnel, it seems the ABIM traced emails from a computer seized from Arora Board Review to a physician in Puerto Rico four years later. In a letter dated May 8, 2012, from Ms. Lynn Landon, Chief Operating Officer of the ABIM, Jaime Antonio Salas-Rushford, MD, was accused of sharing board review questions with the Arora Board Review course. On the sidebar of that letter were other names: Chair Catherine R Lucey, MD, Chair-Elect Robert M Wachter, MD, Secretary-Treasurer Talmadge E King, MD, President and CEO Christine Cassel, MD, Chief Information Officer John K Davis II,  MBA, Senior Vice President and Chief Medical Officer Eric S. Holmboe, MD among others.  With only 10 days notice, the ABIM imposed its harshest penalty: to "indefinitely revoke" Dr. Salas Rushford's Board certification and "notify the Medical Board in every jurisdiction you are licensed." The ABIM then sued Dr. Salas-Rushford for alleged  Copyright infringement.

What the ABIM had not anticipated is that Dr. Salas-Rushford's parents are lawyers and they countersued the ABIM.  Currently, the case has moved from Puerto Rico back to New Jersey and continues in its discovery phase. Lawyers from one of the largest law firms in Philadelphia, Ballard Spahr LLP, are representing the ABIM - all paid for by millions of dollars of practicing physician testing fees.

As you can imagine, the legal fees for Dr. Salas-Rushford's defense are significant. Last evening, a website (doctorsjustice.com) went live to help crowdsource Dr. Salas-Rushford's legal costs. The website contains more about Dr. Salas-Rushford and copies of documents important to his case (including the Langdon letter and the ABIM's final sanction determination). I encourage everyone to review his information carefully.

Given what we know about the ABIM's recent actions, the secret funneling of funds from the ABIM to the ABIM Foundation from 1989 to 1999 to define their version of "medical professionalism," the use of physician testing fees for luxury condominium purchases, the concerning undisclosed conflicts of interest within the leadership of the ABIM (see here and here),  the revolving-door collusion between CMS and the National Quality Forum, the undisclosed political lobbying of this tax-exempt 501(c)(3) organization, their strongman tactics, and their propensity to advertise their self-determined sanctions to mainstream media before due process, it is time practicing physicians demand justice and a full investigation into the ABIM's methods of securing their lucrative physician "quality cartel."

Dr. Salas-Rushford's suit against the ABIM promises to shine a very bright light on the practices of the ABIM whether his case is upheld or not. For that reason, I encourage all practicing physicians, irrespective of specialty, to donate in whatever way you can - $5 or $500 - to his legal fund. You can also help by sharing his website and encouraging others to do the same.

It's time for practicing physicians everywhere to hold the ABIM accountable.

-Wes

Archived ABIM Website Disappears

Anyone who has followed this blog for some time knows that much of my research on the American Board of Internal Medicine (ABIM) and the ABIM Foundation was performed using Internet Archive's Wayback Machine available at http://www.archive.org.

It seems the ABIM no longer wants a record of the changes they make to their ABIM website recorded at archive.org and have opted to have all ABIM archived web pages available after 1 January 2014 removed from the archive.org website. While this is not illegal and any website can opt out from having their web page modifications tracked on the archive.org website, this development is not consistent with the ABIM's promise of transparent policies and practices toward practicing physicians.

*sigh*

-Wes

Part I: Why Washington?

When I lived in Washington DC years ago, there was a saying my wife and I heard on occasion from our friends who worked on the Hill:

"In New York, it's about finance;
In Boston, it's about power;
In Washington (DC), it's about access."

* * *

The invitation came in a regular envelope. An invitation to go to Washington DC.  Who asked me? What was this for? Was it real?

I studied the invitation: a "personal" invite from Congressman Pete Sessions (R-TX), dinner the first night (dutch treat), then meetings started the next day at 08:30 am in the Rayburn Building, presentations, other Senators and Congressman to be invited (names to be decided). New plans. Need input, discussion, dinner afterward.

I showed the invitation to my wife: "Do you think this is the real thing? Why would they ask me?"

"Looks real. Call them," she said. "Find out who's going.  Maybe there's someone you know."(My wife, unphased, used to testify on the Hill when I was a young staff doctor at the National Naval Hospital in Bethesda, MD many years ago).

I waited a few days, then called. "Well, fifty-five doctors have already RSVP'd so far," said the exasperated voice on the end of the line." Ugh, I thought. "We'll be sending out a revised agenda with a list of the attendees when the date gets closer."

Would it be worth it? Fifty-five doctors? Were doctors being asked to come to Washington at their own expense just so it would look like we were "at the table" when, in fact, we were "on the menu?"  Given health care's recent history and how things got to where we are now, it was very hard to suppress my cynicism. Who funds Representative Sessions, I wondered? I checked. Got it. Then I really pondered: why me?

My wife looked at me like I was an idiot. "You have to go," she said. "You can't go through all of these hours of investigation, research, fire, and brimstone, and not go to Washington. Make some appointments.  Maybe you could stay with our old friends Jack and Jill  (not their real names) while you're there."

"But the time from work... it's so expensive..."

"You decide," she said. "But if it was me, I'd make it worth every minute. Look, Washington is really kind of, well, government. Think DMV. Big hallways. Linoleum floors. Fluorescent lighting. All puffed up, but not that glamorous when you think about it, it's no big deal." My wife sure knows how to sell things...

That night, I stared at the computer screen on my desk. "How much does it cost to fly to Washington?" I searched Orbitz. I'd have to cancel a clinic day, maybe two. Maybe I could swing this if I only missed an extra half a day of my clinic. Folks at work won't like this. Oh heck, she's right. I'd never forgive myself if I didn't go.

After weighing things, I booked the flight, then rearranged and blocked my clinic schedule the next day, though I still wasn't sure. Will it be worth it?

A few weeks later a more finalized agenda came with the names of who would be attending. I googled everyone (this seemed to take forever). I made a list. 18 states. Most were practicing doctors. Most of those orthopedic physicians, (Huh?) a few AMA representatives (young and semi-retired), a few older retired doctors, a few lawyers, an economist, a doctor who ran an ICD-10 coding company, a person who owned a medical collection company, some physician advocacy group representatives, a lobbyist.

Sheesh.

"Mouth of the lion," I thought. "How am I going to get a word in edgewise?" Fifty-five people had grown to sixty.  "It'll be a waste of time," I thought.  The next day I finished my overbooked clinic, then returned home to tell my wife what I had decided. I told her I probably won't go to Washington after all.

"You have to go," she reinforced.

"It's all about access."

Can Medical Knowledge Be Copyrighted?

A patient with a history of syncope, first degree AV block with evidence of a bundle branch block and 2:1 block on telemetry is examined and 1:1 conduction ensues with carotid massage. You recommend a pacemaker because you understand the electrophysiologic principle of "gap phenomenon" but realize that you had a question that looked just like that on a prior cardiac electrophysiology medical board examination. You recall that just prior to that examination, you electronically signed a statement that contained something like the following contract language just before the computerized examination started (but recall you were never given a copy of that mystical agreement):

I understand that all ABIM materials are protected by the federal Copyright Act, 17 U.S.C. § 101, et seq. I further understand that ABIM examinations are trade secrets and are the property of ABIM. Access to all such materials, as further detailed below, is strictly conditioned upon agreement to abide by ABIM's rights under the Copyright Act and to maintain examination confidentiality.

I understand that ABIM examinations are confidential, in addition to being protected by federal copyright and trade secret laws. I agree that I will not copy, reproduce, adapt, disclose, solicit, use, review, consult or transmit ABIM examinations, in whole or in part, before or after taking my examination, by any means now known or hereafter invented. I further agree that I will not reconstruct examination content from memory, by dictation, or by any other means or otherwise discuss examination content with others. I further acknowledge that disclosure or any other use of ABIM examination content constitutes professional misconduct and may expose me to criminal as well as civil liability, and may also result in ABIM's imposition of penalties against me, including but not limited to, invalidation of examination results, exclusion from future examinations, suspension, revocation of certification, and other sanctions.

Can you divulge this principle of gap phenomenon (and a similar example of this phenomenon) that once appeared in an almost identical way on your board examination to your residents?

According the American Board of Internal Medicine (ABIM) and the above agreement, it would seem that I cannot.

But is such a medical principle and my personal example displayed on this blog truly copyrightable by the ABIM?

According to prior court decisions, under the principle of the "merger doctrine" my example does not violate the Copyright Act. In fact, according to Mazer v. Stein, 347 U.S. 201, 217 (1954), the Supreme Court stated "Unlike a patent, a copyright gives no exclusive right to the art disclosed; protection is given only to the expression of the idea—not the idea itself." This protects my First Amendments' free speech right and the fact that this same principle was shown to me years before by my mentor, Mel Scheinman, MD at the University of California, San Francisco when I trained as a fellow in cardiac electrophysiology.

To be clear, the disclosure of an exact replica of a board question and its detractors (wrong answers) might be subject to a copyright dispute, but it is clear that simply mentioning to residents that you saw a "similar question" on your specialty board examination and providing an example to your residents and fellows does not compromise your ability instruct your residents about such an important electrophysiologic principle as "gap phenomenon." In actuality, it is hard to copyright medical information that is widely available in the medical literature.

But this has not deterred the ABIM from continuing its legal battles against physicians who they claim may have shared information about their certifying examination question content.

More Suits Against Physicians Filed

Currently, the ABIM is continuing to sue physicians for possible Copyright Act infringement of their secure board examinations from participants in the Arora Board Review course given in 2009 (!), this time a young internal medicine physician from Puerto Rico (the full text of this suit can be viewed here). While this trial has yet to be heard, it will be interesting to see if the ABIM's Copyright Act infringement claims have merit. The suit is interesting because it gives a detailed accounting of the ABIM's test creation methods and the damages they hope to recover. I encourage my physician readers to review the suit.

Even more interesting to me, however, is the answer to the claims made in the ABIM's suit by the defendant and the countersuit filed against them (seen here). The claims of the "ABIM Individuals' Illicit Conduct" (beginning on page 22) are important to review, for if they are found to be true, they offer insight into the extent ABIM will go to protect their intellectual property and the damages they inflict of physicians that might be wrongly accused, including the use of a "spy," claims fo the violation of a "Pledge of Honesty" that the defendant never saw, public claims that he was "unethical and unprofessional," and having only 10 days before every medical licensing board in his jurisdiction would be notified of the ABIM's decision, leaving (in my view) no opportunity for due process.

These are extremely important issues for physicians to understand as the "restructuring" of the ABIM continues in light of the ABIM getting it "wrong" and the financial revelations and deceptive disclosure practices of the ABIM raised on this blog and elsewhere.  If the court finds in favor of the defendant in many of the claims made by him, I have a feeling there will be many more suits against the ABIM to follow.

It also raises the very real possibility that the ABIM Foundation was not created as a means to define and promote "medical professionalism," but rather to serve as a legal defense fund for the ABIM as they protect their monopoly interest in the physician specialty accreditation process.

-Wes

Why Electrophysiologists Need to Flood the MOC "Debate" at HRS2015

Anti-MOC Buttons
Click image to order yours

On 13 May 2015 at 8 am in Room 162A of the Boston Convention Center, a session called "Controversies in Public Policy"will occur at the 2015 Heart Rhythm Society Scientific Sessions. As part of that session, a "debate" on Maintenance of Certification (MOC) entitled "Maintenance of Certification is Important for the Practice of Quality EP and Should be Endorsed by HRS" will occur at approximately 10 AM.  Every cardiac electrophysiologist should attend. (Yes, the Atrial Fibrillation Summit can wait a bit).

Doug Zipes, MD will serve as the protagonist of the "debate" and Fred Kusumoto, MD will serve as the antagonist.  I am sure the so-called "debate" will be cordial.  Both speakers are class acts and I'm sure each will do their best to up-end the other.

But I have many concerns about this "debate," some of which I articulated earlier. Now after reviewing the program format and disclosures for the "debate," I have more concerns.

First of all, the limited time for the debate does not allow time for input from the audience.  This is a shame.  HRS needs to hear concerns from ALL of their membership. Granted no one wants a shouting fest, but polite and pointed discourse should be encouraged at meetings, not squelched.

Secondly, let's look at the disclosures for this debate, because I think this is important.

Dr. Zipes lists his disclosures for the  MOC "debate" as follows:

Douglas P. Zipes, MD, FHRS. Krannert Institute of Cardiology, Indianapolis, IN

Disclosures
  D.P. Zipes: E - Royalty Income; 3; Elsevier. I - Research Grants; 1; Medtronic, Inc.
Abstract
  There is no abstract associated with this presentation.

No where in his current disclosures does Dr. Zipes mention his long relationship with ABIM as a paid "Director," "Chair-Elect," and "Chair" of the organization. Here is what Dr. Zipes earned from the ABIM between July 1, 1998-Jun 30, 2003:

FY 2003 $31,133 as "Chair"
FY 2002 $17,469 as "Chair-Elect"
FY 2001 $13,907 as "Director"
FY 2000 $20,996 as "Director"
FY 1999 $30,484 as "Director"

No doubt Dr. Zipes has good friends at the ABIM and will find it easy to take the "protagonist" role in the "debate," but is he the right person for a non-biased recommendation for endorsement of the  ABIM's MOC program by the Heart Rhythm Society?

We should recall that Christine Cassel, MD was the acting President and CEO of the ABIM and the ABIM Foundation during the time Dr. Zipes' had his appointments there.  Dr. Cassel now is President and CEO of the National Quality Forum (NQF), a non-profit organization called a "consensus-based entity" that sets quality metrics that soon will influence how physicians are paid.  The NQF has close ties to the ABIM and derives most of its revenue from the Center for Medicare and Medicaid Services (CMS) by way of government grants. Recall that the current President and CEO of the ABIM, Richard Baron, MD worked for the National Quality Forum before coming to the ABIM and may have been slated for a leadership role there as evidenced by a screen shot I captured from the National Quality Forum's website in July 5, 2014 (the web page is no longer present).  Also realize that the National Quality Forum continues to employ Ms. Cassel who was responsible for (1) the repeated piecemeal funneling of $30.6 million of our physician testing fees to the ABIM Foundation (and that purchase of the now infamous $2.3 million luxury condominium), (2) the creation and write-off of $3 million dollars for the now defunct "Institute of Clinical Evaluation" created by the Foundation, and (3) the non-disclosure of grants the ABIM Foundation received from the Josiah Macy Jr. Foundation and the "Institute of Medicine as a Profession," a non-profit created by George Soros and his Open Society Institute.  Needless to say, Dr. Zipes' conflicts are very significant in light of this interplay of money and politically-connected individuals and organizations.

Let's now look at Dr. Kusumoto's published conflicts of interest for this "debate:"

Fred M. Kusumoto, MD, FHRS. Mayo Clinic, Jacksonville, FL

Disclosures
F.M. Kusumoto: None.
Abstract
There is no abstract associated with this presentation.

(I did not see Dr. Kusumoto's name on any of the ABIM's Form 990 tax disclosure forms either. )

The Heart Rhythm Society must make a clear choice after the upcoming scientific sessions. They can side with the working community of cardiac electrophysiologists or they can side with continuing their support of government grants, cronyism, and an increasingly political agenda that promises cash flow from the government.  Which will they choose?

So let's show up with a sea of buttons and other bling and make it clear that the HRS's endorsement of MOC must go.  All of it.

To promote the anti-MOC movement, I have created a section of my MedTees.com website specifically to purchase anti-MOC bling. All proceeds I receive (about 1-5% of the prices) will go to the ABIM's competitor, NBPAS.org instead. The rest of the costs go to the manufacturer of the bling, Cafepress.com, including the high shipping prices (sorry, out of my control).

If you'd like to get a FREE 2.25" Anti-MOC button from me before the "debate" session at HRS2015, I will have a hundred of them to distribute(limit one per doctor - I paid for them myself), so get there early.

I look forward to seeing everyone at the meeting.

-Wes

On the Value of Losing

“There is no teacher more discriminating or transforming than loss.”
        ― Pat Conroy, My Losing Season: A Memoir

On April Fools Day I received an email notifying me that I was one of 14 finalists for the National Institute for Health Care Management (NIHCM) Foundation's Digital Media Award for my work exposing the financial practices of the American Board of Internal Medicine (ABIM) and its Foundation on this blog.  Hard to believe, really.  Especially when I looked at the other individuals who were also selected as finalists, many of whom are veteran and highly decorated digital health care media journalists who do amazing work day in and day out.  If you have a few minutes, be sure to read (or watch) each of the works nominated for this award.

Several days ago I learned that I was not selected to receive the grand prize. While I can't deny that an infusion of cash into my bank account after tax day would have been nice, just being nominated and recognized as a finalist with such other distinguished writers in this space is reward enough.  (In fact, I still marvel that I was chosen as a finalist for this award in light of the fact that many of the largest insurance company executives sit on the board of the NIHCM.)

I can recall my reluctance to publish this work. The prospect of publicly labeling a national accreditation organization responsible for "certifying" one quarter of US physicians as potentially corrupt was risky. I ran the piece by other trusted colleagues before publishing who gave me phenomenal edits and suggestions. I had several lawyer friends review the piece as well. After all, I am not a person who enjoys criticizing others or exposing my family to legal risks. I also knew that there was a better-than-even chance that some senior leadership at my institution would not be pleased with the report.

Celebrated syndicated columnist David Brooks once noted that there are things we do as "resumé builders" and other things we do as "eulogy builders." Writing in medical journals builds resumés. Sadly, writing on a blog does not. While I have no doubt that winning the grand prize for this Digital Media Award would have been quite a "resumé builder" for a second chapter after medicine, that was never my motivation for this work. As a working physicians who has now endured the increasingly onerous ABMS Maintenance of Certification® (MOC®) process three times, I have seen it morph from a personal marketing tool to a mandatory and ridiculously onerous biannual money stream for a group of unknown non-clinical physicians hiding behind the thin veil of non-profit leadership hubris and avarice. Then, seeing my residents and fellows shell out large sums of money to pre-register for for MOC® before they were allowed to register for their initial certification added more concerns. Finally, the long history of money transfers between the ABIM and its Foundation, the highly conflicted evidence base with shoddy or colluding peer review that the ABIM promotes, and the subspecialty organization political funding machine that occurs as a result, led me to conclude that MOC® was always been about the money, nothing more.

So thanks to the NIHCM. Thanks to everyone who have supported me and given guidance in this endeavor. (You know who you are.) Thanks (especially) to Charles Cutler, MD whose independent yet highly professional 28-minute critique of the ABIM helped blaze the way for my essay's publication.

It will be interesting to see where this all goes.

-Wes

Physician Civil War or Revolution?

Today, Kurt Eichenwald published a report in Newsweek on the American Board of Internal Medicine (ABIM) scandal entitled "The Ugly Civil War in American Medicine." Here's a small exerpt:

Slass says the suggestion that the ABIM is “purposefully failing candidates on their exams to generate more revenue is flat-out wrong.” Maybe so, but according to the Form 990s filed with the Internal Revenue Service, in 2001—just as the earliest round of new-test standard was kicking in, the ABIM brought in $16 million in revenue. Its total compensation for all of its top officers and directors was $1.3 million. The highest paid officer received about $230,000 a year. Two others made about $200,000, and the starting salary below that was less than $150,000. Printing was its largest contractor expense. That was followed by legal fees of $106,000.

Twelve years later? ABIM is showering cash on its top executives—including some officers earning more than $400,000 a year. In the tax period ending June 2013—the latest data available—ABIM brought in $55 million in revenue. Its highest paid officer made more than $800,000 a year from ABIM and related ventures. The total pay for ABIM’s top officers quadrupled. Its largest contractor expense went to the same law firm it was using a decade earlier, but the amounts charged were 20 times more.

And there is another organization called the ABIM Foundation that does...well, it’s not quite clear what it does. Its website reads like a lot of mumbo-jumbo. The Foundation conducts surveys on how “organizational leaders have advanced professionalism among practicing physicians.” And it is very proud of its “Choosing Wisely” program, an initiative “to help providers and patients engage in conversations to reduce overuse of tests and procedures,” with pamphlets, videos and other means.

Doesn’t sound like much, until you crack open the 990s. This organization is loaded. In the tax year ended 2013, it brought in $20 million—not from contributions, not from selling a product, not for providing a service. No, the foundation earned $20 million on the $74 million in assets it holds.

The foundation racked up $5.2 million in expenses, which—other than $245,000 it gave to the ABIM—was divided into two categories: compensation and “other.” Who is getting all this compensation? The very same people who are top earners at the ABIM. Deep in the filings, it says the foundation spends $1.9 million in “program and project expenses,” with no explanation what the programs and projects are.

There are some expenditures, though, that are easy to understand: The foundation spends $153,439 a year on at least one condominium. And it picks up the tab so the spouse of the top-officer can fly along on business trips for free.

Be sure to read the whole thing.

What the American Board of Medical Specialties and their member boards (like the ABIM) don't realize is that America's practicing physicians are sick and tired of funding organizations that serve as little more than job boards for non-practicing physicians looking for their next career.

-Wes

On the Important Issue of Physician Trust

After a brief foray into the uncomfortable position of being publicly humiliated, the American Board of Internal Medicine is now telling is they have begun a "transformation" of their Maintenance of Certification program.  They said they got "it" wrong. But instead of understanding "it," they want practicing physician to forget "it" and, instead, refocus our efforts to redefine "it."

To begin that process, they are publishing seemingly heartfelt missives claiming they've been "thinking a lot ... about the values that we physicians share." Even after squandering any semblance of trust by their inexcusable financial behaviors, they pretend to understand how practicing physicians feel and claim "we are united in our passion to do right by our patients and our commitment to lifelong learning." This is a straw dog.  They have taken accountability for the most trivial component of what they did to the practicing physician community - as if they hired damage-control consultants.  Instead of coming clean, we now see they have begun a campaign to groom vulnerable physicians into believing their storyline so their largess can continue unabated.

For who is more vulnerable than a junior practicing US physicians saddled with huge educational debt?  Who is more vulnerable than the junior physician trying to find a job as an employee in a large health care system hell bent on cutting costs?  Who is more vulnerable than the majority of physicians who have lost their independent practices and now are placed in the ethically impossible position of serving two masters: their patients or their employers that insist they do more with less? Like a perpetrator trying to identify areas of psychological weakness in the vulnerable practicing physicians, they continue to attempt to position themselves as our savior, rescuer, and someone who holds us in the highest regard.

Trust between physicians is critically important.  We rely on our colleagues in matters of life and death every day.  Actively practicing physicians cannot tolerate faux trust or press-release trust. But the members of the ABIM wouldn't know about that.  They sit on their insulated perches forcing their colleagues to pay into their flawed system first every ten years and now every two.  They have assembled a rich war chest of cash assembled on the backs of their practicing colleagues and then proceed to self-select their finest sycophants to join their merry band of highly-paid regulators.  And remarkably, we now find that their unproven pay-to-play scheme uses the federal government as imprimatur.

But we should understand that this loss of trust goes much further.  Every professional organization that sides with the ABIM in support of the MOC program is also violating their own membership's trust of collegiality, professionalism, and support.  Nowhere was there a better example of the pathologic nature of the siding with the ABIM than that demonstrated by a recent letter from the American College of Physician's Executive Vice President and CEO, Steven Weinberger, MD, to their membership in response to the ABIM's "We Got It Wrong" admission.  Almost unbelievably, rather than acknowledging the realities of the ABIM's actions, Weinberger's letter openly threatens their membership with veiled threats of potential consequences of non-complicance with the ABIM MOC program if they choose an alternate certification pathway:

As many of you know, there has been a movement by some physicians to establish a pathway for “certification” that is independent of either ABIM or the American Board of Medical Specialties (ABMS, the umbrella organization over all specialty boards, including ABIM). We have been asked by a number of our members about “alternative pathways,” and I wanted to outline a series of questions that anyone must consider when assessing alternative options: Will an alternative pathway be credible to substitute as a credentialing requirement for hospitals and health plans? (For example, a requirement of 50 hours of CME credit over 2 years is a very low bar, in fact representing only half of the CME requirement for medical licensure in most states.)

• If you are named in a medical liability lawsuit, how will it appear when it is noted that you have not recertified through ABIM but have instead tried to show that you are “certified” through a process that has not been widely accepted and whose requirements are minimal?


• If you have a time-limited certificate from ABIM, are you willing to forfeit that primary certification in internal medicine and/or a subspecialty of internal medicine when that certificate expires? Recognize that, after your current certificate expires, not participating in ABIM’s MOC program means more than just being listed as “not participating in MOC.” It means that you are no longer certified, i.e. your initial certification is no longer valid.


• Is the fee for an alternative pathway reasonable considering both what you are getting as well as the expenses of the group that has developed the alternative pathway? For example, a fee of $169 every 2 years is almost half of the ABIM’s internal medicine MOC fee, but the alternative organization has no program or product development costs, as all it is doing is sending an electronic certificate (there is an additional charge for a paper certificate).

(Update 2/27/2015 @ 12:07 PM CST: See the NBPAS.org's response to the ACP)

And as if this were not bad enough, the ABIM Foundation continues to use Christine Cassel, MD, former President and CEO of the ABIM, as their spokesperson on matters of waste in our health care system in their highly-produced videos to the public when they themselves have squandered millions.

The ABIM Foundation never mentions they used coerced physician testing fees to fund their Choosing Wisely Campaign and to purchase lavish condominiums for themselves.  They never disclose (and have no future plans to disclose) their many years of conflicts of interests with consulting groups, think tanks, hospital groups and little sweetheart government agency grants (kickbacks?) with practicing physicians or the public. They see no problem squandering $3.3 million dollars of physician testing fees on a contrived promise of psychometric testing techniques to add value their system. They see no problem collecting and circulating practice and meaningless survey data to their many corporate affiliates. And worst of all, they have no plans to examine their sister organization's practice of failing as many as 22% of their test takers without ever evaluating the impact of their actions on a physician's ability to practice or the impact such an action has on the doctors' patients.

The ABIM and their professional society supporters have irrevocably lost the trust of America's practicing physician community.  They can't just "groom" this away hoping for its preservation or offer threats in the MOC program's defense.  What's done is done.

The question now becomes, can they and their many supporters ever earn it back?

-Wes

Related: (registration required) "Physicians are Outraged Despite ABIM Apology for MOC Mess" Medscape - Note: 237 528 comments and growing.