Happy Easter

Happy Easter!

- Wes

ABIM Remains Tonedeaf to Physician Concerns

Recently, Richard Baron MD, the President and CEO of the ABIM, circulated the following email request to a select group of physicians:

(Click to enlarge)

Like a resuscitation attempt that has continued for over an hour, the ABIM appears to want to flog its dying MOC program a few more times, hoping physicians haven't noticed.

But we have.

And they are wasting our time. Despite physicians calling for an end to MOC, the ABIM wants to maintain it. Without it, you see, they'll be bankrupt. Note also that the ABIM wants to offer physicians who participate in their "research" for less than $50/hour. (No compensation is given from travel to and from the testing center). Ironically, UpToDate already makes the need to participate in the ABIM/ABMS MOC program obsolete. Third, most physicians at large hospital settings have access to UpToDate already. Fourth, 20 MOC points seems like bribery when your program is increasingly required for hospital credentialing and insurance company panel participation.

Finally, I wrote the ABIM leadership over a month ago about my concerns of their MOC program in response to a "blueprint survey" request they circulated earlier. I still have not heard from anyone within the organization. This is disappointing. The ABIM needs to respond to its most fervent critics honestly and transparently. But this does not appear to be their modus operandi.  As a participating diplomat in the ABIM, I would expect a response from the organization well within that timeframe if they were serious about improving their credibility. This is a recurrent theme under the helm of Dr. Baron.  In fact, even Dr. Baron has never offered a credible explanation for the tax filing and webpage reporting discrepancies of the ABIM Foundation creation date and domicile location. These communication lapses are inexcusable from a professional organization that pretends to offer public trust in its services.

The ABIM and the ABMS have serious financial conflicts of interest and have demonstrated highly irregular behavior for a tax-funded non-profit organization. It is not proper for a 501(c)(3) organization to have deceptive tax filings and public sanctioning of physicians after home raids to protect their monopoly on re-certification. Their testing subcontractor, PearsonVue, also uses testing "spy" firms that casts wide and unaccountable security nets as well, making the risk for physician participation in such a punative program very real. Until each of these issues are investigated, I could encourage my colleagues to carefully consider the ramifications of participating in this latest ABIM MOC research project that promises to potentiate this expensive and corrupt re-credentialing program that has never shown benefit to patient care.

-Wes

ABIM Slapped With Motion to Dismiss - Files Extension Request

In its ongoing suit claiming copyright infringement against a Puerto Rican physician, American Board of Internal Medicine (ABIM) lawyers of Ballard Spahr were slapped with a Motion to Dismiss on 11 March 2016 for failure to state a claim upon which relief can be granted and for filing their suit well outside the 3-year statute of limitation for the alleged copyright infringement. The details of the motion can be reviewed at the link provided.

In turn, lawyers for the ABIM have filed a request for an extension on 12 March 2016 to file their response. The details of their response will be interesting to review, especially since practicing US physicians are witnessing first-hand how the ABIM, once little more than a testing agency, exploited the learned helplessness of physicians accustomed to years of regulatory Stockholm Syndrome to take advantage of fellow colleagues for personal and political gain.

Thanks to the Penn State mentality inherent to group-think corporate medicine, it now appears the ABIM plotted a strategy using intimidating strongman search and seizure tactics to invade at least one physician's home to obtain "2,000 emails and audio and other communications from physicians disclosing exam questions." Officers of the ABIM unilaterally justified the sanctioning of 139 physicians and the distribution of heavy-handed and psychologically irresponsible letters of reprimand to thousands more as "a message and a deterrent" while pocketing millions for themselves and their corporate clients.

But questions remain and loom larger now. What were the terms of the deal cut between Dr. Arora and the ABIM? Why won't the ABIM release this settlement agreement to the defendant? What personnel and methods were used to track down the Puerto Rican physician via his email communications some five years later? Why were records shredded? Why were physician attendees at the Arora course targeting when similar ACP-sponsored courses and course directors do not undergo similar scrutiny? None of these specifics were aired in the public ABIM press release about the incident.

Until these are explained and justified, I believe all US physicians should refuse to participate in Maintenance of Certification (MOC) until a full investigation and accounting of the ABIM's actions and financial conflicts takes place. Members of hospital medical boards and Medical Executive Committees should insist these questions are answered by the ABIM. After all, hospitals and insurers need practicing physicians focused on patient care more than they need the ABIM, ABMS, or its member boards insisting we take strong-armed tests for their political and personal gain.

To me, it increasingly appears legal challenges are mounting for the ABIM, the ABMS, and their officers as this story unfolds. As a result, I suspect there will be a pivot away from the ABIM/ABMS MOC product by the medical establishment to the new Medicare Physician Payment scheme, MACRA. But MACRA contains parts of the ABMS MOC program with its untested "performance improvement" quality metrics and patient-survey directed care that repeats a similar theme: data-gathering to pad corporate bottom lines with expensive, time-consuming, and unnecessary metrics that add little to no value to direct patient care and, instead, adds costs and detracts further from much-needed patient care.

It is time to learn the whole truth behind MOC, not just for physicians' benefit, but for our patients, too.

-Wes

When the ABIM Comes Knocking

Imagine early one morning your doorbell rings. You wake from sleep and come to the door and open it. There before you is "a lawyer and a few other people from the American Board of Internal Medicine (ABIM)."  They hand you a document, signed by a judge, that they can search your premises and seize things. You're confused and feel powerless to act. They enter, move to your study (home office) that contains the records of your ACGME-accredited board review course that you've given for years, collecting documents. They open your computer, taking portions of it so it no longer works. They rummage through your wife's jewelry box. They spend the entire day boxing and inventorying things that they collect, then leave.

Then, some time later, a settlement deal is cut with you. One that apparently the ABIM does not want others to see. You're advised by your counsel not to bring that subpoenaed settlement agreement with you for your deposition. And remarkably, the very same lawyer that raided your home is there at your deposition representing the ABIM.

Sound unreal?

Yesterday, Dr. Jaime A. Salas Rushford posted on his blog the 142-page deposition of Rajender K. Arora, MD from January 21, 2016, obtained as part of his defense of the ABIM suit filed against him. Dr. Arora ran the board review course that resulted in 5 suits and 134 physician sanctions by the ABIM as reported in the Wall Street Journal. It also prompted physician sanction letters to be sent by Ms. Lynn Langdon, Chief Operating Officer of the ABIM at the time, to thousands more.  Dr. Arora's account of the raid on his home in December 2009 begins on page 62 of the posted transcript.  The lawyer that came to his door is identified on page 63 (Ms. Hara Jacobs). The accounting of the search of Dr. Arora's wife's jewelry box is found on page 93.

So if you've got a few minutes, grab a cup of coffee and read the deposition, especially the part about the raid on Dr. Arora's home. I have a feeling this story is about to get very interesting for practicing US physicians and very uncomfortable for the ABIM as more details about this apparent physician sting operation emerge.

-Wes

Related: "Strongman, Bosses, and the American Board of Internal Medicine" 

When Medical Students Push Back

There are few times when medical academics sound more foolish that when they're caught with their hand in the regulatory cookie jar.

Take, for instance, this response to the recent pushback by medical students against the National Board of Medical Examiners' Step 2 CS requirement.  For those unfamiliar, this is an attempt for the NBME to "standardize" the patient encounter while collecting $1250 at one of only five specialized testing centers is the US for the pleasure.  Their excuse for such a requirement?

"... most medical school faculty don’t have time to observe third- and fourth-year students doing a complete physical exam, so it’s important to test those skills as part of the licensing process.

“It’s really just a part of what we do to become physicians and to demonstrate to the public that we have earned their trust — that they can put their faith in us and feel comfortable with it,” Kastufrakis said.

The exam also serves as a sort of quality assurance test for medical schools, to make sure they’re teaching patient care skills, said Dr. Lia S. Logio, president of the Association of Program Directors in Internal Medicine. “I think everyone coming to my residency program should pass it, and pass it on the first attempt,” Logio said."

Medical school faculty don't have the time? Seriously? That's their job. If medical school faculty, working 9 months a year while planning their resarch projects and next grant application, don't have the time to evaluate the medical students that fund their salaries sufficiently, then perhaps they need to look inward rather than asking medical students to submit themselves to this money grab. Medical school is already incredibly expensive (private schools here in Chicago enjoy a tuition and fees of over $54,000/year). Certification and licensure fees are many more thousands on top of that (again and again and again).  Unnecessary testing is a waste of time and resources for physician-trainees who are increasingly thrown under the bus by the non-practicing bureacratic elite. The whole process needs serious reassessment. Otherwise, our best and brightest will understand all too soon what they're up against and that won't be good for the "public" at all.

I suggest the NBME stop Step 2 CS and adjust their budget accordingly.

-Wes

Addendum: Interesting that the NMBE made $136 million in 2014  from testing fees, 50% of which went to salaries.

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.

Spotlight

I didn't watch the Academy Awards last night, but I had seen the movie "Spotlight." It's an inspirational movie that chronicles the efforts of the investigative journalism team by the same name at the Boston Globe that broke the worldwide Catholic priest child-molestation cover-up story. If you haven't seen it, you should.

Earlier this morning I learned that "Spotlight" won the "Best Picture" award at the Academy Awards, much to the disappointment of the bear attack fans. But as one who has dipped his toe into the art of investigative journalism for the past three years as an amateur, I found the appreciation of the film's message reassuring in today's click-through culture. Being an investigative journalist is not only difficult, but also frightening at times, both professionally and personally. As the movie nicely documents, the revelations of corruption can shake closely-held narratives of decency and trust so critical to important societal institutions.  The movie also nicely portrays how difficult it is to fact-check, obtain evidence, and clearly document the story to both gain credibility and affect change. Unfortunately, classic investigative journalism has fallen victim to increasingly limited funding and a world with a shorter and shorter information attention span.

I fear the story of the financial cover-up at the American Board of Internal Medicine (ABIM) is quickly falling victim to similar pressures. With the exception of one veteran news reporter at Newsweek, Kurt Eichenwald (see here, here, here, and here), few journalists have had the interest, patience, or fortitude to expose the truth of the multi-million dollar US physician specialty Board certification racket. Perhaps, like the thought of priests caught molesting children, the thought a non-practicing physician cartel extorting high fees from their colleagues for their personal and political gain is too uncomfortable to accept. Perhaps it is too hard for patients to believe that board re-certification is not about assuring their safety, but rather for little more than money and power. But for working U.S. physicians who are still strong-armed into paying into the ABMS cartel every ten years just so they can continue to do the job they love, this coercion is all too real.

Last October, I had hoped this story would be different.  I was interviewed for over an hour and a half by a reporter from CNBC at my hospital who was investigating the ABMS board certification monopoly. I was told she also interviewed Richard Baron, MD of the ABIM and Lois Nora, MD, JD, of the American Board of Medical Specialties. I spent over an hour in the interview, had a cameraman shoot shots in of my office with its board certificates, and introduced the reporter to one of my patients (with permission given my the patient first) under the watchful eye of my hospital's PR department. "Finally!" I thought.

But the story never aired. I called and inquired. It was an on again, off again affair, buffeted by more compelling stories of the day, I was told. Then, "we've decided to go forward." But now months later, still nothing.

I believe that freedom of the press and careful investigative journalism fills an important role in our society. I still believe the day will come when the truth about the ABIM's actions will be told and thoroughly investigated to end the injustice and waste from the ABMS Board Certification monopoly. Let's hope last night's victory of "Spotlight" as "Best Picture" at the Academy Awards can rekindle main stream media's appreciation for the importance of responsible reporting unencumbered by political and financial pressures.

After all, this isn't Hollywood that we are dealing with, this is real life, real doctors, and real patient care - even yours.

-Wes

My Letter to the Chair, Cardiovascular Board, ABIM

Recently, an email was sent to all Cardiovascular Disease diplomats requesting a review of the American Board of Internal Medicine Cardiovascular Disease Examination "Blueprint" for content on the Cardiovascular Disease Examination. The email was authored by Mariel Jessup, MD, Chair of the Cardiovascular Board and George W. Dec, Jr., MD, Chair, Cardiovascular Board of Cardiovascular Disease Exam Committee (I'm not really sure how these titles differ, but I digress).

The purpose of the "survey" and "blueprint" was to "assure the MOC examination is reflective of CV disease specialists are actually doing today, and we hope you share your perspectives to help get us there." Petitioning cardiovascular disease specialists through "short surveys" so the responses of physicians can be spun by the ABIM as evidence of "buy-in" by the cardiovascular community is a classic and well-recognized political tactic. 

Here's my letter I sent to the ABIM Cardiovascular leadership in charge of this endeavor.  I encourage my cardiovascular colleagues to send them your thoughts at ABIMBlueprintReview@abim.org :

18 Feb 2016

Dear Drs. Dec and Jessup-

I received your 11 Feb 2016 email to update the content of the Cardiovascular Disease MOC examination by way of your Blueprint Review Tool. No doubt you have plenty of people who have blindly edited your “Blueprint” without considering why we must perform the ABMS MOC program in the first place. I have no idea if this letter will resonate with you or make you seriously reconsider your support of this endeavor, but I feel compelled to notify you why US physicians are no longer content with the MOC status quo that was imposed unilaterally by the ABIM and their supporting professional organizations in 1990. MOC was a financial model that bailed the ABIM out of a financial hole then and now has created a much bigger set of problems for the ABIM.

As I’m sure you are well aware, there had been no credible, independent, peer-reviewed studies that have shown the ABMS MOC program improves patient outcomes in any way. There are, however, limitless propaganda pieces written by staff at the ABIM about the purported “benefits” of MOC. Tax disclosures have shown serious financial mismanagement and erroneous tax filings by the ABIM. Most of the financial transgressions pertain to the secret creation and funneling of over $70 million of our physician testing fees to the ABIM Foundation from 1989-2007, an organization that was reportedly created to define and publish a self-generated definition of “medical professionalism” that included a “social justice” imperative as one of its prerequisites. Their $2.3 million condominium purchase in December, 2007 didn’t help either. The fact that the cost for MOC has increased $247 percent in the last 15 years (over 16%/yr – far in excess of inflation) with $55 million of physician fees paid annually to the ABIM needs serious reconsideration in this era of astronomical health care costs. The ABIM is an independent, non-profit corporation that enjoys a tax-exempt status from the federal government as a 501(c)(3) corporation with requirements to be apolitical, but lobbied Congress without disclosure – a violation of rules for non-profit status of that kind. As a 501(c)(3) corporation, the ABIM’s membership is not elected, but rather appointed (as I’m sure you both were). Conflicts of interest with the leadership remain an unaddressed issue with the ABIM and bylaws reflect they continue. One only has to see the conflicts between Christine Cassel, MD and CECity/Premier/Kaiser Health Plan and Hospitals and Robert M. Wachter, MD and IPC Hospitalist Co/TeamHealth (and their ongoing federal investigation on Medicare overbilling) to appreciate how problematic these conflicts have become for the ABIM as a credible organization to practicing physicians and patients.

Furthermore, the ABIM took the unprecedented action to sue 5 physicians and sanction 134 more who were attempting to study for their certification examinations at a board review course in 2009 and then publishing a press release with the five physicians’ names in the Wall Street Journal in 2010 before due process. While the ABIM claimed “Copyright infringement” with their sanctions, none of the five physicians EVER paid a fine for such since all were covered in their actions by merger doctrine. (It’s very hard to copyright general medical knowledge.) With this move and the contract entrapment physicians must endure when they enroll in MOC, trust in the ABIM as a credible physician quality measure has been seriously compromised.

Blueprints don’t restore trust. Credible, trustworthy actions that acknowledge prior wrongs and meaningful efforts to correct them does. Ending the lucrative MOC program and restoring the ABIM to an elected organization with bylaws that remove double-dipping with corporations that stand to benefit from physician certification reporting (see abmssolutions.org, for instance) would go a long way at correcting the current situation. Ending MOC busywork and retracting the failed MOC program and using credible CME to suffice in its stead would also be necessary.

I propose you make these last actions your “Blueprint for Success” for the ABMS Cardiovascular Disease MOC program. Anything else will fail to restore the trust of practicing cardiologists and is doomed to fail. I wish you both the best of luck.

Respectfully,


Westby G. Fisher, MD
ABIM Diplomat #127308

-Wes

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

The American Rebellion is Hitting the House of Medicine

From Peggy Noonan:

We’re in the midst of a rebellion. The bottom and middle are pushing against the top. It’s a throwing off of old claims and it’s been going on for a while, but we’re seeing it more sharply after New Hampshire. This is not politics as usual, which by its nature is full of surprise. There’s something deep, suggestive, even epochal about what’s happening now.

Physicians, too, are rebelling against the established sheltered and elite institutions of the House of Medicine: the ACGME. I can see it. I feel it.

I mention this to say we are in a precarious position in the U.S. with so many of our institutions going down. Many of those pushing against the system have no idea how precarious it is or what they will be destroying. Those defending it don’t know how precarious its position is or even what they’re defending, or why. But people lose respect for a reason.

So true. Greed does this to people. So does money.

It will be interesting to see where things land but one thing is for certain, the staid bureaucratic institutions within the House of Medicine are in trouble and they brought this on themselves.

-Wes

On the Anniversary of the ABIM's MOC Mea Culpa

Happy (belated) Anniversary, ABIM!

It's been over a year since you told us your now famous mea culpa message that said you "got it wrong" with your Maintenance of Certification (MOC) program.

And yet the program still continues despite everything your colleagues have disclosed about this travesty to our medical profession.

Let's review what you've done instead:

• You've suspended (temporarily to the end of 2018 when MACRA blossoms forth) Part 4 of the MOC program with its Practice Improvement Modules and Patient Safety and "Voice" sections because you were caught red-handed performing research on physicians for your own gain.


• You've finally stopped making residents pay for "maintaining" their certification before they even sat for their first certification examination.


• You also stopped requiring that physicians subject themselves to a "double jeopardy" situation where those with more than one Board certification had two pass BOTH examinations to maintain each one of their certifications.


• You also made sure you took down the comment section on your blog. So much for transparency and a sense that you really cared what your practicing colleagues thought about your program.


• And now, according to Stephen Weinberg, MD at the American College of Physicians in a recent email to ACP members, you've been "addressing any factors that might be contributing to the relatively high failure rates" by "making changes to the most recent internal medicine MOC examination administered in October" and "changing the process" for setting the pass rate cut-off resulted in ABIM reporting "a notably higher pass rate for the 2015 Internal Medicine MOC examinations." It seems those declining pass rates that you dismissed in your Medscape interview were getting lower after all.

But what STILL hasn't happened more than a FULL YEAR later is tell us about all about the money and the secret deals.

• You haven't explained why you funneled over $70 million of our testing fees from the ABIM to your secretly-created ABIM Foundation.


• You haven't explained why you paid Christine Cassel, MD a whopping $8.9 million from May, 2003 through 30 June 2013 and allowed her to earn another $1.9 million from Kaiser Foundation Health Plans and Hospitals and $230,000 in cash and stock from Premier Inc while she was supposedly working full time at the ABIM. And why on earth did Ms. Langdon - a non-physician administrator - deserve a bonus of over $297,646 in fiscal year 2012? Was it because of all those sanction letters she sent out to physicians acusing them of cheating?


• You haven't explained why cash-flush ABIM Foundation had to purchase a $2.3 million luxury condominium complete with a chauffeur-driven Mercedes S-Class town car. Was it really as an "investment" or was this another perk for Ms. Cassel as she and her husband flitted back and forth from Philadelphia to their home in Arizona?


• You also haven't disclosed how test and physician demographic and practice data, paired with your unproven re-certification metric, are being sold to the likes of CECity Premier, Inc and others for political and personal favors.

It is now clear to practicing physicians everywhere that you can't let go. That's what happens to people who have an addiction problem. Given these and prior actions it is clear you have an addiction. You are addicted to spending other people's money. And we understand that when an addict is caught with their hand in the cookie jar, they get creative with new ways to support their habits and obsessions. They change the rules. They make fellow doctors co-dependents. They make others feel guilty for not playing the game and not paying in. They even result to strongman tactics with threats of revocation of board status and using threats of Copyright infringment to protect the money flow.

Anyone who has ever had a loved one caught in this viscous addiction cycle understands. This is what the hostile-dependent relationship with an addict looks like: untrusting, two-faced, dysfunctional, love-you-one-minute-then-stab-you-in-the-back, sneaky.

From the very beginning when time-limited board certification was introduced to the physician community, this is what how you and your supporters framed it::

Previous attempts by the ABIM to mount programs of voluntary recertification for non-time-limited certificate holders had met with only limited and declining interest. Over four exams, only 8621 candidates were issued since 1974. The last of these efforts, the Advanced Achievement in Internal Medicine exam given in May 1987 attracted only 1403 registrants from an estimated pool of over 40,000 eligible certified internists despite extensive marketing efforts by the Board. Thus, the stage was set for the Board to embark on an era in which diplomats would be asked, but not required, to renew the validity of their certificates at periodic intervals or face the uncertain consequences of loss of their status as certified internists, subspecialists, or holders of certificates of added qualification." (emphasis mine)

Back then as it is now, the ABMS/ABIM MOC participation was born upon a strongman/boss approach, not on proof of its value to patients or our profession.

But there's still time. You can start your 12-step process, but first, you must admit you have a problem. Committing to an $85 million lease through October 2040 and shaking down your fellow physicians for your extravagent ways is part of the problem. But you know and I know there's even more behind the scenes. You really don't want us to tell the rest of the story and all of the sneaky and disturbing ways you secured your monopoly. This story is very messy, Gruber-esc, indeed. It will take bravery and resolve, but you can do it.

Here's how.

I would suggest you come clean. Stop trying to clean up your horrible MOC mess. Change your bylaws to one that supports working physicians, rather than yourselves and your "stakeholders." Insist that ALL financial and political efforts be disclosed - that's right: ALL of them - including all of your leadership and directors' securities deals and consulting arrangements. Disclose all of the fees that flow between professional societies, medical journals, and other members of the ACGME hierarchy as well. Dissolve the Foundation and return the money to those who funded it: practicing physicians. Make certification free for the next ten years (the same amount of time you (quite literally) stole from us for your political agenda). And stop insisting that MOC can be improved when it's clearly little more than a corrupt, dysfunctional, and untrustworthy self-created credential for your income stream. MOC (and all the sickening and non-transparent permutations that keep getting created) needs to end completely.

Because here's a secret: clinical doctors won't participate in this program without these actions to dissolve MOC, no matter how much pressure you and your cronies apply.

-Wes
Reference: Glassock RJ Benson JA, Copeland RB, Godwin HA, Johanson WG, Point W, Popp RL, Scherr L, Stein JH, Tounton OD. Time-Limited Certification and Recertification: The Program of the American Board of Internal Medicine. Ann Intern Med 1991; 114(1): 59-62.

Love, Ethics, and the Quality Assessment Industry

"I think that commercialization of care is a big mistake. Health care is a sacred mission. It is a moral enterprise and a scientific enterprise but not fundamentally a commercial one. We are not selling a product. We don’t have a consumer who understands everything and makes rational choices — and I include myself here. Doctors and nurses are stewards of something precious. Their work is a kind of vocation rather than simply a job; commercial values don’t really capture what they do for patients and for society as a whole.

Systems awareness and systems design are important for health professionals but are not enough. They are enabling mechanisms only. It is the ethical dimension of individuals that is essential to a system’s success. Ultimately, the secret of quality is love. You have to love your patient, you have to love your profession, you have to love your God. If you have love, you can then work backward to monitor and improve the system. Commercialism should not be a principal force in the system. That people should make money by investing in health care without actually being providers of health care seems somewhat perverse, like a kind of racketeering."

- Avedis Donabedian

* * *

Don Draper in the finale of Mad Men

Many of us recall the final scene of Mad Men where Machiavellian dealmaker, philanderer, and ad mogul Don Draper sits in lotus position finding either true inner peace or the next cynical direction from which to profit. This scene came to mind as I read another apparent conversion experience by Robert M. Wachter, MD in his recent opinion piece in the New York Times on how the metric measurement business fails physicians and teachers. Remarkably, Dr. Wachter, once the Chairman of the  American Board of Internal Medicine (ABIM) that is responsible for "continuously" measuring, re-testing, and re-certifying US physicians, seemed to pivot from his former self by quoting a few of Avedis Donabedian's words on quality assessment suggesting "the secret of quality is love." Unfortunately, Dr. Wachter conspicuously failed to acknowledge the full context of Donabedian's words.

Robert Wachter, MD, as "Elton John"
SHM Meeting 2014
Mandalay Bay Casino, Las Vegas and
Modern Healthcare's Most Influential
Physician Executive and Leader 2015
(Full video of the performance here)

I suppose if he can transition from a physician executive to a "down to earth" Bob Wachter, MD hitting "high notes" as Elton John at the Mandalay Casino while simultaneously profiting from a company that now under federal investigation for overbilling Medicare, why not?  Such is our current reality of politics, medicine, and corporate cronyism.

It was nearly four short years ago that Dr. Wachter wrote that we needed the ABIM's Maintenance of Certification program "more than ever." Perhaps the lucrative Digital Party in medicine was just too big for the ABIM leadership and the members of its Foundation to ignore. At the time, those in Wachter's World held the view that assuring physician quality meant physicians not only had to be re-certified every ten years but soon had to participate in some form of the ABIM's measurement program every two years for the sake of  "external stakeholders and a troubled public."  As a result, physicians were required to perform unproven practice improvement exercises, perform un-monitored research on themselves, and become glorified data entry personnel to continuously "maintain" their "board certification" or risk losing their right to practice. All of these exercises were subsequently revealed to be primarily for the medical industrial complex's extraordinary monetary gain and undisclosed political activities.  Such "love," indeed.

The expanded ABIM board certification requirements after 1990 have served as the goose that laid the Golden Egg for condo purchases, chauffeur-driven Mercedes rides, spousal travel fees, undisclosed corporate consulting arrangements, corporate mergers, political influence and the program's continuing transition to Assessment2020 - much of these occurring while Dr. Wachter served as a Director or Chairman of the ABIM. For the ABIM and its parent organization, the American Board of Medical Specialties (ABMS), success in the digital medical world still appears to mean the doctor-patient relationship has to be owned, bartered, and commoditized to serve their bottom line without really understanding all that this entails to the doctor, their patients, and the credibility of our profession.

If Bob Wachter, MD is a true physician advocate and is now having a genuine conversion experience, he would be speaking out about these abuses of physicians' trust. In fact, as the "Most Influential Physician Executive and Leader 2015," he would be leading this charge. Or perhaps I am missing something.

Meanwhile, despite all of the fast-paced changes in health care under way, the same rubber soles continue to speed down linoleum hallways, call lights blink, keyboards pound, family meetings are held with tears shed, young physicians wonder how they'll pay their educational debt, productivity quotas expand, administrative meetings multiply, patients grow furious about their rising premiums, co-pays and deductibles, physician autonomy and morale withers, and patient access to their doctor shrinks.

Fortunately, rather than standing idly by, practicing doctors are mobilizing. They are realizing that the bloated and costly bureaucratic arm of our profession has lost its way and are working to restore its integrity. Practicing physicians are finding they have a voice and are not powerless against these corporate entities that unjustifiably risk compromising their ability do their job. With these efforts, members of Wachter's World are beginning to realize they're at risk of losing their golden goose:

Last week, Andy Slavitt, Medicare’s acting administrator, announced the end of a program that tied Medicare payments to a long list of measures related to the use of electronic health records. “We have to get the hearts and minds of physicians back,” said Mr. Slavitt. “I think we’ve lost them.”

Despite these concerns of a few of our bureaucratic medical policy elite, practicing physicians remain little more than an account to be landed, a work to be optimized. To them, practicing physicians represent an opportunity to invest in new corporate ventures like Health2047, no doubt for the "love" that's involved. The respectful partnership that practicing physicians would like to have would not include the many corrupt financial practices and undisclosed conflicts of interest of the AMA and the ABMS specialty board credentialing system, their collaborating subspecialty societies, and numerous for-profit physician reporting businesses. They invoke ethics, morals, and "love" at their own risk.

In my career, I'm unaware of a broader breach of the trust of working physicians and of medical ethics by fellow colleagues than by those who secretly created the ABIM Foundation in 1989 and then funneled over $55 million of testing fees collected from working physicians while hiding its existence from physicians and the public until 1999. Yet many in our academic and bureaucratic physician community continue to support this testing agency that appears to have been expanded solely for political, corporate, and personal gain, and are indifferent to them using strongman tactics with physicians. What a perverted form of "love."

This system must change.

As health care moves forward in these uncertain times, a few of Donabedian's (other) words on quality assessment, uttered a month before his death, are prescient:

"It is the ethical dimension of individuals that is essential to a system’s success. ... Commercialism should not be a principal force in the system. That people should make money by investing in health care without actually being providers of health care seems somewhat perverse, like a kind of racketeering."

Perverse indeed.

Right now there are residents who have no idea how they'll ever pay off their educational debt and millions of patients who can't afford insurance or their drugs. If the House of Medicine can't look inward at its own bloated, self-serving, bureaucratic ranks of the ACGME that are sucking the life from direct patient care, what does this say about the prognosis for US health care?

As Tina Turner once sang, "What's love got to do with it?"

-Wes

Reference: Donabedian A. A founder of quality assessment encounters a troubled system firsthand. Interview by Fitzhugh Mullan. Health Aff (Millwood). 2001 Jan-Feb;20(1):137-41.

Are ABIM-certified Physicians Research Subjects?

I logged on to the ABIM website last evening and was greated by this pop-up screen. It seems the ABIM is in the business of "research" at my expense to "understand how to improve health care."  They are mandating that I enter my "practice characteristics" in a 15-minute survey. 

Yet I have no idea what the ABIM's "research" entails, I have not been informed how that "research" will be conducted, nor how it might affect my ability to practice medicine, or if  my information will be sold to other entities for a price on the basis of the ABIM's valuable "research." Since we know that the ABIM has partnered with companies like Premier, Inc (which just purchased CECity, Inc a subcontractor for the ABIM from 2010-2014) for $400 million, I would like to review the research protocol the ABIM is conducting, the risks and benefits to me for that research, and how my data will be used and protected.

The ABIM should be aware that the Department of Health and Human Services has VERY specific rules and regulations (45 CFR 46) about how "research" is to be conducted, particularly as it pertains to the protection of human subjects like myself who have increasingly found their ability to practice medicine in a hospital setting compromised unless we participate in the ABIM's Maintenance of Certification (MOC) program. We have not been given proper informed consent and, instead, find that this data entry in "mandatory for all Board Certified physicians enrolled in Maintenance of Certification (MOC)." Furthermore, physician's are aware their "MOC status" is being sold by the American Board of Medical Specialties (ABMS) via its ABMSSolutions.org website to a whole host of third parties for a fee.

Needless to say, I won't enter this information until the ABIM makes public the "research" protocol they are conducting.

Richard Baron, MD, ABIM President and CEO, needs to explain to all ABIM diplomats why they are ignoring Health and Human Services regulations on the protection of human subjects (physicians) in their collection of "practice characteristics" for the purpose of improving health care.

-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

The Maintenance of Certification Controversy 2015: The Year in Review

With so much controversy surrounding the American Board of Medical Specialties' (ABMS) Maintenance of Certification (MOC) program in 2015, especially as it pertained to the American Board of Internal Medicine (ABIM), I thought it would be helpful to recap some of the earlier announcements about the ABMS MOC program, and then summarize this year's most pertinent developments to serve as a springboard for 2016. To keep it simple, I will use a timeline approach of the developments as I've seen them occur. (Remember: hind sight is always 20:20.)

• 24 July 2012 - ABIM announces Medicare payment incentives for participation in their MOC program on their website.


• August 14, 2012 - Robert Wachter, MD assumes chairmanship of the ABIM, writes missive on his industry-sponsored blog justifying why board certification "matters more than ever." This post shows anticipated collusion for acceptance of MOC as a "quality measure" between Medicare, the Joint Commission, the Federation of State Licensing Boards, and the ABIM Foundation's Choosing Wisely campaign. Wachter fails to mention his simultaneous affiliation as director of IPC The Hospitalist Company, Inc., a company that "is the nation's leading national physician group practice focused on the delivery of hospital medicine and related facility-based services" in that announcement.


• 27 Apr 2013 - Drs. Wachter and Cassel named to Modern Healthcare's "Most Influential Physician Executives."


• 1 Aug 2013 - Robert Wachter, MD receives 1,355 shares of IPC The Hospitalist Company stock options valued at $50.68 per share (Market Value: $68,671.40).


• 12 Jun 2013 - ABMS lobbies Chairman Upton and Ranking Member Waxman of the US House of Representatives Energy and Commerce Committee to have MOC program included in MACRA (the SGR Fix bill) as a physician quality measure.


• 30 June 2013 - Christine Cassel, MD to step down from ABIM as President and CEO of ABIM and ABIM Foundation. Earns $1.7 million as she leaves to begin work at the National Quality Forum.


• 1 July 2013 - Richard Baron, MD becomes ABIM and ABIM Foundation President and CEO


• 25 Sep 2013 - Christine Cassel, MD issued 3706 shares of Premier, Inc (PINC) stock


• 31 Dec 2013 - Physicians who participate in MOC program by Dec 2013 are able to claim 0.5% payment incentive from Medicare


• 1 Jan 2014 - ABIM offers either one-time (every 10-years) or annual payment plan option for its MOC program.


• 2 Jan 2014 - Robert Wachter, MD receives another 2,640 shares of ICP The Hospitalist Company stock options valued at $58.50 (Market value: $154,440)


• 10 Dec 2014 - Study appears in JAMA showing no effect of MOC program at improving patient outcomes.


• 16 Dec 2014 - The first detailed review of the MOC corruption appears on this blog with the publishing of "The ABIM Foundation, 'Choosing Wisely' and the $2.3 Million Condominium."


• 30 Jan 2015 - The ABIM is caught in the act if omitting 6 key financial schedules from its 2014 Consolidated Financial Statement that it released to the public.


• 31 Jan 2015 - A virtual tour of the ABIM Foundation's condominium is published.


• 3 Feb 2015 - ABIM issues previously unimaginable apology to the physician community stating "ABIM clearly got it wrong" but fails to mention the financial, tax filing, and financial conflicts of interest of its President and CEO and members of its board leadership.


• 3 Feb 2015 - Physicians (especially this one) are not impressed with ABIM's announcement that failed to acknowledge ABIM's history of serious financial and public reporting actions. Work continues to uncover what's being hidden.


• 16 Feb 2015 - ABIM initially fails to publish full financials for 2014 until pressured to do so. Apparent cover-up continues.


• 10 Mar 2015 - Veteran Newsweek reporter Kurt Eichenwald publishes his first take on the MOC controversy with his article entitled "The Ugly Civil War in American Medicine."


• 11 Mar 2015 - ABIM Board Chairman David H. Johnson, MD issues statement attempting to discredit Eichenwald's article claiming "numerous and serious misstatements, selective omissions, inaccurate information and erroneous reporting." Johnson disputes claims that ABIM pass rates have fallen, that ABIM has a monompoly on re-certification, claimed that Eichenwald was "selective" about the data presented and has a "poor understanding" of the tax records, and that Eichenwald had failed to disclose his wife was an internist.


• 30 Mar 2015 - New board (NBPAS.org) formed and doctors are moving on after more of the financial transgressions come to light.


• 3 Apr 2015 - Dr. Robert Wachter, the former chairman of board at the ABIM, tops Modern Healthcare's Top Fifty Most Influential Physician Executives and is "not afraid to challenge the status quo." Not surprisingly, Dr. Christine Cassel again makes the list as well.


• 7 Apr 2015 - Kurt Eichenwald's next Newsweek article on the ABIM MOC program, "A Certified Medical Controversy," is published and begins to target many of ABIM Board Clair David H. Johnson's criticisms.


• 8 May 2015 - Consequences to physicians who fail their unproven MOC re-certification secure examination published online.


• 21 May 2015 - Kurt Eichenwald's third expose on the ABIM's finances called "Medical Mystery: Making Sense of ABIM's Financial Report" hits the pages of Newsweek disclosing the unreported lobbying efforts and the convoluted and large payments made to the ABIM leadership including $1,712,847 made to Christine Cassel, MD in fiscal year 2014.


• 22 May 2015 - Richard Baron, MD publishes another official ABIM response to Kurt Eichenwald's articles claiming "we have never made any effort to obfuscate, hide or delay ABIM's financial information." Baron did not acknowledge that they failed to release all of their audited financials (see 16 Feb 2015 entry on this timeline). Baron also fails to mention that the ABIM failed to release 12 years of audited financials requested by a reporter from the Wall Street Journal in August 2014. Additional attempts to obtain the reports from the PA Attorney General's office were also unsuccessful. Financial data were only obtained after a request was made to the office of the Pennsylvania governor's press secretary.


• 23 May 2015 - ABIM, it's finances, and the great revolving door collusion between the National Quality Forum, the ABIM, ABIM Foundation, and other specialty organizations published.


• 31 May 2015 - The ABIM's tax-filing cover-up of its lobbying activities with Congress exposed.


• 29 June 2015 - Robert Wachter, MD attempts to defend the actions of the ABIM on his blog after leaving his post as Chairman and speaks out. No corporate conflicts of interest are specifically mentioned by Dr. Wachter. Comments to his post are worth a read.


• 28 July 2015 - An independent cost analysis of the ABMS MOC program in published before print in the Annals of Internal Medicine.


• 15 Aug 2015 - ABIM Foundation tries to bury its old "About Us" webpage that claimed the creation date of the Foundation was in 1999 by editing the page to disclose the correct date of origin (1989) and then includes information regarding "$55 million" that was transferred from the ABIM to its Foundation from 1989 to 2007. The amount transferred was actually much larger and made secretly without disclosing the Foundation's existence to the physician community or public until 1999. The reasons for the secrecy and large annual payments made to the now defunct 1838 Investment Advisors (a spin-off of Drexel Burham Lampert financial fiasco - most of whom were indicted) made during that time have never been investigated or disclosed. One thing is now clear: it does NOT appear the sole reason for creation of the ABIM Foundation was to define and promote the term "medical professionalism" as originally claimed by the Foundation.


• 9 Sep 2015 - The ABIM's prior activities stumping for Big Tobacco in 1963 are revealed, lending less credibility to their claim that their certification program is for "public good."


• 15 Sep 2015 - Veteran Newsweek reporter Kurt Eichenwald publishes his last installment of a four-part series on the ABIM scandal entitled, "To the Barricades! The Doctors' Revolt Against ABIM is Succeeding!" highlighting how the ABIM MOC program has hurt physicians and patient care and what doctors are doing about it.


• 23 Sep 2015 - Graph of the growth in ABIM MOC Fees from 2000-2014 published showing at least 244% growth in cost (16.3%/year - far exceeding inflation) to internists over that 15-year time period.


• 25 Sep 2015 - ABIM's own Maintenance of Certification First-Time Pass Rates from 2000-2014 are published and document a negative pass rate trend line over that period of time in every subspecialty of internal medicine except Geriatric Medicine. The data trend stands in stark contrast to ABIM Board Chair David H. Johnson, MD's statement regardng MOC pass rates made 11 March 2015.


• 11 Nov 2015 - Concerning conflicts of interest with Christine Cassel, MD and the little-known company CECity, Inc. are published. Cassel's long-standing relationship with Premier, Inc. raises real questions regarding possible insider funding of CECity to prop up its value prior to its purchase by Premier, Inc. on 4 August 2015 for $400 million.


• 23 Nov 2015 - TeamHealth (TMH) acquires IPC The Hospitalist Company for $80.25 per share netting Dr. Wachter and his university, the University of California, San Francisco, a comfortable profit.


• 23 Nov 2015 - Graph of ABIM legal fees pre-ABMS MOC program (instituted in 2005) vs. post-MOC (ongoing) appears.


• 29 Nov 2015 - ABMS's income stream for selling daily updates of physician certification status from the unproven and un-vetted data gathered from its member boards via ABMSSolutions.org disclosed bringing the legitimacy of the entire ABMS MOC empire sharply into question.


• 6 December 2015 - A copy of the physician sanction letter issued June 8, 2010 surfaces on this blog and gives a glimpse into the strongman/boss tactics used by the ABIM to protect their certification monopoly. The tactics used to track down physicians late after they participated in a board review course years before are now coming under intense scrutiny.


• 16 Dec 2015 - ABIM announces its intent to extend its practice assessment decision through 2018.


• 17 Dec 2015 - Christine Cassel, MD leaves her role as the President and CEO of the National Quality Forum (in charge of setting "quality" standards for the nation's hospitals) to join the leadership team of Kaiser Permanente's School of Medicine. Dr. Cassel had long-standing financial dealings with Kaiser since at least 2003.

Yes, folks, it has been quite a year. Still, various member boards of the ABMS continue to try to modify and "improve" the highly conflicted and ethically corrupt ABMS MOC program. While I would like to have other things to write about on this blog from time to time, I find it important to continue to expose the corruption and financial conflicts created by the ABMS and their member boards. 2016 promises more developments as others begin to dip their toe into exposing this complex and unfortunate story.

My prediction for 2016: the ABIM collapse under its own spending weight but not before "grants" are issued from the ABIM Foundation back to the ABIM to support its operations.

If the ABIM does collapse, what happens to the certification process for US internal medicine physicians? Clearly, significant change (including electable board members and disclosure of conflicts of interest publicly) are of paramount importance. Returning board certification to a lifetime designation also seems paramount since the MOC program continues to prove itself as highly destructive to our profession.

So stay tuned in 2016. It promises to be an interesting year as more revelations regarding the ABMS MOC program develop.

-Wes

Addendum: 28 Dec 2015 @13:04 - Post updated to include 27 Dec 2012 and the failure of Dr. Baron to report his conflicts as Director of the Seamless Care Model Group in the NEJM publication. Also, 28 July 2015 was added to include the cost analysis of the ABMS MOC program published in the Annals of Internal Medicine.

Addendum: 28 Dec 2015 @ 13:21 - 27 Dec 2015 deleted from timeline - Author of the NEJM piece was Robert Baron from the University of California, San Francisco, not Richard Baron, MD - hence why there was no disclosure of this conflict on the NEJM publication. I regret the error.

Addendum 30 Dec 2015 @ 10:45 - Timeline updated with additional information revealed on 23 Sep 2015 and 23 Nov 2015 regarding growth of costs and legal fees.

The ABIM Maintenance of Certification (MOC) Controversy a Year Later

It has been one year since the story of the ABIM Foundation, Choosing Wisely, and the $2.3 million Condominium appeared on this blog. It has been one year without answers to the many financial, conflicts of interest, and likely illegal tax dealings of the American Board of Internal Medicine discussed within this blog's pages.

But as this story has unfolded, it is clear that this story is much more than a story of the purchase of a luxury condominium by a little known non-profit organization. It has been the story of betrayal of the entire practicing physician community in the United States and their patients everywhere in the name of self-serving power and greed by a relatively select few.

The story is also an embarrassing demonstration of the inability of our professional medical societies to deal forthrightly and honestly with all that has transpired. The vast network of the interconnected medical Specialty Board System led by the American Board of Medical Specialties in the United States that earns hundreds of millions of dollars annually from physician testing fees is incredibly wasteful and counterproductive. Instead of honest examination and disclosure of the facts, the ongoing deception, double-speak, and cover-ups of this system continues.

To date this story has also been about the failure of our legal, government, and law enforcement agencies to investigate the secret financial and tax filing discrepancies of the American Board of Internal Medicine and the ABIM Foundation. This has created a colossal erosion of physicians' trust with our US medical regulatory agencies, especially when doctors can't trust these agencies to protect them from fraud and abuse.

Why the lack of governmental investigation into over $70 million of physician testing fees that were secretly funneled from working physicians (preoccupied with the real work of patient care) into a shadow "Foundation" hellbent on making shady investments and enriching its leadership? The wanton disregard of the basic tenets of law and a civil society displayed by the ABIM is an anathema to honest physicians. Most physicians would prefer to believe that we do not work in an environment that rewards deception, theft, and greed. Yet here we are.

Finally, with the notable exception of a veteran Newsweek reporter, Kurt Eichenwald (see here, here, here, and here) and the tireless efforts of a single forensic accountant, Mr. Charles P. Kroll with whom I have had the pleasure to meet, there has been precious little true investigative reporting into the financial and anti-trust activities of the ABMS and their member boards by major outlets of main stream media. "It's a doctor problem" or "it's too complicated," I've been told. Is that the reason?

We'll see.

One thing's for sure: there's a lot of money at stake in the testing and control of practicing physicians and it is increasingly clear that these organizations (and even some segments of government for which they now work) won't open up willingly or relinquish their lucrative MOC re-certification program without a fight. They know they simply can't afford to maintain their current ways without it.

Getting It Wrong Again

Because of this reality of cover-up and backed by remarkable hubris and ego, the ABIM leadership appears to have made a more recent critical error - another little thing it appears they got "wrong." The ABIM decided to track down and hunt a young physician attendee of the Arora Board Review course attended in 2009 using an email that was found on the server at the residence of Dr. Arora and sued him almost five years later. These guys are serious.  It seems maintaining monopoly control of the lucrative board re-certification process using threats and intimidation (aka, The Chicago Way) was just too important to the ABIM.  But what the ABIM didn't expect is that this young man had at least one parent who was a lawyer,  and he sued back. Time wil tell if this brave man dealt the ABIM (already in the midst of their own financial and ethical mess) a potentially mortal blow.

This case is about to get interesting. So interesting, in fact, that it appears the ABIM's legal team will stop at nothing to try confuse and deceive the judge or magistrate who will soon hear oral arguments in late January 2016 about the case.

Perhaps then the truth will come out: all of the facts of the business of testing physicians; all of the tactics used to bully physicians into compliance with the ABIM MOC program; everything laid bare.

For this story is similar to the disturbing story of a subcontracting security firm that works with Pearson (a company reviewed earlier on this blog) and paid by the state of New Jersey that has been spying on children to protect their monopoly interest in the content of the national Common Core test. For physicians, it is no coincidence that a different division of Pearson, PearsonVue, is the professional testing division of Pearson that the ABIM uses to secure its examinations and cherished test questions.

When the facts come to light about the spying, the tracking, the hunting of physicians by an organization profiting handsomely from intimidation and thuggery, it will be hard for the ABIM and its Foundation to survive. So, too, the basic construct of the ABMS and our entire professional specialty board system.

It is increasingly clear that the ABMS MOC program is about threats and intimidation so people can enrich themselves selling unproven quality data to unwitting customers, and little more.  Physician education, if it happens, is really secondary. Is this what the physicians need from these sheltered and unaccountable non-profit organizations? How much time, energy, and money have we already wasted and turned from the delivery of health care with this program?  How many physicians' lives has the current system in its perverted construct ruined?

When all of the facts of the MOC program become known, maybe, just maybe, the ongoing fleecing of US physicians by the corrupt and misguided ABMS MOC progam and the irresponsible Code of Silence held by their subordinate member boards will end and our profession can get back to doing what its meant to do: treat patients.

One can only hope.

-Wes

PS: By the way, today in history on December 16, 1773, the Boston Tea Party took place.
Seems apropos, doesn't it?

Strongmen, Bosses, and the American Board of Internal Medicine

From John Kass, political reporter from the Chicago Tribune, this morning:

"Chicago is the most American of American cities," Emanuel has said, repeatedly. "It's not just any city. If you want to come and see America, you come to its heartland. And what is the capital of that heartland? Chicago."

Democratic political stars with Chicago ties — from his old boss President Barack Obama to presumptive 2016 Democratic nominee Hillary Clinton — must enjoy hearing it.

Politicians running for the office of emperor in a Republic just love fairy tales.

But there's one thing wrong with the mayor's favorite saying: It's wrong.

Chicago is not the most American of American cities. Chicago is the most Soviet of American cities.

The people of Chicago know this and it's time the rest of the nation understands it, too.

Chicago may appear to be an American city. But it is actually run on the old Soviet model, where the people were bossed for generations by ruthless and cynical strongmen.

The Russians call them strongmen. In Chicago, we call them bosses. But strongman-boss, boss-strongman, what difference, at this point, does it make?

The strongman of Chicago rules by fear. He holds the terrible hammer of big government in his hand. And if you're a corporate titan or a corner shopkeeper, you don't want that hammer to strike you down.

While Chicago is embroiled in a horrible police scandal uncovered by the flow of information via the digital age, I couldn't help but think how true Mr. Kass's words were in terms of US medical care and the control of practicing physicians on the front lines of health care today.

While nowhere near the seriousness of the police story in Chicago, the story of similar strongmen/boss tactics used against practicing physicians is a sad story that has been growing for years. Until recently, physicians have been oblivious to these tactics used by the American Board of Medical Specialties (ABMS) (based in Chicago) and the American Board of Internal Medicine (ABIM) who used their political and professional connections to foist their Soviet-style strongmen tactics on practicing physicians via their board re-certification requirement called "Maintenance of Certification®."

Participate every two years or lose your job.

Participate every two years or never see another penny from a major insurer.

Attend a board certification course that does not bow to the ABMS/ABIM strongmen?

Get sued or sanctioned.

Here's a redacted copy of the ABIM sanction letter sent to a physician who attended the former Arora Board Review course.  It came FedEx to the physician labeled with the instructions "destroy if undeliverable." To my knowledge this letter, sent to some 2000+ physicians who attended the Arora Board Review Course over the years it operated, has never been made public by the ABIM:

ABIM Sanction Letter issued by Lynn O. Langdon, MS,
Chief Operating Officer, ABIM (Click to enlarge)

It is a threatening letter, issued by a non-physician Chief Operating Officer of the ABIM who served as strongman for the ABIM and ABMS and later earned a $297,646 bonus from the ABIM in FY2012 (Page 22). The letter suggests the physician-attendee of the Arora Board Review Course violated a "Pledge of Honesty" and failed to call the obscure and unvetted ABIM Exam Integrity Hotline. And because the ABIM now has "ethical and professional concerns" about that physician, it is "placing a copy of this letter in your file."


Threats. Intimidation.  Strong-arming.

Maintenance of Certification®: the Chicago Way.

To think this whole process was been transported from Chicago to Washington, DC and is now deeply embedded in the Affordable Care Act as a physician quality registry, courtesy of heavy lobbying by the ABMS (and likely the ABIM), is sickening and wrong.

Practicing physicians, like the citizens of Chicago, deserve to know the truth of how and why this occurred.

-Wes

PS: Ms. Langdon no longer serves as Chief Operating Officer of the ABIM. She was quietly replaced by Nkanta “Nick” Hines, MSc, MBA. Ms. Langdon now serves as a board member of the American Board of Medical Specialties.

Edging Toward the Tipping Point

We've seen the "We got it wrong" messages."

We've seen the "We're listening to our members" messages.

We've seen the "changes" to board certification: from the change from permanent certification to time-limited in 1986, from dropping the requirement for dual board certification for subspecialists to the requirement for just one subspecialty certification, and from board certification being about a more "continuous" requirement for education.

And we keep hearing the excuses by all 24 ABMS member boards that they really want to change the MOC program after all of the corruption of the system has been exposed over the past two years.

But what you won't hear about from anyone involved with the Accreditation Council of Graduate Medical Education (ACGME) is anything about the money involved.

Practicing physicians are funding a profiteering racket.

This is what time-limited board certification is about, nothing more.

Proof of this can be found quite plainly at this website run by the American Board of Medical Specialties that promotes "ABMS Solutions." (video here).

ABMS "Solutions"sells "CertiFACTS Online®," "ABMS Certification Profile Service®," and "Direct Connect Select™" through Cactus, CredentialSmart, MD-Staff, and Vistar software systems.

We can see how the ABMS colludes with the Federation of State Medical Boards' (FSMB) newly-launched DocInfo service that "provides professional information on physicians and physician assistants licensed in the United States including information on disciplinary sanctions, education, medical specialty, licensure history and locations."

And now we see clearly how all of these privately-held non-profits of the 24 ABMS member boards are colluding together to prop up the very broken ABMS Specialty Board System financially:

Only CertiFACTS’ products connect professionals with board certification information that is updated daily with data provided by the 24 certifying ABMS Member Boards.

Physician ABMS board certification status, updated daily, and shot to a certification database near you. All for the low, low price of hundreds of millions of dollars a year and funded (in part) by every US physician.

It doesn't matter what new changes each of the member boards of the ABMS propose to change Maintenance of Certification (MOC).  The whole time-limited ABMS board certification is all about the money.

Always has been.

This is just one example of how the money pipeline overrides the welfare of the physician and their patients.

Between surveys, productivity ratios, data entry requirements, and now the board certification monopoly created by the ABMS,  I wonder how far the System thinks it can go before our new nation of employee-physicians unionize.

-Wes

ABIM Legal Fees: Pre-MOC vs Post-MOC

Pre-MOC Average: $146,073/year
Post-MOC Average: $1,090,184/year

This graph sums up another reason the American Board of Medical Specialties' Maintenance of Certification (MOC) program (implemented by the American Board of Internal Medicine in 2005) is such a mess.

(h/t @CharlesPKroll via Twitter)

-Wes

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Two days ago after a typical day performing procedures in the EP lab, doing inpatient consults, fielding patient messages, attending administrative and research meetings, reading EKGs, Holter monitor recordings, and co-signing device clinic charts, I opened my email and saw this:

ABIM Email to Diplomats 11/20/2015

I was appalled. MOC is not longer about "keeping up" for physicians. It is a major distraction. This program is of unproven benefit to my patients and me. Thanks to haphazard and self-serving rule changes by the ABIM and their member boards over the past 25 years, the US Specialty Board system has become increasingly coercive. In fact, MOC program now threatens my ability to practice the work that I love because I could lose my facility privileges and ability to receive payments from insurers on December 31, 2015. That is my reality. This is the reality of every physician subspecialist who participates in the ABMS MOC program in US medicine today.

Remarkably, I just re-certified in Cardiovascular Diseases and Cardiac Electrophysiology in 2013 for the third time.  I have never failed. I have over thirty years of experience treating patients and standing in the cross hairs of what it means to be truly accountable to those I treat. I have had over thirty years of nights when I lie awake at night worrying about by patients, about if I did enough, about why a patient had to die. My family, too, has endured years of being woken in the middle of the night or seeing their father have to leave a school play, holiday concert, or friend's dinner party to place an emergency pacemaker.

I am not unique. I am a practicing physician everyman. I stand in unison with hundreds of thousands of others here in the United States just like me who get up every day, kiss their loved ones, and head off to do their favorite job in the world - a vocation so completely immersive and rewarding that we gladly give up a part of ourselves to earn the trust and faith of our patients and fellow physicians.

And because I've been practicing medicine so long, I know I do not need a private, unaccountable, and irresponsible organization to tell me how to behave. I am better than that. After experiencing the busywork of the evolving MOC program and its lack of value for the time spent, I looked into the corporations who promote this exercise. I had the help of accountants and fellow physicians who were similarly upset and uncovered a vast array of hidden financial activities of the ABIM and their collaborators. There is so much financial corruption it is mind-boggling. The conflicts of interest that are never acknowledged and corrected make my stomach churn. The practice of medicine is better than this. Practicing physicians are better than this. We do not need some dystopic corporate Big Brother watching over us to assure we log into a computer every so often to enter data that can be used against us. We do not need webcams, video monitors, body inspections, keyboard tracking, and palm scans to prove we are honest and ethical and won't cheat on examinations. But this is what the ABIM has become: some new form of quasi-police state for monitoring physicians.

Working in fear is not what I want for medicine. It certainly is not how I want my youngest colleagues to grow up learning and practicing medicine. But the ABIM and their parent organization, the American Board of Medical Specialties (ABMS), seem to love fear, humiliation, and intimidation to get doctors to participate in their lucrative MOC program. It is sickening. It is also the height of hypocrisy for these organizations to claim to run an organization that attempts to "Choose Wisely" when that same organization funnels tens of millions of dollars for itself from hard working physicians so they can choose an investment portfolio with multi-million dollar condos, meet at swank meeting venues, pay for spousal travel fees and first class airfares as they preen themselves in front of media lights. The ABIM Foundation "created to define medical professionalism" for the public? Give it a break.

Rest assured I am not naive. I know how important this MOC program is to certain investors. As I peel back layer after layer of the interconnected workings of these ABMS member boards and the ACGME, I know how high this MOC program goes and how dark this MOC program and its tactics have become. I completely understand that these specialty board organizations have managed to wedge themselves into our new health care law that calls itself "Affordable," wedged there by undisclosed lobbying efforts funded by the very doctors whose blinded trust was violated beyond comprehension. Just because these corporations want to make a buck.

So let me take the stick a moment.  Let me be perfectly clear and I don't say this lightly. I'm sure I say this on behalf of tens of thousands of other hard-working, honest, and ethical physicians. We have had enough of the ABIM and the ABMS MOC program. It is time to end it - completely.  No more "modifications" to make this broken program "easier." No more "listening" to our concerns but continuing this failed experiment. No more "MOCA Minutes" that we have to turn our gaze from our patients toward the computer screen or iPhone even longer. Continuing the ABMS MOC that has proven itself to be morally and financially corrupt, and exceedingly expensive to physicians, patients, and our health care system is ill-advised for our profession. The conflicts of interests alone are worth hundreds of millions of dollars to the corporations that stand to make millions from physician assessment, yet we never hear a word about this from them ABMS or the ABIM on this reality.

I am better than how the ABIM and ABMS threaten to label me. I served this great country for twenty-six years as a physician with the United States Naval Reserves and I continue to work every day to make sure I do the best I can for my patients in this increasingly difficult health care delivery environment. I worked then and work now beside hard-working corpsman, nurses, administrators and technicians who don't want to rock the boat and just want to do what's needed to finish our job every day. These people and the patients I care for are why I go to work every day.

So I ask the leadership of the ABIM: "Why does the ABIM insist on placing a "scarlet A" on my reputation by labeling me a "Not Participating in MOC?"  Such labels are offensive. I participate in ACGME-accredited CME as required by my license to practice medicine in the State of Illinois. I am not a slacker. I teach residents and fellows, for goodness sakes. I am certainly not one who doesn't mind working hard. I am a proud practicing physician with more years of clinical experience and direct patient care than any of you.

Please don't be libelous and cast aspersions my way with your on-line labels. I've got much more important things to deal with. Stop pretending that you speak for "the public" and know what's best for them in health care when you don't even crack the door of an examination room or know what I do. Proceeding to take away my hard-earned reputation and ability to practice medicine because of your little label is both threatening and hugely upsetting.

Think about these words. Think about them carefully.

I beg of you and your affiliated private organizations to stop the labels.

The profession of medicine is better than this.

Your everyman,

Wes