Baron: "No Robust Evidence" for Maintenance of Certification

With the soft tinkling of gentle piano music playing in the background, Richard Baron, MD, President and CEO of the American Board of Internal Medicine (ABIM) and the ABIM Foundation, published a video on 20 May 2016 2014* attempting to justify the ABIM's high fees and requirement for "continuous" "Maintenance of Certification" (MOC) of physicians despite "no robust evidence" for the measure. Instead, he refers the viewer to the ABIM's "evidence summary" on their website and states "it's not randomized controlled trials but lots of what we do in healthcare is not randomized controlled trials. We do some things on a gut level of evidence, we do other things on a preponderance of evidence." (My detailed review of a portion of their "evidence" base can be found here.)

For $812,000 a year and countless lost hours of patient care and financial mismanagement, you would think he could do better than that.

Instead, Dr. Baron justifies the ABIM's actions on the basis that the ABIM was "preserving and protecting self-regulation at a time of change... otherwise it will be people, not physicians, who drive what all the expectations are for physicians." He claims the ABIM helps physicians "communicate to the public ways in which they communicate to the public that they have skills and that they have knowledge that other people don't have." As if physician's degree and training and countless years of experience and nights on call aren't enough.

According to Baron's own words, it appears the ABIM is little more than an exceedingly expensive marketing team working on our behalf.

But the real evidence of whom the ABIM has been working for can be found in the financial, political, and strong-man tactics used by the ABIM over the past forty years since "continuous" certification was conceived.

Dr. Baron never mentions the ABIM's secret transfer and cover-up of $55 million dollars taken from working physicians' test fees from 1990 to 2008 to create the ABIM Foundation and how the Foundation has moved a portion of those funds offshore.

Dr. Baron never mentions that the ABIM spent hundreds of thousands of dollars lobbying Congress to assure a perpetual money flow to the organization and hid these actions from the IRS to avoid paying taxes.

Dr. Baron never mentions that within all of their propaganda research the ABIM or ABIM Foundation never (once) studied the negative psychosocial effects of failing even one of their unjustified MOC examinations, nor the potential negative effects of cost saving initiatives promoted by the Foundation's "Choosing Wisely" campaign for the individual patient. He never mentions that  13.2% of clinically experienced physicians tested by their unproven metric failed their examination on their first try to the financial benefit of the ABIM and their partner professional societies.

Dr. Baron never mentions the his predecessor, Christine Cassel, MD, earned $10.88 million (nearly $9 million of that amount from ABIM diplomats and an amount that included spousal travel fees) during her 11-year leadership at the ABIM and ABIM Foundation. Nor does Dr. Baron mention Dr. Cassel's long-standing conflicts of interest with Premier, Inc or Kaiser Foundation Healthcare and Hospital system. Nor does Dr. Baron mention Robert Wachter, MD's conflicts of interest with IPC Hospitalist company that is now under federal investigation for overbilling Medicare.

Dr. Baron also fails to mention how serious they are about protecting their monopoly - that they even use Federal Marshals to raid homes and seize assets, call physicians cheaters, then collect an amount estimated to be $3 to $4.5 million in hush money to justify their program that has "no robust evidence." He fails to mention have 139 physicians were sanctioned because the ABIM felt doctors were the one cheating. He also fails to mention that the ABIM continues to track down and hunt physicians from as far away as Puerto Rico some four years later after publishing their one-sided account of details of their raid in the Wall Street Journal for their benefit "as a message and a deterrent."

But not all of the blame for the acceptance of MOC as a facade for physician competency rests with just the ABIM.  The American Board of Medical Specialties (ABMS) and the Accreditation Council on Graduate Medical Education (ACGME) that has quietly insisted on this credential for hospital and graduate training programs just so they can assure they receive more money from Medicare deserves blame as well. Their lack of leadership to expose the egregious behavior of the ABIM is at least as concerning, if not more so, for our profession and society.

-Wes

* Note, it appears this ABIM video was published in 2014, not 2016 as I first published. I regret the error and have corrected the post. Thanks to the anonymous commenter to corrected the date. Hopefully that same commenter will address the other issues brought up in this blog post as well.

ABIM Foundation Moves Assets Offshore

In a move that is more reminiscent of a sophisticated investment broker rather than a non-profit, tax-exempt 501(c)(3) corporation interested in promoting "medical professionalism," this year's tax records of the ABIM Foundation (which is affiliated with and shares the same address as the American Board of Internal Medicine (ABIM) in Philadelphia, PA) show the Foundation has total assets of $81,831,953 and moved some of its assets offshore to the Cayman Islands and Dublin, Ireland in the form of non-publicly traded investments.

Recall that the ABIM Foundation was created by secretly funneling $55 million in physician testing fees from the ABIM to their undisclosed "American Board of Internal Medicine Foundation" (later renamed the "ABIM Foundation" in 2009) from 1989 through 2008. Only after the name change with the IRS in 2009 was the ABIM Foundation revealed publicly.

According to this most Form 990, not only does the ABIM Foundation continue to hold their $2,356,267 Philadelphia condominium bought with practicing physician testing fees, we now find they have systematically transferred $6,516,936 of our fees offshore to ten different funds (nine in the Cayman Islands totaling $6,042, 336 and one in Dublin, Ireland totaling $474,600).

Meanwhile, younger physicians can't afford the fees for certification and re-certification mandated by the ABIM. We should also note that the President and CEO of the ABIM and ABIM Foundation,  Richard Baron, MD, pocketed a cool $812,006 last year without night call or having to subject himself to any of the tough discussions with patients.

The Internal Revenue Service (IRS) needs to immediately revoke the non-profit status of the ABIM and its Foundation.  Practicing physicians now realize these organizations are more about protecting and growing their assets than benefiting physicians, their patients, or the public.

-Wes

Thuggery and Strongman Tactics Grow at the ABIM

There's a wonderful social media principle that might just stop Maintenance of Certification: the Streisand Effect.

The Streisand Effect is the phenomenon whereby an attempt to hide, remove, or censor a piece of information has the unintended consequence of publicizing the information more widely, usually facilitated by the Internet. And when the American Board of Internal Medicine (ABIM) resorts to thuggery and strongman tactics against a physician, this might just come back to bite them in the private parts.

Imagine, you are a physician and your regulatory agency strips you of your privileges to practice medicine without due process. Then imagine the same regulatory agency refuses to release information pertitent to your defense for months and months.

Then imagine, that same self-appointed regulatory agency decides to subpoena you for additional information for their case against you on the busiest travel weekend of the year with only 17 days notice (usual and customary time is 30 days notice). Then, after your attorney politely tries to plea for an adjustment of dates, that same regulatory agency that seems unable to provide information to you, basically says to your attorney: "Your client may choose to disregard it - and the sanctions such disregard will bring - at his own peril."

Welcome to the legal tactics of the ABIM that is feeling the heat of Dr. Salas Rushford's discovery requests and their upcoming meeting with the judge in the case on 3 June 2016.

In 2015, Dr. Salas Rushford had a  gross income $69,725 and a net loss of $1875 in 2015. Compare this amount to the $10.88 million Christine Cassel, MD earned from the ABIM and her cronies during her stint as President and CEO at ABIM from 2003-2013. According to their recently-released tax forms for fiscal year 2015, the ABIM recieved revenues of over $57,620,000 in its fiscal year ending Jun 30, 2015 and Richard Baron, MD (the current President and CEO) pocketed a cool $812,000.

One thing I know. The Internet doesn't like bullies that are trying to hide something from the public (just ask Barbara Streisand).

To me, this young man who has been accused of wrongdoing by the ABIM deserves a fair shake. Imagine what would happen if every US physician, internist, or medical student donated $1, $5 or $10 (or more) to his efforts - it would be a game-changer for the ABIM and for working physicians.

Consider donating to Dr. Salas Rushford's defense and countersuit of the ABIM here.

After all: bullies suck.

-Wes

P.S.: Consider sharing this post with friends.

A Critical Review of ABIM's Recent MOC Changes

In its never ending push to preserve the lucrative Maintenance of Certification (MOC) revenue stream, the American Board of Internal Medicine (ABIM) once again announced a "new option" to complete their corrupt MOC program to beginning January, 2018 (corresponding press release here).

The real details of the new option were sketchy and only promised the following:

• Take the form of shorter assessments that doctors can choose to take on their personal or office computer—with appropriate identity verification and security (emphasis mine)—more frequently than every 10 years but no more than annually;


• Provide feedback on important knowledge gap areas so physicians can better plan their learning to stay current in knowledge and practice and;


• Allow physicians who engage in and perform well on these shorter assessments to test out of the current assessment taken every 10 years.

What was not mentioned was the following:

• What this "new pathway" will cost and


• What "identify verification and security" tactics will be proposed to maintain control of the American Board of Medical Specialties' (ABMS) proprietary MOC program.

Let's break these two unmentioned issues down, since they are increasingly at the crux of the corruption at the ABIM and ABMS.

COST

While I do not know what the "new pathway" will cost, we should note that the changes promised by 2018 only provides another way doctors can provide funds to the ABIM. Their proposed "change" does not remove the requirement for the clinically unproven re-certification MOC metric or its secure examination. Importantly, the new proposal does not address prior fraudulent tax filings or secretive funding of their ABIM Foundation from physician testing fees. What we can be assured, however, is the ABIM is desperate for cash to fund its operations and protect its tests. Given what we now know about the ABIM financial burn rate, it is safe to estimate that the ABIM needs to extract at least $200 per year from each and every internist in the United States (and maybe $300/year from specialists) to maintain their current cash flow.

Look for cost of ABIM's MOC program to be $200-300 per year for physicians irrespective of the various "options" or "pathways" the ABIM constructs to fulfill its MOC re-certification requirement.

TEST SECURITY

This is where things get interesting.

Test security is everything to the ABIM. Without it, anyone could replicate their process or "steal" their copyright-registered health information. Few details of how the ABIM plans to perform "identity verification and security" are forthcoming with their latest press release. But one thing we know, the ABIM will continue to have physicians entrap themselves in contract language promising secrecy and to observe obscure "pledges of honesty" before performing any MOC testing.

How might they protect their tests? Well, let's look at one of the test security options available to ABMS from a little-known test security firm, Kryterion. It seems Kryterion would monitor physicians who opt for the "at home" option using a webcam and microphones. According to Kryterion's Terms of Service, physicians will be asked to scan the room using their webcam before sitting before the computer with a live proctor on the other end of the line:

The Kryterion Certified Online Proctors (KCOPs) are trained to watch and listen for any unusual behaviors from the test taker. For example, unusual eye movements, removing oneself from the field of vision and making atypical noises are all noted and a behavior alert is sent to the test taker, depending on the business rules you set. The test taker is required to acknowledge the alert before continuing with the test and the KCOP resumes or stops the testing process, depending on the action you’d like us to take.

What legal action does the ABIM or Kryterion plan to invoke if they feel my eye movements are questionable? Yet this is the reality of "secure testing" that the ABIM might utilize. And as we've seen, it appears the ABIM is all to happy to deploy their lawyers on physicians at the slightest hint of a "testing irregularity" to extract even more revenue from physicians and to protect their monopoly.

Sorry. but I don't want Big Brother in my house. If this is how the ABIM plans to assure I'm compliant with my continuing medical education just so they can extract more revenue from me under the threat of litigation, they've got another thing coming.

ABIM has still not addressed its financial transgressions, multiple corporate conflicts of interest, high salary structure, and fraudulent tax filings. Unless and until these issues are addressed, look for the practicing physician community to avoid further interaction with the corrupt ABMS MOC program irrespective of any further changes to their MOC program the ABIM might propose.

-Wes

Fearing Exodus: American Board of Medical Specialties Issues Statement on Oklahoma

Fearing a mass exodus of physicians from the lucrative ACGME-mandated Maintenance of Certification (MOC) program, two member organizations of the ACGME, the American Board of Medical Specialties (ABMS) and the American Osteopathic Association (AOA), recently issued statements of "disappointment" or "promising to innovate."

The ABMS stated they were "disappointed" on the passage of the Oklahoma law outlawing the use of the ABMS MOC program for board certification, physician hospital credentialing, or insurance company payments and were "committed to improving their programs for physician certification and assuring that participation in MOC provides physicians with meaningful improvement opportunities." No mention of how they might cut the cost of their "commitment" to physicians was made.

The AOA's statement, issued just after the National Board of Physicians and surgeons open its credentialing process to osteopaths, "promised to innovate" so they could reach their "Rooftop Goals." Too bad the AOA still doesn't seem to understand that their statement promotes just what physicians don't need: another bureaucratic building project.

Neither statement issued by the ACGME member organizations provide convincing arguments of sincerity to practicing physicians that have seen their hard-earned cash squandered by these organizations and have failed to truly prove the clinical relevance or need for re-certification of any kind. Further, no accountability for the financial mismanagement, strongman tactics used by ABMS member boards to assure physician payments into this unproven metric, and fraudulent tax filings by member boards of the ABMS has yet to take place.

This outdated ACGME physician MOC re-credentialing system built on political and corporate cronyism is being rendered obsolete by the presence of real competition to the status quo by the National Board of Physicians and Surgeons' credentialing process that is credible, more affordable, and financially transparent. There is simply no going back.

Good riddance MOC.  Trust me: you won't be missed.

Nor will those who've made a living for themselves promoting this very broken and highly conflicted ABMS MOC program.

-Wes

NEJM Fails to Publish Comments Critical of ACCME Perspective Piece

Screen Shot was taken 4/19/2016 of NEJM web page showing undeclared conflict of interest
(Click to enlarge)

I find it interesting that my comment to the New England of Journal of Medicine pointing out the undisclosed conflict of interest highlighted above and mentioned two days ago on this blog has yet to be published in the comments section appended to the article. Authors must disclose their financial conflicts. Why don't the editors of the New England Journal of Medicine?

It appears the cronyism displayed by the ACGME in support of the American Board of Medical Specialties Maintenance of Certification (MOC) product also extends to our "finest" medical publications.

Caveat emptor.

-Wes


Addendum 07:50AM CST: 9 Comments (including mine) now appear on the NEJM website.

Rethinking Our Medical Education and Publishing Bureaucracy

Medicine has an image problem.

On one hand, medicine is full of wonder: incredible technology, incredible innovation, and incredibly bright people.

On the other, medicine is full of avarice, full of greed, and full of waste, much of it by the very same folks who bring us all that medicine has to offer: the Accreditation Council for Graduate Medical Education (ACGME).

The ACGME is an incredibly rich and powerful organization in medicine. It is comprised of the American Medical Association, (AMA), the American Board of Medical Specialties (ABMS) and its 24 member boards (including my "favorite", the American Board of Internal Medicine (ABIM)),  the American Hospital Association (AHA), the Association of American Medical Colleges (AAMC), the Council of Medical Specialty Societies (CMSS), the American Osteopathic Association (AOA), and the American Association of Colleges of Osteopathic Medicine (AACOM). Collectively, member organizations of the ACGME represent an annual burn rate of almost $1 billion dollars for medicine (Latest annual income figures from Guidestar.org: AMA ($261,328,052), AHA ($126,339,392), ABMS and its 24 member boards (Approximately $300,000,000; $54,454,584 for the ABIM alone), CMSS ($967,541), AOA ($44,376,054), AACOM ($10,855,122)).

As part of the ACGME's "Vision" statement, they "imagine a world" where residents and fellows are "prepared to become Virtuous Physicians who will place the needs and well-being of patients first."

This is where the ACGME's "vision" clashes with reality.

Right now, the average "Virtuous Physician" has a median debt load of $180,000 before they graduate from medical school and patients are experiencing bankruptcies from health care as our Medical Education Establishment dines at the Four Seasons and takes a few more reps in the gym.

The ACGME and their kin are still living in the world where first class air travel, memberships at health clubs, and $2.3 million condominiums with chauffeur-driven Mercedes S-class town cars are the norm. The ACGME seems blind to the irony of serving Virtuous Physicians while having one of its core values the "Engagement of Stakeholders" like their "friends in accreditation" at the Accreditation Council for Continuing Medicine Education, the Joint Commission on Accreditation of Hospital Organizations, the National Board of Medical Examiners, and the Federation of State Medical Boards, who foist educational programs like their unproven and wasteful Maintenance of Certification (MOC) program to fund their largess.

So it should come as no surprise that even our most "prestigious" academic journals like the New England Journal of Medicine (NEJM) are joining in on the fun. This week they permitted a promotional "perspective" piece entitled "What Do I Need to Learn Today - the Evolution of CME" to be published by the head of the Accreditation Council for Continuing Medical Education (ACCME), Graham T. McMahon, MD. Like other accreditation organizations within the ACGME, Dr. McMahon enjoys paid first class airfare and health club membership while promoting the legitimacy and expense of the costly and unproven ABMS MOC program that finds itself in a whirl of ethical controversy already. Meanwhile, the NEJM is selling its expanded and remarkably expensive  "Knowledge +" MOC educational product without ever acknowledging this conflict to its readers in this week's issue.

Our tired and inefficient "non-profit" bureaucratic medical education system better wake up soon to the new reality in medicine: practicing physicians and their patients are feeling the adverse effects of all those health clubs and first-class airfares.

In this time of serious cuts to patient care budgets in medicine, it's time our Medical Education and Publishing Establishment starts "learning what it needs to do today" besides stumping for wasteful "CME" programs and harvesting its budget from those who are finding it harder and harder to believe that our expensive medical education bureaucracy has their best interests in mind.

-Wes

Propaganda Machine: How ABIM Spins Its Survey Results

As it continues to spiral out of control, the American Board of Internal Medicine (ABIM) issued a press release telling practicing physicians what they've "learned" from "key findings from a representative sample" of internists.

Sadly, how their "representative sample" of internists' survey responses was collected and reported for this press release is telling.

Reviewing the methods used for the survey collection, we see ABIM's "ALL DIPLOMATE" survey was really created from less than 0.2% of all internists they polled. (360 respondents of 196,867 emails sent) and the results were "weighted" from a select subset of the internists whom they repeatedly queried to assure an acceptable response rate, introducing substantial selection bias).

What the ABIM continues to ignore is the overwhelming rebuke of the MOC process from over 23,000 physicians in 2014 and a similar survey result from the membership of the American College of Cardiology.

Propaganda masquerading as flawed survey results that are obtained by unaccountable organizations with large conflicts of interest with the physician testing/quality industry has no place in the practice of medicine. Press releases such as this one issued by the ABIM are both irresponsible and misleading. By issuing this press release, the ABIM demonstrates its blatant disregard for the best interests of physicians and patient care just so they can maintain their lucrative MOC program.

-Wes

Medical Societies to ABIM: What Gives?

In an unusual show of solidarity, twelve membership societies sent a carefully worded letter to Richard Baron, MD, President and CEO of the American Board of Internal Medicine (ABIM), asking him, basically, WTF?

For the past year, ABIM has actively solicited feedback from and encouraged the internal medicine community to engage in co-creating an MOC (Maintenance of Certification) program for the future. Despite these interactions—and even though our societies dedicate considerable resources to helping our members complete the MOC process—we are struggling to understand ABIM’s plan for re-engineering MOC to reflect the changing nature of medical practice.

However well intentioned, the overall vision, philosophy or strategy of ABIM’s changes to MOC are not clearly stated. Further, the lack of a shared vision makes it more difficult and costly for societies to adjust to changes made by ABIM that are implemented with little input from or notice to the societies.

While this letter might be "well-intentioned," it still buys into the notion that all MOC needs is to be properly “fixed.” These leaders completely ignore all of the financial improprieties that are part and parcel of the ABIM and MOC. They should be calling for its demise, or ensuring that MOC remains forever truly voluntary,by decrying any future linkage to licensure, reimbursement from payors, or hospital privileges, or they should join the mass noncompliance bandwagon.

Let's hope, however, that this letter represents the first crack in the ABIM's MOC "foundation." It is time membership societies stop beating around the bush and acknowledge how deeply corrupt and flawed the MOC program has become and understand that their membership is ready to jump ship if they don't.

They have a choice to make: ally with their practicing physician membership or ally with ABIM. Which will it be? I would suggest they start working on their next letter explaining to the ABIM what is actually happening.

-Wes

How the Feds Plan to Federalize MOC

From the Commonwealth Fund's Washington Weekly Health Policy Week in Review:

March 31, 2016 -- Health professional societies and consumer groups have asked Medicare to tread carefully while overhauling its system for paying doctors, raising concerns about an agency suggestion to include guidelines from a campaign that seeks to curb the use of often unneeded procedures and treatments.

Medicare officials are awaiting White House clearance of a draft rule designed to tie payments for doctors to judgments about the quality of care they provide. The Office of Management and Budget has been reviewing this proposal since March 25. The Centers for Medicare and Medicaid Services (CMS) rule would carry out the changes mandated in last year's congressional overhaul of Medicare physician payments (PL 114-10).

CMS last year sought public comments on how to design a new payment. In a request for information, the agency raised myriad questions about how the so-called Merit-Based Incentive Payment System program for doctors could be designed.

CMS asked if there might be some benefit to weaving in new system measures from a 2012 initiative known as the Choosing Wisely program, which asked doctors to identify commonly used medical tests, treatments and procedures that may be unnecessary for many patients. (Emphasis mine) More than 70 medical specialty societies have since released recommendations as part of the campaign.

Practicing physicians and patients should understand how the ABIM and its corrupt Foundation planned to federalize Maintenance of Certification (MOC), an unproven quality metric, as a pay-to-play money stream using the soon-to-be-deployed CMS "Merit-Based Incentive Payment System." By stealing over $70 million of physician testing fees, they created the ABIM Foundation and secretly lobbied Congress to assure that participation in MOC would become tied to physician pay, incentivizing physicians to participate in MOC. It increasingly appears Richard Baron, MD was instrumental at forwarding this model when he served the "Seamless Care Models Group" at CMS.

Senior citizens should be very concerned that top-down measures created from the ABIM Foundation's Choosing Wisely® campaign are really in their best interest.

After all, Choosing Wisely®, the ABIM, ABMS, and the ABIM Foundation are all about the money for these unaccountable non-profit organizations.

-Wes

 Image reference: The Heartland Blog

Pivoting

It was Friday, the weekend not far away. It always seems that hospital people step lightly on Fridays, hurrying to get work done in anticipation of a few days off, the kids' soccer game, a concert, a dinner out. Upbeat, if you will.

So when the elevator door opened and he walked in, it was very different. I recognized him immediately for I had cared for him years before.  Gentle, kind man, usually with a smile, a polite nod. He was always with his wife. His a heart rhythm problem as I recalled. Now he and I alone. I struggled to remember his name.

His look was very different that I had remembered.  This time, the smile was very brief, tired. His face and frame much thinner. He looked away, fumbling for the elevator button, found it, and leaned back against the wall.  There, peeking out from beneath the right-hand side of his shirt were the edges of a bag and tubing. The diagnosis and prognosis now plainly coming into view.

It was hard to speak, not knowing what to say, so we just waited together, feeling the elevator travel its one short floor. Suddenly, the door opened again, our time together too brief, our earlier time so trivial in comparison. His journey much different now. I was lost for words but said goodbye. I could tell his mind was elsewhere. Anywhere but Friday.

It was so brief, telling, humbling, and real.

I'll never forget, sir.

God speed.

-Wes

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