Why the U.S. Specialty Boards Were Sued and Why Those Lawsuits Are Important

I hope every working U.S. physician takes 9 minutes to view this video on why the lawsuits against  the American Board of Medical Specialties (ABMS) member boards were filed and why those lawsuits are so important to our profession.

Please view and share with your colleagues.

An update on the status of those lawsuits will appear on this blog's pages soon.



-Wes

Video: 7007 US Physicians Weigh In on US Board Certification

From January through March 2018, a voluntary Internet-based survey of US physicians and surgeons was conducted by Practicing Physicians of America concerning ABMS Board Certification. 7007 completed surveys were available for analysis. Here is a brief video summary of many of the survey's findings as promised:



-Wes

Reference: pdf file of PPA Physician survey questions that formed the basis of this report.

US Board Certification Survey Results to Be Presented at the June AMA Meeting

The largest independent voluntary survey of US physicians on the topic of US Board Certification (and continuous certification) will be presented at the 2018 Annual Meeting of the AMA House of Delegates at the Hyatt Regency Chicago on June 11, 2018, at 9 AM. The social media-promoted national survey was conducted by Practicing Physicians of America and explores the topics of value, cost, burnout, research methods, physician awareness of conflicts of interest, and the negative consequences physicians have experienced from the process. Physicians from all 50 states and nearly all US territories and subspecialties responded.

Pennsylvania Medical Society is hosting the event and I will be presenting. Given your busy schedules, I look forward to meeting all three of you who can make it.

-Wes

Money for Nothing

Imagine paying $4,675 for a piece of paper. It would make the days of $436 military hammers look pretty cheap, wouldn't it?

Now imagine that piece of paper comes with a promise of having to pay more for your own good and where time spent acquiring that paper meant nothing.  Most rational people would have visions of Bernie Madoff or some other Ponzi scheme.

Yet this is the reality of the American Board of Medical Specialties' Maintenance of Certification (MOC) program for practicing US physicians.

I recently went throughout the Maintenance of Certification process in 2013.  I sat for both by Cardiovascular Diseases Certification (that expired in 2013) and Clinical Cardiac Electrophysiology recertification (that expired in 2014) secure examinations in October of 2013.  Here's what I got for my cardiovascular recertification fees:

ABIM Cardiovascular Disease Certificate 2013 - Click to enlarge

Note that because the cardiovascular certificate was renewed in 2013, it now was extended from 2013 through 2023.  The cover letter that came with the new Cardiovascular Disease certificate was also notable for the three references its cited as "proof" of the value of these certificates. The three references were (1) Arch Intern Med 2010; 170(16): 1442-9, (2) Arch Intern Med 2009 (sic - Editor's note: actually 2008) 168: 1396-1403 and (3) JAMA 2005 294(4): 473-81.

Reference (1) concludes that "Publically available characteristics of individual physicians are poor proxies for performance on clinical quality measures." Reference (3) is a cross-sectional retrospective analysis of data on US physician respondents to the 2000-2001 Community Tracking Study linked to Medicare beneficiaries they treated in 2001 that only generated the hypothesis that "profiling practices may help develop tailored interventions that can be directed to sites where the opportunities for quality improvement are greatest."

But the worst reference was Reference (2).  This reference is notable in part because of the glaring and inexcusable conflict of interests of every author on the manuscript. Each author was either a paid member of ABIM or an employee of Qualidigm of Middletown, CT, a data analytics firm that does the following according to its website:

Collecting relevant data, turning that data into information, and that information into action, drives almost every Qualidigm initiative and contract.

Qualidigm analysts have the qualitative and quantitative knowledge, skills and experience to provide a wide range of services including but not limited to:

• the analysis of claims data from a single source or aggregating claims data from multiple sources;
• the collection, integration and analysis of claims data, administrative data and medical records data;
• the geographic analysis of various types of databases, e.g., claims, medical records;

So it appears that Qualidigm's authors (and the purpose of these certificates and entire MOC program) was manufactured not only for the money it creates for these boards, but for insurance company claim denials.

Because my Cardiac Electrophysiology certificate expired in 2014, doctors should be aware of the changes that have occurred to board certificates.  I recieved this new certificate after passing by secure examination and countless hours collecting survey data, attending board review courses, and reading enough material to put the Encyclopedia Britannica to shame:

ABIM Clinical Cardiac Electrophysiology Certificate 2014 - Click to enlarge

Note the fine print below the words "Clinical Cardiac Electrophysiology:"

"Ongoing certification is contingent upon meeting the requirements of Maintenance of Certification. Please visit www.abim.org to verify certification status."

In essense the new 2014 (and later) "Maintenance of Certification" certificates are nothing more than very expensive hyperlinks to the ABIM.org website.

Sorry, but I will never recertify and participate in this Ponzi scheme again.

Ever.

-Wes

Reviewing The Regulators

In 1990 the American Board of Medical Specialties (ABMS) and the American Board of Internal Medicine (ABIM) changed their requirements for physician board certification from a voluntary life-long designation and educational process to a time-limited designation lasting 10 years.  This decision to require repeated testing, the public was told, was based on data from a single highly flawed retrospective literature review that suggested physician competence deteriorates over time.  Despite this, over the ensuing years hospitals and insurance companies increasingly require physicians to be board certified for credentialing or billing purposes.  And as a result of changing the life-long designation of board certification to a temporary one, physicians were left with little choice but to pay for and participate in the ABMS/ABIM MOC program to practice their trade.

In 2005, the ABMS modified their re-certification requirements and created a program called "Maintenance of Certification" (MOC).  This program required completion of "Practice Improvement Modules" in addition to the completion of certain knowledge-base testing modules before a physician could sit for their secure re-certifying examination.  This decision to include "Practice Improvement Modules" was a unilateral one by the ABMS and its subsidiaries and was never scientifically challenged or validated by the independent physician community.

This year, the requirements for MOC changed again when all US physicians were now required to pay for and participate in the ABMS/ABIM MOC process every two years, in addition to re-taking their certifying examination every 10 years.  Because of the added cost and time requirements with the most recent change to the ABMS/ABIM  MOC process, physicians began questioning the MOC program's legitimacy as a means of assuring physician quality verses the ABIM's bottom line.  An online petition was signed by over 18,850 physicians asking to "recall the changes to MOC and to institute a simple pathway consisting of a recertification test every ten years."   In his response to this petition and to support the credibility of the MOC process, the President and CEO of the ABIM referred to the research conducted by the ABIM leadership and staff:

"There is a good deal of research demonstrating the value of MOC: from the validity of the examination, to the importance of independent assessments – clinicians are not good at evaluating their own weaknesses. All of this research drives and informs our program requirements and product development."  

Review of the ABIM’s "research" topics showed they cover a wide range of important clinical care issues including trust, teamwork, ethics, obligations of the Hippocratic Oath, characteristics of internal medicine physicians and their practices, teaching, staffing patterns, electronic health records, clinical skills, and the structure of medical homes. But closer inspection of much of this work shows it was not research, but rather opinion and editorial.  Much of the "research" resides behind expensive online paywalls free to the academic community, but expensive for the non-academic physician and public to review.  Given these realities, before casting aspersions on physicians' ability to evaluate their own weaknesses, it appears a review of the ABIM's "research" in regard to its clinical legitimacy is in order.

In 2014, the Center for Medicare and Medicaid Services (CMS) published the entire database of $77 billion dollars of payments made to US health care providers in 2012.  The data are easily reviewed using a website created by the Wall Street Journal.  In an effort to establish the credibility of the ABIM leadership and staff's journal publications as it pertains to the various aspects of medical practice they claim to actively monitor, each author published in the 2014 collection of journal articles published on the ABIM website was cross-referenced with their CMS 2012 Medicare provider payment data.

Methods

 The ABIM publishes journal articles authored by ABIM staff and leadership for the years 2000-2014 on its website.  The 31 articles published so far in 2014 were randomly selected for review. Each author of each paper was then compared to their 2012 Medicare payment data.  If the payment data for a particular author were non-zero, then the total number of inpatient and outpatient new and existing patient encounters were totaled to determine the total 2012 annual Medicare patient care encounters seen by the author.  Procedure counts were not added to this total of encounters, since the intent here was to "even the playing field" between "proceduralists" and hospital- or office-based clinicians in terms of the number of patient contact episodes they had each year.  In the event more than one physician author's first and last names were identical, the source article was reviewed to assure the proper physician data was obtained based on their city, state, or academic institution.

Authors designated as employees of ABIM, those with acknowledged conflicts of interest or those with non-academic or policy affiliations were also recorded. The average, median and standard deviation of 2012 Medicare payments and patient encounters were then calculated.

As a point of reference, the author of this blog post received a total of $163,184.55 in Medicare payments representing 529 patient encounters (298+75+13 established outpatient visits, 31 outpatient new visits, 82+14 initial hospital/inpatient care and 16 subsequent hospital care visits) according to the 2012 Medicare database. This number of encounters represented 1.5 days of outpatient clinic visits per week in 2012 (personal data) as well as inpatient patient care encounters payments received from Medicare patients. This encounter volume represented 42% of this author’s total number of clinical encounters billed in 2012 (personal data).

 Results

Thirty-one articles published by the ABIM staff and leadership in 2014 (so far) represented work by 150 authors.  Of the 31 articles published on the ABIM's website to date for 2014, ten of them (33%) were published solely by ABIM employees or leadership. Only 80 of the 150 authors held an MD degree.  The authors were a heterogeneous mix of US and non-US physicians, one veterinarian, nurses, students, statisticians, researchers, representatives from National Board of Medical Examiners, Center for Medicare and Medicaid Services, the Urban League, the Foundation for Advancement of International Medical Education and Research, Mathematica Policy Research, Inc., the National Collaborative for Improving Primary Care Through Industrial and Systems Engineering, the VA medical system, staff members of the American Board of Internal Medicine Foundation, and others from Consumer Reports Health.

Clinical Involvement

Of  physicians with an MD degree, the average 2012 Medicare payment amount was $18,196.97 ± $68,220.55 (median $0). Only thirty-seven of the 80 physician authors (46%) had Medicare payments paid to them in 2012.  Three authors had payments exceeding $100,000 in 2012 while the vast majority (30 of the 37) received under $25,000. This average payment amount corresponded to an average of 131 ± 308 patient encounters (median 0) for the entire year 2012.

If all of the authors were included in the analysis, the average 2012 Medicare payment was $9705.05 ± $50,502.95. The median Medicare payment to the authors published in 2014 to date was $0. The average number of patient encounters per year in 2014 was 70 ± 234. The median number of patient encounters in 2012 by the authors published to date was 0.

The entire spreadsheet (pdf) of the 2012 Medicare payment and encounter data by each author that published with ABIM leadership and staff in 2014 can be reviewed here.

 Discussion

This study is the first to cross-reference a portion of ABIM publishing authors to the 2012 Medicare provider payment database. While Medicare payment data might not represent the full workload of today's clinical physicians, it is the most complete database of US physician clinical work performed on patients in the United States published to date.

The ABMS/ABIM's Maintenance of Certification program has been criticized by many working physicians as onerous, expensive, time-consuming and a poor reflection of physician quality. In his response to physician concerns over the MOC process, the President and CEO of the ABIM stated:

"ABIM's mission is to enhance the quality of health care by certifying internists and subspecialists who demonstrate the knowledge, skills and attitudes essential for excellent patient care."

Dramatic changes to the health care landscape have occurred over the past five years.  If the mission of the ABIM is to truly certify internists who with “skills and attitudes essential for excellent patient care," we are left to question the legitimacy of recommendations made by physicians who no longer care for patients in today’s health care arena. The ABIM seems content with making recommendations to physicians while being woefully inxperienced about the challenges that face internists today.   In fact, the data presented in their work confirms that physician quality is being regulated by an unqualified body.

While some might argue that regimented study and time-consuming non-clinical data acquisitions are required to assure physician quality, it remains quite possible that such a dishonest and lopsided approach will backfire as physicians refuse to participate in this process or retire early from medicine just as more patients are entering our health care system. Burdening clinical physicians with unrealistic and unproven demands for non-clinical tasks detracts from needed patient care.  Recall that only three of the physicians included in the author list of ABIM's 2014 publications received over $100,000 of Medicare payments while 30 of 37 physicians in the published articles in 2014 received less than $25,000.   Might the recommendations and data that the ABIM is making available to hospital groups and insurance organizations be seriously flawed?

Even a cursory review of the background of the authors of several published works of the ABIM staff and leadership reviewed suggests a troubling narrative. For instance, one article included with the ABIM's 2014 list of journal articles is entitled "Internists' attitudes about assessing and maintaining clinical competence" (J General Int Med 2014; 29(4):608-614).  While this title might seem reassuring to the public that the ABIM is serious about their mission, their credibility becomes suspect when closer inspection of the background of the authors revealed only one of the six authors had any clinical encounters in 2012 and another author was a veterinarian. In another article entitled "Time to trust: longitudinal integrated clerkships and entrustable professional activities," (Academic Medicine, 89(2), pp 201-4) none of the authors received payments for patient care in 2012 and the authors acknowledge the ideas presented were provided by two political "think tanks."  Should these be the people we entrust to develop clerkship ideals and "entrustable professional activities" (whatever that is) for our future physicians?

We should note that despite fourteen years of articles on the ABIM's website, none of the ABIM’s "research" has ever evaluated any negative consequence of their MOC program.  Rather, these ABIM papers "drives and informs" additional unsubstantiated "program development" like a public relations firm. Without independent assessment of their practices, it remains completely possible that the MOC process causes more harm than benefit to actual patient care delivery as a result.

The Medicare payment data of ABIM authors also begs the question, how are the ABIM physicians and legislators spending their time?  It is apparent that most physician members of the ABIM are not involved in clinical care.  Given the conflicts of interest mentioned in the various citations, physician quality assurance is not the ABIM's priority.  Perhaps the physician members of the ABIM would have more credibility advising struggling doctor-employees on beefing up their curriculum vitae, earning consulting fees, perfecting public relations skills, and creating multiple income streams since their annual revenue take with their MOC program implementation went from $46,131,129 in 2010 to $55,625,925 in 2012 (Data from the 2011 and 2013 IRS Form 990 published on guidestar.org/).  Given these data, it is appears that the ABIM is more concerned about padding their resume to (1) create and air of legitimacy, (2) serve a political agenda, and (3) to provide a smoke screen for the high salaries of their board members.

Clearly, busy front-line full-time practicing physicians do not have the time for creating publishing mills or for scientifically meaningless survey collection.  Patients want capable practicing physician availability, not survey collectors. Assuring physician quality should not be about creating and funding a political action committee subservient to a political agenda, but rather understanding the challenges physicians face in their workplace and knowledge base and working collaboratively to offer continuous professional improvement.

Limitations

There are several limitations to this study.  First, because the CMS Medicare payment database does not capture work performed on patients under the age of 65, the database does not accurately reflect the total clinical work load a physician performs each year.  Physicians who do not accept Medicare for payment would not appear on this database.  However, since older patients commonly access our health care system more frequently as they age, it would be expected that internists writing policy for health care delivery would participate in the Medicare government program.  Second, the 2012 Medicare payment data reviewed does not correlate to the year the articles were published in the literature.  However, one would expect that experienced physicians who changed the testing requirements for MOC in 2014 would have recent direct patient care experience to appreciate the many factors that impact physicians today.  Finally, reviewing only one year's literature published on the ABIM's website might have introduced sampling bias.  Still, the sampling of the most recent year offers the advantage of reviewing articles that might affect upcoming policy decisions.

Conclusions

Physicians are not above proving their competence and establishing quality standards, especially if those standards are scientifically sound and transparent.  The legitimacy of the MOC process to assure physician quality should be called into question based on a careful literature review of the many conflicts exposed by this review and the limited recent clinical experience of those that contribute to their evidence base.  Citing numerous publications to legitimize the MOC program creates the illusion that this process of insuring quality care and has been vetted by actual scientific data.  Nothing could be further from the truth.

-Wes

On the ACC's Response to ABIM’s MOC Requirements

The American College of Cardiology (ACC) recently issued a response to the American Board of Medical Specialties (ABMS) and American Board of Internal Medicine's (ABIM) recent change to their Maintenance of Certification (MOC) requirements. The ACC's response was based in part on the results of a completed member survey that was distributed through their state chapters in the spring of 2014. The survey was completed within four weeks by over 4,400 members (12 percent of the total solicited). Nearly 90 percent of respondents opposed the changes to the American Board of Medical Specialty (ABMS)/American Board of Internal Medicine (ABIM)'s new Maintenance of Certification (MOC) requirements, citing, among multiple concerns, higher than expected costs. Nearly a third of respondents indicated that the changes will affect their future career plans and will likely accelerate career decisions such as early retirement, part-time work, or transition to non-clinical work. Approximately one-quarter of physicians in practice for 15 years or more specified that early retirement was a probable outcome.

If true, the implication of this change to MOC has significant implications for patients everywhere.

This must have prompted the leadership of the ACC to throw their considerable weight into the discussion with the ABIM. In their statement, the ACC promised to:

• Have "ongoing discussions" with ABIM leadership, in partnership with other cardiovascular professional organizations whose members are similarly affected, to review these issues and to explore changes in MOC requirements that will result in more meaningful outcomes and less onerous burdens for ACC members (Editor's note: To date, MOC has never been shown to alter outcomes, so we are left to wonder what this statement really means.)
• Request for ACC representation at ABIM to participate in discussions involving MOC, including its educational and financial aspects (Editor's note: What financial aspects might they mean? Does the ACC want in on this cash cow, too? Or might they want to strike a deal offset some of the fees since they want to keep their educational MOC-preparation income stream coming?
• Review of the evidence base underlying current recommendations (Editor's note: Let me help: there are none. Any positive articles are likely authored by those standing to profit from the endeavor or research paid for by the ABMS. Negative articles are also suppressed from publications sympathetic to the regulatory world. And we should recognize that we have never developed a definition of the "quality" physician. Quality to whom? Is "quality" following rubrics and care pathways? Or might "quality" be something very different, like empathy, listening skills, interpretative skills, or surgical skill? The reality is, if you can't agree on what defines quality, you can't define how to measure it.)
• Investigation of impact of MOC changes on non-ABIM certified members (Editor's note: I strongly agree with this - it is unethical to impose MOC mandates of any kind without first understanding how they negatively affect doctors, especially if a doctor should not pass and is unable to practice their vocation on the basis of a 180-question timed test)
• In the interim, ACC will support its membership by:
  • Free provision of web-based MOC modules and navigation tools to ACC members
  • Expansion of Part IV MOC modules through ACC programs such as the NCDR’s inpatient registries and the PINNACLE Registry
  • Creation of mechanisms for ACC members by which patient safety and patient survey requirements can be efficiently fulfilled
  • Bidirectional communication with and engagement of membership through Chapters, Sections and Councils.
  (Editor's note: It's okay to make MORE MOC modules available to us? Is that what doctors want? How many more hours must we spend on this drill and for how much time in lost revenue? "Free" is in the eye of the ACC, not those who have to endure these processes.)

The good news (if there is any with the ACC's announcement), is that front-line doctors are starting to be heard. While the ACC's actions might be a step in the right direction (one can hope), it is disappointing that their statement still sides with the ABIM's requirements for the unproven MOC process in the first place, the busy-work requirement for "Practice Improvement Modules" (especially when quality measures are already required by hospitals), and for permitting a private organization to monopolize the ability of physicians to practice their trade. Furthermore, the ACC's statement does nothing to insist upon changes to the ABIM's non-transparent and self-serving Conflict of Interest policies that keeps conflicts confidential except to certain chosen individuals within the ABIM.

Unless the ACC can convince the ABMS and ABIM to come clean on these important issues, significant physician resistance to this process will remain. Furthermore, the lack of involvement by other subspecialty boards in resisting the ABMS/ABIM's MOC process is concerning. Hopefully, other subspecialty boards will be encouraged by the ACC's example.

After all, cardiologists aren't the only ones frustrated by this change in MOC policy.

-Wes

Mission Impossible V: The MOC Exam

"Place the palm of your hand on the palm scanner," she said.

 He complied and watched the computer screen in front of her read "Verified" in bold green letters.

With that, she looked up at him, shrugging her shoulders.  "In my time here at the testing center, I'm still waiting for someone's identity to change between where you scanned your hand around the corner to here, just 10 yards away!" He smiled and she chuckled to herself.  "Now pull out those pockets and let's seem 'em."

He complied.

"And the back pockets."

He turned. "Nothing.  See?" he said.

"Now roll up your sleeves..."

Secretly at this moment, he was hoping a rabbit would appear, but complied again.

She handed him back his driver's license, rose from her computer, and said, "Follow me."

She led the way through a high security door toward a testing cubicle and quietly sat him at a screen that contained an image of his face shot earlier during his check-in process.  She logged him in and there before him was a computer screen with a large American Board of Internal Medicine logo on it.  She pointed out the silver headphones for to the left of the screen.

"Those are for audio, in case there's any of that on your test.  And these to the right are noise-cancelling headphones if you prefer to wear them.  Here's a white board for your use.  Remember we are audio and videotaping everything.  Whatever you do, don't raise your hand at any time unless you need us.  Got that?  We will come get you.  Don't raise your hand otherwise.   Any questions?  Good luck..."

With that the escort left the room.  He sat before the screen and placed the noise headphones on his head.  The screen asked if he wanted to take a tour to familiarize himself with the features available on the software before starting his test.  He clicked the "Yes, tour" button.

With that, the screen flickered and went black. He could hear the noise cancelling headphone suddenly begin to make sounds.

"Good morning, Dr. Phleps."

A picture appeared on the screen as the mysterious voice continued: "This is Dr. Richard J. Baron, the mastermind and ring-leader of the American Board of Internal Medicine that supports the security and secrecy procedures that you have just endured.  He and his many well-paid collaborators have conspired to create a series of time-consuming and anxiety-producing tests and questionnaires designed to frustrate and instill fear in their professional membership. It has become clear that their processes are being promoted as a measure of physician excellence, when in fact, it sets a floor of performance standards for physicians while assuring the continuation of their administrative positions. Your mission, should you decide to accept it, is to pass your test so you can continue to demand accountability for the high salaries of these physician admistrators and the expense of this process that are soon to be imposed on physicians every two years. ... But remember, if you fail to pass, the Secretary will disavow and knowledge of your actions and perhaps your ability to practice medicine...  Good luck.  (This program will self-destruct in five seconds)..... * bbbbzzzzaaaaaaaappppppp *"

And with that, a small puff of smoke arose from computer and the screen went black briefly before it returned to the ABIM logo screen. The menu there again asked if he wanted to start the test.  He clicked the "Yes, start the test" button on the screen. A contract screen appeared reminding him that he'd only be able to take the test if he agreed to be disavowed and reported to credentialling agencies if he divulged any test content or materials to anyone at anytime.

Realizing his wife would kill him for wasting thousands of dollars if he refused, he clicked "I Agree."

The first question appaered while the clock in the upper right corner of the screen began counting down. (A familiar theme song began playing in the background)

-Wes

(Epilogue: Yes, dear reader, Dr. Phelps recently learned that he accomplished the impossible.)

What Board Recertification Is Failing to Teach Doctors

I continue to study for my third ABIM re-certifications in both cardiovascular disease and cardiac electrophysiology. In preparation for the examinations, I purchased the review materials offered by the American College of Cardiology called ACCSAP-8 and took the surprisingly expensive Cardiac Electrophysiology Board Review course held in Chicago recently. I find I have little time to study all of this material while delivering patient care, so I've been getting up at 4:30-5:00 am each day when by brain is rested to review the material. Needless to say, the material is so plentiful and dense that I feel like I'm reading through the Encyclopedia Britanica.

After studying for these boards for the third time, I have come to the realization that there's a million ways the ABIM could write test questions to pimp those of us required to re-take these exams. I can only hope that the few items I've learned as a consequence of answering the accompanying questions at the end of each section of the materials gets me by in a test whose curve is set by some statistical method that no one really understands. But what if I don't pass, God forbid? What would it mean for me professionally? While doctors are reassurred they can re-take the examination (for a fee, of course), does the ABIM's "scarlet letter" affect my ability to practice medicine? Should doctors be educated on the implications of non-certification and what it might mean to a doctor professionally rather than just touting the benefits of this process? Since the implications of not passing re-certification boards may have large financial and emotional implications to physicians, what ethical and legal responsibility does the ABIM and American Board of Medical Specialties hold to their members? I really don't know.

But my point in this post is not to re-hash my concerns about the non-objective and money-making nature of this recertification process, but rather to identify other problematic areas that the ABIM and professional societies like the American College of Cardiology and Heart Rhythm Society are missing in this re-certification process.

First of all, cardiology practice has changed. Cardiology specialists and subspecialists are now increasingly employees of huge health care systems as a result of the health care reform efforts underway. Increasingly, our subspecialties of cardiovascular medicine and cardiac electrophysiology are divided and continue to diverge clincially as knowledge and discovery expands at an unprecedented pace in both fields. As a result of these realities, there is little need any longer for electropysiologists to understand the nuanced differences between various glycoprotein GIIa/IIIb inhibitors, for instance. EPs just need to know that all of these drugs make patients' pacemaker pockets bleed more after surgery. Likewise, do electrophysiologists really need to know the differences between multi-detector CT and SPECT scanning protocols for the diagnostic evaluation of coronary disease in our new subspecialized world of medicine that remains far too litiginous? Electrophysiologists would be foolhardy to recommend a particular scan or the proper antiplatelet agent after a drug-eluting stent given these realities. Instead, doctors of varying skill areas need each other more than ever to provide quality care, not try to harbor every factoid in textbooks between our earlobes. To think any EP or cardiologist should (or could) know the ropes of the other specialty is unrealistic. As such, I continue to wonder why the added expense of cardiovascular medicine board recertification must be added on top of electrophysiology board recertification for tomorrow's doctors, especially in this era of Uptodate and Google. No matter that your view is of these arduous re-certification processes, we need to leverage technology to improve patient care and physician knowledge rather than pretend we don't need it. Force-feeding busy clnical doctors with more facts than they can ever hope to recall is frustrating, unnecessarily time-consuming, and may even have the unintended consequence of detracting from actual patient care delivery.

Secondly, ABIM re-certification test-writers fail to teach doctors how new CMS coding and billing requirements can adversely affect their colleagues and patients. For instance, no where is this more evident than the confusion that surrounds classification of patients coming to a hospital for "observation" or "inpatient" admission. As any skilled clinical doctor understands, what is billed and paid to the patient, doctor and hospital system rests heavily on this definition. Does the ABIM teach doctors this? No. Yet the financial and quality of care implications of this definition to both patients and doctors are very significant depending on how a patient stay in the hospital is defined by payers. (If you don't know this, dear doctor, you should.)

Thirdly, clinical physicians can even teach the more academic ABIM members a thing or two. For instance, maybe doctors who actually care for patients could insist that ABIM members teach doctors how to use vascular ultrasound devices to improve the safety of vascular access for our patients. Why isn't such a skill taught by our board reviewers who claim they are interested in improved patient outcomes? Might it be because it requires each of us to actually touch and care for a patient, something we get pretty good at after thirty years of providing care? Requiring academic discussions of obscure genetic disorders might make for good test fodder, but such obscure instruction completely misses important aspects of physician competency and patient safety.

This is not to say that all academic learning in medicine is without utility. On the contrary, learning by physicians will always remain an essential aspect of caring for our patients. I know that the many excellent doctors that have written modules for board certification preparation purposes have made every effort to make the re-certification process as meaningful as possible for doctors. But we should acknowledge that all doctors already have to "prove" that we participate in learning when we have to submit "certified" CME certificates to maintain licensure. Every doctor in America constantly has to "prove" we don't hurt people to our quality assurance committees and to the legal community. To force additional expensive and unproven training that is out of touch in so many ways with the way medical care is being delivered now may be having significant unintended negative consequences, too. We should start asking if the ABIM could be causing more harm than good as doctors become increasingly frustrated by the many bureaucratic and administrative hoops that increasingly detract from patient care.

After all, it's the lack of time left in the day to care for our patients that's most likely to harm them, not whether we pass a test or not.

-Wes

The American Board of Medical Specialties Gets Sued Over MOC

From Sermo this AM:

The Association of of American Physicians and Surgeons (AAPS) filed suit  in federal court against the Amercan Board of Medical Specialties (ABMS) for restraining trade and causing reduction in access by patients to their physicians. 

According to the complaint:

"Defendent ABMS has agreed with 24 separate corporations, and acted in concert with the Joint Commission, to compel physicians to spend enormous amounts of time and money to comply with Defendent's proprietary ABMS Maintenance of Certification (MOC).©  There is no justification for requiring the purchase of Defendant's product as a condition of practicing medicine or being on hospital medical staffs, yet ABMS has agreed with others to cause exclusion of physicians who do not purchase or comply with Defendent's program.  Defendent's program is a money-making , self-enrichment scheme that reduces the supply of hospital-based physicians and decreases the time physicians have available for patients, in violation of Section 1 of the Sherman Act."

Read the whole complaint because there's more.  Physicians interested in supporting this effort should consider contributing to the American Health Legal Foundation.

-Wes

Maintaining Board Certification Every Two Years

Remember the good ol' days when taking a single board certification examination from the American Board of Internal Medicine (ABIM) was good enough to call yourself "board certified" in a medical specialty?

Those were the days.

In 1990, things changed.  Board certifications became time limited.  To remain "board certified," the ABIM stipulated that doctors had to undergo a Maintenance of Certification (MOC) examination every 10 years to remain board certified, even though no data existed then (or now) that such testing achieves the ABIM's stated goals of promoting "lifelong learning and enhancement of the clinical judgment and skills essential for high quality patient care."

Now things are changing again.

I just received a notice in the mail (pdf here) that states the following: beginning 1 January 2014, the ABIM will require that at least one Maintenance of Certification "activity" be performed every TWO years and for EVERY TWO YEARS thereafter.  In addition, doctors will have to earn 100 ABIM "points and complete a patient survey and a patient safety module by December 2018 (in FIVE years and EVERY FIVE YEARS  thereafter). That's right: more testing of doctors and no data to support the testing's ability to maintain a quality physician workforce.

For those interested, more information can be found at http://moc2014.abim.org .  According to this website, annual cost to physicians will be "about $200 per year" and "If you are maintaining more than one certification, the cost will be the fee of the most expensive certification plus half for each of the others."

Instead of assuring quality, then, it seems doctors are really being asked to improve the ABIM's cash flow.  Also, as a result of this initiative doctors will be spending consistently more time away from patients.  

It's crazy.

Clearly no one is listening to doctors on the front line.  Doctors are already overburdened with too many unproven bureaucratic requirements.  Adding these costly, unproven "certification" requirements to things like meaningful use, pay-for-performance, results checking, email answering, patient satisfaction surveys and the like just adds insult to injury.  How much time do the members of the ABIM think we have?

How much quality to we impart to our patients when we asked to stare at more and more computer screens rather than care for our patients?

Hello?

Hello?

-Wes

Psychocardiology: An New Cardiovascular Subspecialty?

I kid you not (sorry, Medscape registration required):

At the recently held World Psychiatric Association Thematic Conference on Intersectional Collaboration and 4th European Congress of the International Neuropsychiatric Association in Athens, Greece, Angelos Halaris, MD, PhD, made the case for this new subspecialty, which he believes would forge closer working relationships between psychiatrists and cardiologists, provide the training and expertise needed to detect cardiovascular disease (CVD) risk in psychiatric patients (and vice versa), provide continuing education regarding the safe use of medications for patients with these comorbid disorders, and raise public awareness.

"The formation of a formal subspecialty is a bit of a pipe dream at this point," Dr. Halaris, professor in the Department of Psychiatry and Behavioral Neurosciences at Loyola University Stritch School of Medicine in Maywood, Illinois, told Medscape Medical News.

"But I wanted to put it out there because our colleagues in cardiology as well as in psychiatry need to realize there is a very clear association between emotional/psychiatric/psychological conditions and cardiovascular health."

He noted that 40% to 60% of patients with CVD also have clinical depression. And 30% to 50% who have a diagnosis of depression are at risk of developing CVD.

"Multidisciplinary teams need to forge an alliance because of these comorbidities. This will allow an earlier diagnosis of our patients, vigorous treatment, and the prevention of worse conditions that would happen otherwise," said Dr. Halaris.

Wow.  More subspecialty regulation and titles?  This is the best we can do?

Psycho, indeed.

-Wes

It's Time to Look Critically at Board Certification

From Edwin Leap, MD:

Unfortunately, the rank and file is very unhappy. There is remarkable discontent, and considerable anger, among the lesser physicians. That is, the test takers, the physicians in practice subject to the new rules, the ones who have to add one more rule, one more activity, one more form, one more check to their already busy lives.

That discontent, that anger, that frustration on the part of practicing physicians is, in my opinion, very rational. It’s a tough time in medicine. Our regulatory burden grows by leaps and bounds every year. We are watched and harassed, by CMS, by JCAHO, by our state medical boards, by our insurers, by our hospital staff offices and now, most painfully, by our own specialties.

Of course, all of it comes in the context of falling reimbursements, a federal government licking its lips for any spurious allegation of fraud and a system in which EMTALA forces physicians of all specialties to see patients for free, even as government insurance programs pay less than the over-head to see their patients (and fulfill the regulatory guidelines required for the privilege of doing so).

In light of all of this, I have to ask ABEM and every other board certifying body, a simple question:

“What are you people thinking?”

Here’s the reality. Our certifying bodies should be our greatest, most passionate advocates. When the Institute of Medicine issued a report some years ago that said physicians were killing people on a scale consistent with the holocaust, ABEM should have looked at the data and refuted it. ABEM, and ABIM and all the others should have taken our fees, run out and found the best PR firm they could afford. “We stand by our physicians and we have serious questions with these research results and the way they are being interpreted.” That would have been a good use of my dues. That would have merited high salaries for everyone in every board that stepped up for its members.

Instead, at every step, ABEM seems to argue that “the public” wants us to be watched more closely and tested more frequently. Except, I’m not confident that’s true. The public never cares where you went to medical school. The public thinks most emergency physicians are interns hoping for a “real practice” someday. The public wants affordable, quality care. The public, in practical terms, doesn’t know the difference between a physician, a PA and a nurse practitioner, and often calls all of them “doctor.” The public, furthermore, tends to believe that mid-level providers are more attentive to their needs. (Despite their lack of board certification; shocking indeed!)

There's plenty more.

Go now. Read the whole thing.

-Wes

From my archives on the same subject:

1) Posers
2) Alphabet Soup
3) BoxTop Board Certification
4) Board Certification - Pay to Play?
5) The Cost of Our Medical Licensure Complex

Will Doctors Have to Take Out Loans to Pay for (Re-)Certification?

I have recently realized that if I want to remain board certified in cardiovascular disease and cardiac electrophysiology, I must begin the lengthy process to re-certify now. No longer are doctors board certified for life; the process must be repeated very ten years. For me, it won't be long before I'm taking the tests for the third time and I carry two board certifications that are subject to this every-10-year requirement.

But while preparing for this gauntlet again, I was struck by the fees I must pay just for prep-courses and registration fees: well over $10,000.

CV Board Review Course	$998.00
EP Board Review Course	$1420.00
Maintenance of Certification (MOC) Fee - CV Disease	$1810.00
MOC Fee - EP (with 2nd MOC discount)	$760.00
Board Certification Fee - EP	$2785.00
Board Certification Fee - CV Disease	$2165.00
Test Center Fee - Board Cert	$500.00
Test Center Fee - MOC	$500.00
TOTAL:	$10,938.00

Realize these costs don't include transporation and housing costs that might be required, not to mention the costs incurred from time off from work.

I realize that it's expensive to prepare, review, monitor and regulate this testing, but these costs are growing at a ridiculous rate - I hate to think what new doctors saddled with significant educational loans must endure just to get started.

Hey, I think I have a new idea for a business: a loan company that funds doctors to help doctors pay for their certification fees!

Oh wait: it already exists.

-Wes

Addendum 5/9/2011 08:45 AM CST - I received this follow-up e-mail from Lori B. Slass, VP for Communications at the ABIM, with the following clarification of their fees for dual-boarded individuals like myself:

"As the VP for Communications at ABIM I did want to clarify some of the fees you presented today.

As someone who is already board certified in CV and EP, your costs to recertify would be $1,810 + $760 for the 2nd (EP) exam. Total cost is $2,570 – good for ten years.

So it is about $250 a year to maintain certification for someone like yourself who is dual certified. I agree this is not an insignificant amount, and many physicians take review courses to prepare and that does add to the costs, but it is much less than you highlighted in your post. The test center fees you note are only for international candidates.

It is also worth noting that the fee includes all the modules you need for both certifications, and over the course of ten years, even after you complete the MOC requirements you can complete modules for CME credit at no extra cost.

The ABIM Board of Directors are very careful in establishing fees. We are a non profit and to a great extent, the key determinant of the fee for MOC is the direct cost of developing and administering the program. Costs associated with the examination have also risen with the introduction of Computer Testing Centers. We have found, and our candidates confirm, that computer based testing has important advantages over the older method of testing. Hope this is helpful."

I have provided links to the published ABIM fees in my post. It states clearly that the examination fee (alone) for EP is $2,795. I have asked for additional clarification.

Addendum #2 9 May 2011 09:43AM CST: Additional clarification is now provided:

"We will try to make it clearer on our website, but you do not have to repay certification fees once you are certified. Only the MOC fees – total cost for you $2570 for Card and EP (covering two exams) and you correctly noted that you do not have to maintain IM, only those certifications relevant to your practice.(emphasis mine) We also like to think the free CME for 10 years is a nice addition."

Board Certification - Pay to Play?

Board certification used to be a voluntary means for physicians to demonstrate their clinical competencies and separate themselves amongst their peers. Now, it looks like it will just be one more way for insurers and regulators to withhold physician payments in the name of "accountability:"

Physician licenses are issued by state medical agencies. That's not the same with specialty boards, which used to test doctors once and granted certification for life.

In recent years, these groups have changed their policies and now require physicians to be tested every six to 10 years. But many older physicians are grandfathered in and don't have to update their qualifications.

Those doctors say they stay current by reading medical journals and taking continuing-education courses that are required for their state licenses.

Plus, board recertification can require travel to Chicago or Atlanta and cost $3,000 to $4,000 for the test.

"I think the initial reaction from a lot of people is, 'This is a bunch of crap; I did all my work in medical school. Why do I have to do it now?'" said Dr. William Cotton, a Columbus pediatrician.

But constant changes in medicine can quickly make what a doctor learned in school outdated, he said.

Cotton, who graduated from medical school in 1981, was grandfathered in in his specialty but decided this year to recertify to stay current.

Who cares about up-to-date certifications beyond savvy patients? Health insurers and hospitals. Starting next year, doctors who are recertified might be paid more by Medicare under federal health-care reform.

"There needs to be accountability in showing that they are, in fact, a specialist and are up to date on changes in their medical profession," said Kelly McGivern, president of the Ohio Association of Health Plans.

Sadly, board certification is a straw dog for exceptional clinical competency. It has been devalued by the lack of enforcement of the meaning of "board certification." Even the American Board of Internal Medicine who receives large sums of money from physicians and creates the instructional material and tests admits to the sad fact there are still guys out there you can pay $500 to to get a "certificate" to hang on your "board" so you can call yourself "board certified."

By permitting the board certification process to become devalued and merely a means to justify full payment from insurers and hospitals, the American Board of Internal Medicine has officially acknowledged that they are now serving new masters. Because of this, we now understand why the board certification has become a complicated floor of minimalist competencies rather than the pinnacle of one's professional achievement.

And it's one incredibly expensive floor that will now cost you even more dearly if you don't renew.

-Wes

BoxTop Board Certification

Remember when you were a child and an offer to be a member of a special spy club appeared on your morning cereal box? You knew, yes knew that the offer was the real deal. All you had to do is send in three cereal box tops and you'd be sent all the prerequisite items. Of course, when the plastic trinkets arrived weeks later, there always seemed to be the air of buzzkill when the reality of what you received for your efforts was revealed.

This could never happen with board certification, could it?

Yesterday, we learned that this year, every specialist has to re-certify to maintain their status as a board certified specialist. In the past, this was a voluntary process that doctors participated in to show a jury of their peers that they had the right stuff to practice medicine at the highest level possible. It was a respected term. Doctors generally knew that a board certified specialist meant something. Even though doctors pay thousands of dollars to the American Board of Internal Medicine for the opportunity to study for and take the certification exam, once passed doctors were proud to hang that certificate on their wall. In effect, it is the crowning achievement of one's career.

But what if that certificate on the wall had the value of certificate purchased from a cereal box top spy club? Doctors might be pretty upset, right?

Well guess what. Although the majority of those certificates hanging on the wall are the real deal, many are not.

That's because the term "board certification" is not a legally protected term in most states of the United States, and if you want a "board certificate," you can just purchase one and hang it on your wall. No test, no nothing. Just send a guy several hundred bucks and fill out a very important sounding questionnaire and you're a member of the club!

Now this has been against the law. This has been illegal for many years. But none of this has made much difference - the scams continue. The sad reality is, the government does not have a history of effective oversight of these shiny new "certifying" initiatives.

For long-time readers of this blog, many are aware of my dealings that I stumbled upon by way of an anonymous comment that appeared on this blog several years ago that exposed a certain individual known to be operating such a fraudulent board certification scam. This scam is known by the American Board of Internal Medicine. This scam is known by the Illinois States Attorney's office and the Connecticut States Attorney's Office. But despite knowing about this individual for over nine years and his over thirty specialty "certificates" that he targets to primarily foreign medical graduates, he continues to operate this scam on-line.

Doctors who pay thousands of dollars for legitimate board certification should demand their states protect the term "board certification" to mean what it's supposed to mean: certification by the American Board of Internal Medicine. It must imply that they have taken the steps necessary to demonstrate they are at the top of their specialty. They should also demand from the American Board of Internal Medicine that they get something in return for their significant financial investment that is increasingly mandated by credentialing bodies: protection of the value of their certification.

And that means bringing these scam artists to justice.

Otherwise those certificates will be nothing more than a piece of paper from a cereal box top.

-Wes

Bogus Medical Board Certification Targets Immigrant Physicians

In October 2007, I wrote a post about a fraudulent board certification scheme that I researched after being sent an application for "certification" in the bogus American Academy of Cardiology spearheaded by a "Reverend A. Lasko, MD" or "Reverend K. Lasko, MD" - I wasn't sure. Later, I was subpoenaed by this man to appear before his lawyer in a suit between he and his sister (I was not a party to the suit). The subpoena insisted I bring down my blog post and identify the the URLs of those who commented. After fighting to have the subpoena quashed, the subpoena was rendered "moot" after the suit was dismissed.

Since that time, the American Board of Internal Medicine has been busy tracking Mr. Lasko's whereabouts. Today, the Connecticut Attorney General's Office offered this press release verifying Mr. Lasko's identity and alias's used for his scam:

"Blumenthal's office has learned that an out-of-state individual known as Keith Alan Lasko -- who also uses the names K. Lasko, Keith Ferrari, K. Ferrari, and KA James Windsor -- has sold phony certifications to doctors in a variety of medical specialties in exchange for submitting only basic information and a substantial fee.

At least 130 more complaints have been reported, including at least one in Connecticut.

Lasko's alleged scheme particularly targets foreign-born or foreign-taught doctors who may be unaware of the proper certification process.

"Real and recognized medical board certifications require rigorous examination and education -- not simply payment for a piece of paper," Blumenthal said. "This scheme deceives patients and medical professionals, and endangers lives -- misleading consumers into believing that their physicians possess a level of expertise that they lack.

"This alleged con artist used false names -- for himself and for fictitious medical boards whose fake certificates he sold. Doctors face potential legal action if they misrepresent their credentials with phony certificates. These specialty-seeking doctors who paid substantial sums -- $500 or higher -- were typically foreign born or foreign educated, and now should know better."

Bottom line: buyer beware.

I sincerely hope they catch this guy. After all, I've got some serious legal fees I need repaid.

-Wes

What It Means to Be "Board Certified"

The American Board of Internal Medicine issued this press release yesterday regarding scam medical boards. I reported on this last October and notified the ABIM about this ploy: pay a few hundred bucks and you can have plenty of alphabet soup after your name and you get an authoritative "certificate" without taking any test.

I applaud them for protecting the value of the term "board certified" and states that have not already done so should enact legislation to protect this term. Patients and doctors alike should feel confident that the term "board certified" conveys special mastery of knowledge and skill in medicine rather than just paying to own a "certificate."

-Wes

Alphabet Soup

What does “MD” mean to you after someone’s name?

To many, in conjures an image of a trusty elder statesman of medicine, a healer, a researcher, a teacher and therapist of all things related to diseases of the human body.

It comes from the Latin, Medicinæ Doctor, meaning “Teacher of Medicine.” In the US, it is the first professional degree for physicians while in other countries, such as Germany or England, it is a higher doctoral research degree resembling the PhD (Philosophiæ Doctor, meaning "teacher of philosophy").

For reasons that are unclear to me, physicians also occasionally include other letters beyond the “MD” in their name. These add little to the MD descriptor, other than to define a professional society with whom the doctor associates themselves. For instance, I am a Fellow or the American College of Cardiology, and have “FACC” sometimes appear on my stationary. I never write this designator when signing my name, but I know my referring colleagues in medicine want to know I’m one of the gang, so it appears there. It also implies that I pay my dues to the American College of Cardiology which also serves as our political and advocacy branch of our subspecialty.

I find patients rarely understand what these letters mean, for there are many such designations. FACS means a Fellow in the American College of Surgeons, a surgical professional group, and FACP means Fellow of the American College of Physicians, a professional group of internists, for instance. Some people, like cardiologists who have first been internists before becoming a cardiologist, like to add both the FACP and FACC designator after their name. Providing, they’ve paid the fee and been vetted by the respective professional groups, no one seems to mind. A signature line becomes virtual alphabet soup as doctors sign their name “John R. Smith, MD, FACP, FACC.”

Big deal.

Regrettably, these initials are nothing more than a narcissistic exercise of self-aggrandizement, rather than meaningful milestone of additional education or skill. Further, in our zeal to differentiate ourselves from our less-specialized colleagues, they have promoted the fragmentation of our profession as a collective bargaining body in matters of public policy important to physicians collectively. The alphabet soup conveys no indication of additional qualification of the physician, only that they have paid for the privilege to add these to their names, have a valid license, and know a few colleagues in their same subspecialty club.

Importantly, these letters do not imply an individual is “board certified” by any one of the 24 Member Boards that make up the American Board of Medical Specialties. Within each specialty like Internal Medicine are often other subspecialties, like gastroenterology, rheumatology, cardiology or cardiac electrophysiology. In total, there are presently 145 specialties and subspecialties in which a doctor can become “board certified” and 145 ways we fragment our negotiating power on Capital Hill as each group fights for their own interests. It’s also 145 ways we confuse the public (and each other), 145 ways we lose our focus on the bigger picture of healthcare in America, and 145 ways that third parties can play us off one another as they forward their agendas over ours.

In effect, our sub-specialized egos and alphabet soup have neutered us as effective voices in healthcare reform.

Worse still, while “board certification” defines an important level of competence that should not be undervalued or disrespected in terms of the expertise required to achieve such certification, the term itself has been confused with the sponsoring professional society memberships' alphabet soup and has obscured our ability to protect this important credentialing designation.

More on this soon.

-Wes

A Cocktail Conversation

"I have to recertify for boards for the second time on Thursday. My year was the first year they started this every-10-year re-certification game."

"Are you nervous?"

"I think frustrated is a better word - I mean, why does a busy orthopedist in private practice with my experience have to prove his expertise every 10 years? I'm a spine guy. I haven't done club feet in years. I have no intention of doing club feet again - and yet I have to learn not only about club feet, but the whole gamut of orthopedics for this stupid test. And the practice questions - you take them and they give you five answers, none of which are really the right answer - but you have to figure out the "best" answer of the group. Stupid.

Worst of all, no one pays you for taking these tests. I mean, they're expensive. You have to take 50 hours or so of continuing medical education credits per year, just to qualify, at what, four to five thousand dollars a pop? And you're away from your practice losing money all the while… Then you sit for an expensive test that doesn't really cover your knowledge base.

Those regulators should be paying me to take their required tests.

I can tell you one thing...

... I'm not doing it a third time."