An Internet Quiz: ABIM's Website Moves the Goalposts Again

The Internet loves mystery...

and cover-up.

There are very bright minds out there, and nothing gets those juices flowing for the dedicated Internet sleuths than when someone is trying to hide a carefully crafted change that benefits the Big Guy and screws the Little Man.

Lately, I've been watching the myriad of changes to the ABIM website.

It's got a whole new look and feel, full of big flashy graphics, but little on content. They will argue, no doubt, that it's all made to improve the navigation on their website and to introduce the bold new ideas they have concocted to be sure the fine print is missed.

So here's the challenge.

Take a minute and go the the ABIM website. (Warning, you'll need more than just a minute for this contest, but if you've got the time, this might satisfy criteria for some MOC points/CME credit).

Click on the Maintenance of Certification banner.

Look over to the left and find the "Policies" button. Here's what the screen looks like today:

(Click to enlarge)

Scroll down to look at what you've missed below the fold, as shown here: 

(Click to enlarge)

Now, this is where things get fun. It will be like The Price Is Right, where Bob Barker asks the contestant to look behind Door Number 1, Door Number 2, or Door Number 3. Go ahead, and click on one of those drop-down arrows of your choosing. What you don't realize, it that behind every one of those arrows, is the hidden surprise that has changed - your MOC® contract with ABIM in all its (hidden) glory.

So here's the challenge...

... which part(s) has(have) changed in the last six months?

Good luck!

-Wes

The Business of Testing Physicians

If you want to understand the world of professional board certification, it is important to understand the business and politics of testing professionals. Such testing is big business. So big in fact, that huge international media and education companies that trade on the New York Stock Exchange have been created to service this need. According to one article on Reuters from 2012, "the entire education sector, including college and mid-career training, represents nearly 9 percent of U.S. gross domestic product, more than the energy or technology sectors."

Part of the expense of "maintaining" one's professional board certification goes for fees for the testing center where the computerized testing occurs.  Because cardiac electrophysiologists must hold two board certificates (Cardiac EP and Cardiology), we must pay for two rounds of test-taking fees: the first is included with our cardiology maintenance of certification (MOC), then we must pay a second $750 testing fee for the second EP test.  (Each test contained 180 questions - $4.17 per question).  I am assuming almost all of this goes to the company that administered my test: Pearson VUE.

ABIM holds a contract with Pearson VUE, a professional testing subsidiary of Pearson Education, the North American subsidiary of Pearson, PLC (NYSE: PSO) - an 9 billion dollar British corporation that claims it is the largest commercial testing company and education publisher in the world. It boasts Penguin Random House publishing and the Financial Times Group as some of its other far-reaching subsidiaries. Mr. John Fallon is the 52 year-old Chief Executive Officer of Pearson, PLC and earns a cool $2.55 million dollars annually while holding 282,147 shares of Pearson stock and plently of stock options.  He is joined by Mr. William T. Ethridge, age 62, who serves as "advisor" currently, but was previously responsible for the North American Educational Division of Pearson.  According to one source, William Ethridge was once chief executive of Pearson's North American Education division in 2008. According to Forbes, his total compensation in 2011 was $1,390,000 and he held a half million shares of Pearson stock at that time.

Pearson VUE states it "is built on a foundation of experience in electronic testing."  My experience with Pearson VUE was parodied in an earlier blog post. As I reflect, it seemed that Peason VUE was more concerned about storing my biometric palm scans and a digital photograph as much as they wanted to assure a fair testing environment. While the ABIM discloses this process on their website, doctors unaccustomed to such paranoid security measures are caught off-guard by these tactics and should be concerned about how this information is stored and used. Are previously-certified doctors really this sketchy?

Pearson VUE earns a pretty penny from its professional testing and its physician testing in particular. According to Pearson's most recent SEC filing:

"Professional testing continued to see good revenue and profit with growth test volumes at Pearson VUE up 25% on 2012 to almost 12 million [pounds] ($19.9 million). Key contract renewals included tests for the American Board of Internal Medicine, the Association of Social Work Boards and the Pharmacy Technician Certification Board. "

But profitting from physician education is a politically hot topic, too. Not surprisingly, Pearson Education seems quite active in this space spending $2,100,000 to lobby Washington during the last presidential election cycle in 2011 and 2012, contributing 7:1 to the Democratic side of the political aisle. Also, 6 of the eight current Pearson lobbyists have previously held government jobs.

Doctors should understand how and where their money and personal information are being used in the ABIM's MOC testing process, since much of those funds seem to support the corporations and political aspirations of those who are doing the testing rather than the needs of patients that the ABIM is pretending to protect.

-Wes

Jackpot

Want to earn lots of money for your cardiology department? Just place an online "heart risk" assessment on your hospital's website and label 37.4% of the respondents "at risk:"

Since going live in late January, 7,072 people had completed the HeartAware assessment through early May, and 2,645 have been labeled "at risk."

"There's an awful lot of people who develop a bad event from heart disease on a yearly basis, not to mention the 8 or 9 million folks walking around with some form of blocked arteries and abnormal functions," said Dr. Vince Bufalino, medical director of cardiovascular services at Edward Heart Hospital.

"But when you look at the random public you wouldn't predict [these HeartAware at-risk numbers] up front," said Bufalino.

More than half of the at-risk test takers (1,597) accepted Edward's offer for follow-up services.

Wow. Think of all that testing, office visits and the like. Who knew?

Well someone did. Because with the stroke of a little logo change and voilà - another hospital in Maryland or Ohio or anywhere else you please can have the same assessment.

This is a program started by the HeartAware organization, a program of the National Heart Association. So who is the National Heart Association?

Well, I'm not sure. I'm not sure it's a real organization, but rather a front.

What I can tell you is that HeartAware is a product of Byrne Healthcare who labels this program as a "strategic marketing program for healthcare providers that identifies undiagnosed and at-risk individuals in their community that have disease and mobilizes them into their hospital or clinic." So it seems to me that the National Heart Association is really a marketing firm, and has nothing to do with heart health, other than to do marketing for hospital systems.

More impressive, they also have a whole line similar risk assessment tools for orthopedics, diabetes, stroke, sleep disorders, lung disease and cancer!

Now there certainly is nothing wrong with people being empowered with performing their tests online and seeing how their "risk bars" turn from "healthy green" to "threateningly red." But when Congress wants to look for ways to trim costs, maybe they should look at the fact that over 1/3rd of on-line people are found "at-risk" and a remarkably high number are undergoing testing that is likely to be of very low yield, moderate cost, has a real and significant false-positive rate to every test done that might incur more costs and more testing, and some of which might be quite invasive and carry significant risks.

But it's all about awareness, right?

Well, now you're aware that the so-called National Heart Association does not exist and maybe this prevention thing promoted by our President and government organizations to save costs in health care might just be doing the opposite.

-Wes

Colonoscopy Sweepstakes

I'm not making this up. I saw this on TV tonight.

It seems CBS Broadcasting has teamed with the advertising giant Marden-Kane, Inc. and Loews Regency Hotel to develop the CBS Cares Colonoscopy Sweepstakes open to 40-79 year olds. Yep, that's right: people under 50 are eligible, even though they should not be screened for colon cancer.

The website states:

"When the colonoscopy is about to begin, you'll be given drugs which will make you feel like you're at Woodstock... only without the music. If you start to believe that you actually are at Woodstock (for example, Dr. Miskovitz starts to look like Jimi Hendrix or you feel inclined to say "far out!" in response to questions), please report the side effect to Dr. Miskovitz or Jimi Hendrix (whomever you see first) immediately."

While sounding like I might have a cob up my... well, you know... I wonder, what in the world are they promoting? A free "high" or colon cancer screening? Is this how we discuss screening tests now? Where are the risks of colonsocopy and sedation discussed? How will the list of people who register for the "free" colonoscopy that don't win be used? I wonder, will they be targeted later by the posh Center for Specialty Care, with its origins in plastic surgery and where the colonscopy will presumably take place, for mailings about more testing?

We're not sure.

But we are told on CBS's website:

"If you post personal information in User Forums or on other publicly available areas of the Web Sites then you may receive unsolicited messages from third parties. Company cannot ensure the security of any information you post on publicly available areas of the Web Sites. Under no circumstances will we be liable in any way for any of Your Upload Information including, but not limited to, any errors or omissions in Your Upload Information, or for any loss or damage of any kind incurred as a result of Your Upload Information."

Furthermore:

"Your Upload Information will be treated as non-confidential and non-proprietary and we will not be liable for any use or disclosure to anyone, including but not limited to claimed intellectual property owners. When you upload Your Upload Information via the Web Sites, you irrevocably grant to Company, its parent, subsidiaries, affiliates, and partners a non-exclusive, worldwide, royalty-free license containing, without limitation, all right, title and interest in Your Upload Information, including, without limitation, all patents, trademarks, service marks, trade names, trade identities, copyrights, trade secrets, logos, domain names, know-how, source code and object code, mask-work rights, inventions, moral rights, author's rights, algorithms, rights in packaging, goodwill and other intellectual property and proprietary rights whatsoever in Your Upload Information. You further agree that Company, its parent, subsidiaries, affiliates, and partners and the directors, officers, employees, licensees and other representatives of each of them will have the unfettered right throughout the universe, in perpetuity, without any credit or compensation to you, to use, reuse, modify, alter, display, archive, publish, sub-license, perform, reproduce, disclose, transmit, broadcast, post, sell, translate, create derivative works of, distribute and use for advertising, marketing, publicity and promotional purposes, any of Your Upload Information or portions of Your Upload Information, and your name, voice, likeness and other identifying information, in any form, media, software or technology of any kind now known or developed in the future for any purposes whatsoever including, without limitation, developing, manufacturing and marketing products using such Uploaded Information. You hereby waive any moral rights you may have in and to any of Your Upload Information, even if such material is altered or changed in a manner not agreeable to you. You agree and understand that Company, its parent, subsidiaries, affiliates, and partners are not obligated to use Your Upload Information submitted through the Web Sites or otherwise, and may alternatively choose to discard, and limit or block access to Your Uploaded Information without any liability whatsoever."

Now if these rules don't fly in the face of the privacy intent of HIPAA, I don't know what does. What's worse is this whole cute charade is being "supported and helped" by our own National Cancer Institute.

Here's the thing: CBS, through this sweepstake, is offering free health care to one lucky "winner." As such, shouldn't this media company be bound by HIPAA privacy laws, too? Does this campaign really have the patient's best interests at heart or is this really about driving more business to gastroenterologists? Finally, if cancer is found on the screening and the patient is uninsured, who will assume responsibility for ongoing treatment of the patient?

Oh, but we're not asking those questions...

... because that wouldn't be so funny.

-Wes

Health Care Cut Backs

... are affecting everyone:

"Doctors are noticing the trend as patients skip or defer treatments because of the troubled economy.

Many decline procedures even when they have medical insurance, doctors said, because the procedures are so expensive they can't afford the out-of-pocket costs. For a colonoscopy, a stress test, an MRI or a CT scan, the patient's co-pay can run to hundreds of dollars."

It was interesting to note that the article quoted a local "recently retired" internist. The untold story within this story is that hospital systems are equally strained as procedural revenues dwindle, placing increased pressure on their physician workforces to "produce."

-Wes

Implications of a New Screening Test for Lung Cancer

Lung cancer is a devastating disease. It is one of those diseases, like ovarian cancer, that has often metastasized before it is detected. Certain forms of lung cancer can be particularly lethal, with mortalities of 50% or more within 6 months of diagnosis. That is why early detection is so critical.

Now we learn of a clever way of screening for lung cancer using… are you ready?… genetic profiling.

That’s right. Take 80 or so of the most likely genes from the DNA of the cells lining the patient’s airways and test them for the presence of certain gene sequences implicated in lung cancer to predict their likelihood of having lung cancer.

The authors from Boston University studied 129 patients undergoing bronchoscopy for the diagnosis of lung cancer that had a nearly 50% incidence of the disease in their study population (60 patients were diagnosed with lung cancer). Their test utilized microarray genechips made by Affymetrix for their analysis. The authors acknowledged an 80% sensitivity and 83% specificity with their test – far higher than other tests available to date, but had some important limitations:

In the setting of our study, where disease prevalence was 50%, a negative bronchoscopy and negative biomarker for lung cancer resulted in a 95% negative predictive value, potentially allowing these individuals to be followed nonaggressively with serial imaging studies. For individuals with a negative bronchoscopy and positive gene-expression signature, the positive predictive value was 70%; these individuals would probably require further invasive testing to confirm the presumptive lung cancer diagnosis. However, compared to bronchoscopy alone, the strong negative predictive value of the combined cytopathology and gene-expression biomarker test should substantially reduce the number of individuals requiring further invasive diagnostic testing.

The notion of a cancer-specific airway-wide injury suggests that cancer-specific alterations in gene expression that occur as a result of smoking might precede the development of lung cancer. If this is true, the lag between alterations in gene expression and the appearance of lung cancer could contribute to the biomarker's false-positive rate in our cross-sectional study. A longitudinal study will be needed to assess whether false-positive biomarker diagnoses represent smokers at higher risk for developing lung cancer. If this is the case, our biomarker might be useful as a screening tool for lung cancer among healthy smokers and may have the potential to identify high-risk smokers who would derive the most benefit from chemoprophylaxis.

So What Do These Data Mean?

Well, I’m not sure we’re ready to go the chemoprophylaxis or even the screening of smokers route just yet. To better understand the implications of a test with 80% sensitivity and 83% specificity, one must understand the statistical definitions of these two terms. For sensitivity, it means the probability that a test is positive in the population of people known to have the disease. Specificity, on the other hand, is the probability that a test is negative in the population known not to have the disease.

So how can these numbers be applied here? Doing some back-of-the-envelope calculations from the authors’ data, their test with its 80% sensitivity in 60 people known to have lung cancer means that 48 had a positive test that appropriately detected the cancer while 12 had cancer that the test failed to detect. Likewise, if 69 patients did not have cancer and the test had an 83% sensitivity, then 57 patients who did not have cancer tested appropriately negative for the disease, but 12 tested positive for the disease, even though they did not have cancer.

Now, in this population with a strikingly high incidence of cancer, the reliability of this test is reasonable, but in the population at large (i.e., all smokers) where the prevalence of disease if likely to be much lower, there will be far too many false positive tests (diagnosing cancer in people actually free of disease) and importantly, still a significant false negative rate (thinking a person is free from cancer based on a negative test, when, in fact, they have a cancer).

So there’s still some work to be done before such a test can be applied to the general population. But the study authors should be commended on their clever use of micro-array DNA genomic phenotyping to improve the detection of lung cancer during bronchoscopy over current cytologic (cell analysis) techniques.