Lewis R. First, MD, MS, David A Gremse, MD, and Joseph W. St. Geme, III, MD join forces to publish their opinion piece entitled "Maintenance of Certification - A Prescription for Improved Child Health" in JAMA Pediatrics on 27 Feb 2017. The only conflicts of interests they disclose to the public are their various associations with their institutions and various professional medical organizations with which they have been affiliated with over the years. As is typical for many of the JAMA publications published by the American Medical Association (AMA), they failed to disclose their ties to the pharmaceutical industry or the fact that annual Maintenance of Certification (MOC) revenues almost matches that of initial certification for the American Board of Pediatrics (ABP) every year.
Lewis R. First, MD, MS advertises himself as restricting this practice to inpatients only on his University of Vermont website. Such a practice is hardly representative to the vast majority of pediatricians in the U.S. who primarily care for outpatients. It would not be surprising, then, that the hours required to participate in MOC would seem trivial to one who works in a sheltered inpatient workshop. He never mentions that he "won" the Joseph St. Geme Jr. Leadership award created in the honor of the father of his co-author, Joseph St. Geme III, MD, by the Academic Pediatric Association, American Academy of Pediatrics, American Pediatric Society, the Association of Medical School Pediatric Department Chairs (AMSPDC), the Association of Pediatric Program Chairs and the Society for Pediatric Research. To his credit, Dr. First does disclose the fact that the is chair of the AMSPDC Education Committee, member of the ABP Research Advisory Committee, member of the AMSPDC Planning Committee, editor of Pediatrics, and past chair of the National Board of Medical Examiners, so his enthusiasm for lifelong repeated testing of physicians is at least understandable as part of the vast network of Accreditation Council of Graduate Medical Education (ACGME) certification member organizations' fixation with lifelong testing and revenue generation.
David A Gremse, MD disclosed that he is chair of the department of pediatrics at South Alabama University, chair-elect of the ABP, member of the AMSPDC Planning Committee, and past member of the AMSDPC Board of Directors. He failed to mention that he was secretary-treasurer of the ABP and a pediatric gastroenterologist.
Finally Joseph W. St. Geme III, MD discloses he is chair of the department of pediatrics at the Children's Hospital of Philadelphia and the University of Pennsylvania, associate chair of the AMSPDC Research Committee, immediate past chair of the ABP (often with first class travel from the ABP) and Dr. St. Geme failed to mention his advisory role with PureTech Health, a "cross-disciplinary biopharmaceutical company."
Why mention these conflicts? Because their article is filled with misinformation.
First, board certification for pediatricians in America is no longer "voluntary"as these authors claim. It is disingenuous for them to claim board certification is "voluntary" when the next sentence they note "Hospitals increasingly require board certification for medical staff privileges credentialing bodies and payers often require board certification for participation in provider networks and for reimbursement."
Two "Quality Improvement" projects are mentioned by the authors that they claim can be used to justify Maintenance of Certification to all general pediatricians in the United States. These studies were less than robust and filled with uncontrolled endpoints. For instance, one involved a QI project with the "ImproveCareNow Collaborative" funded by many pharmaceutical companies and the American Board of Pediatrics Foundation that actually admitted in their paper:
First, board certification for pediatricians in America is no longer "voluntary"as these authors claim. It is disingenuous for them to claim board certification is "voluntary" when the next sentence they note "Hospitals increasingly require board certification for medical staff privileges credentialing bodies and payers often require board certification for participation in provider networks and for reimbursement."
Two "Quality Improvement" projects are mentioned by the authors that they claim can be used to justify Maintenance of Certification to all general pediatricians in the United States. These studies were less than robust and filled with uncontrolled endpoints. For instance, one involved a QI project with the "ImproveCareNow Collaborative" funded by many pharmaceutical companies and the American Board of Pediatrics Foundation that actually admitted in their paper:
'Third, improvements in outcome occurring over time could have taken place independent of changes in care delivery as part of the network. No external comparator group was available to help with this determination. However, not all centers showed improvement, and the improvement we observed took place over a relatively short period of time during which no new therapies were introduced into routine clinical practice. Finally, the processes we measured may not be directly responsible for the observed improvement in remission."In fiscal year 2015 (from the 2014 IRS Form 990) - the latest tax form the public can review - the American Board of Pediatrics earned $10,644,504 from the Maintenance of Certification program while their senior executives enjoyed first class airfare and paid spousal travel fees. They paid their former President and CEO who worked only 8 hours per week, James Stockman, III, MD, $793,991 - more money than their current highest paid employees, Executive Vice President of Credentialing and Exam Administration ($675,055) and President and CEO ($624.001). By comparison, one source cites the current median pediatrician salary in the US in 2017 as $187,376. Might these facts be more important to explain the authors' enthusiasm for promoting MOC than the flawed studies they cite regarding MOC's importance to patient care?
These authors need to understand the days of pulling the wool over working physicians' eyes by publishing opinion pieces in journals sponsored by the AMA that has refused to end MOC despite recommendations made by their own House of Delegates are over. These continued efforts to justify MOC without acknowledging the programs many flaws and financial conflicts of interest must end. While physicians who chose to continue to work have little choice but to participate in MOC currently, efforts are underway across the nation to end MOC for all subspecialties on the basis of its discriminatory practice against younger physicians and because its adverse effects on physicians and their patients have never been studied (or even acknowledged) by these organizations that profit from the program without legitimate independent oversight.
-Wes
