Saturday, December 03, 2016

Chicago's Cold December Game Plan

In June 2016, "Chicago" had a problem. A small renegade group of doctors had uncovered some dirty secrets about the Chicago-based American Medical Association's (AMA) subordinate organizations, the Philadelphia-based American Board of Internal Medicine (ABIM) and its Chicago-based mothership, the American Board of Medical Specialties (ABMS). Action was needed. It would have to be invisible to the lay public. It would take a slick, well-coordinated game plan. It would also take some money. People don't mess with The Chicago Machine.

The major players assembled in the room to get some background on the problem. They'd have to understand the depth and breadth of what was known before they could structure a counter-offensive using every option at their disposal: ties to leadership at medical journals, public relations groups, finely-tuned email lists, and buy-in from like-minded medical societies who needed the AMA's political clout on Capital Hill - the works.

There they were, all the major players in one room, looking less than happy to be there to hear me (of all people) and my colleagues who were rattled to our core at what had transpired in the bureaucratic House of Medicine for all these years.

The room took a while to fill at first, but as time for the presentations approached, they were standing room only. The early attendees looked a bit worried. Those arriving later appeared less concerned for time and money were on their side. Many of the dignitaries were introduced to me by Charles Cutler, MD, from the Pennsylvania Medical Society who had invited a few of us to attend: the President of the Board of the American Medical Association (AMA), the Executive Vice President of the American College of Physicians (ACP), members of some of the medical national medical societies. All in one room to hear me and Mr. Charles Kroll, a certified public account, give our little talks (seen here and here).

They listened intently. They asked no questions. They needed to think. Poor Lois Margaret Nora, MD tried to come to the microphone to defend her actions feebly. It was clear to them she was a liability. More senior veterans at this game would have to step in.

It was a time to marshall the considerable resources of Chicago's medical establishment's senior spin experts: the American Medical Association and their collaborators at the Accreditation Council of Graduate Medical Education. They knew they could do this. After all, it had been done before when Thomas Brem, MD testified before Congress 30 April 1969 after he was paid from "Special Account No. 4" maintained by tobacco lobbyists. (See US District Court for the District of Columbia, United States of America v. Phillip Morris USA, Inc, et al., Case 1:99-cv-02496-GK Filed 8/17/06. Page 174 of 1683. Available at: ) We are beginning to see telltale signs of a similar well-coordinated plan to forward a separate, non-patient care agenda against the practicing physicians who had grown restless.

First, the leadership recognized that change was needed. Dr. Steve Weinberger, Executive Vice President of the PhiladelphiaChicago-based ACP had heard enough and wisely wanted out. He could see the writing on the wall and had given plenty of time, energy and effort to the ACP. He announced his retirement. Lois Margaret Nora, MD, JD wanted to stay on but knew she couldn't. She, too, announced her retirement but was asked to stay on until the end of 2017 to help "smooth" the transition. Or to be a fall guy. (This is Chicago, remember.)

Second, a "go live" date had to be set. 1 December 2016, just before the new US President took office, would be perfect.

Third, an article would have to appear in the New England Journal of Medicine without an accompanying rebuttal article reaffirming the importance of MOC and how hard the ABIM are working to modify it. This article would serve as the "starting gun" for all that was to occur next. In turn, Richard Baron, MD would serve, once again, as sacrificial lamb and receive a "special fee" above and beyond $800,000-a-year ABIM salary in return for "publishing" the article (see the article's disclosures). Perhaps this was because Dr. Baron and Braddock didn't write a substantial part of the it, we can't be sure. Practicing physicians would be appalled by the piece containing many non-scientific assertions. It didn't matter. They liked the use of the example where anyone can become an ordained minister online to justify ABIM's unproven maintenance of certification program as a "solid," and "valuable" standard. No one would dare comment that the ABIM's secret, black-box antiquated questions (held secret behind a thin veil of threats of prosecution for leaking those "secrets") were any more "solid" or "valuable" than those "internet based" ministry credentials. Especially if the New England Journal of Medicine didn't allow comments. Furthermore, Baron and Braddock's must make board certification sound as though it was "always" supposed to be time-limited. No one must know that Walter Bierring, MD, the unpaid organizer and first officer of the ABIM never intended the test to become a mark of adequacy to practice medicine rather than an optional sign of excellence. (See: Bierring WL. The American Board of Internal Medicine. Ann Intern Med 1937 10(12):1746-1751.) Denis M. O’Day, MD and Mary R. Ladden, BA's peer-reviewed article on the history of board certification, published the criteria of the American Board of Medical Specialties member boards that stated their voluntary nature and the requirement their tests and programs NOT be tied to the ability of a physician to practice. And practicing physicians certainly should not know about the first recertification test, taken by internists on 26 October 1974,  recommended that "no one should lose their primary certification as a result of the examination."(Meskaukas JA and Webster JD, The American Board of Internal Medicine Recertification Examination: Process and Results. Ann Intern Med 1975 82: 577-581). To provide cover to these facts, Drs. Baron and Braddock must use ABIM's usual strongman tactics and threaten "escalating consequences for unsatisfactory performance over time" in their piece. And so it was.

Fourth, that evening after the New England Journal of Medicine article appears and people have a chance to digest it, a mass email must be sent to all members of the American College of Physicians announcing their "new pilot MOC program" in coordination with the American College of Cardiology (ACC) and the ABIM that promised to "ease the burden and increase the relevance" of the ABIM MOC process. Specific details like time frame, cost, and methods must not be disclosed, however.

Fifth, more pressure must be applied. The AMA and the Committee of Medical Subspecialty Societies (based in Chicago) will coordinate with the American College of Cardiology to use the ACC's considerable financial and political clout to re-introduce the previously-suspended Part IV "Practice Improvement and Safety Modules" via an email to its members the following day. After all, it took a lot of lobbying to assure Part IV of the ABIM MOC program was woven into the new physician "value-based" payment scheme called the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). For their help, the ACC should be granted "Program Sponsor" status of the ABMS Multi-Specialty Portfolio Approval Program. The message to lowly physicians MUST be: "Participate in MOC or don't get paid, sucker!"

It all seemed like such a good idea at the time. Those pitiful physicians wouldn't stand a chance. The Chicago Machine was in charge. It would be easy to roll over those quiet, unassuming doctors with this plan once and for all!

And then the unimaginable happened. An unanticipated Presidential candidate won the election. Like BREXIT, the medical political establishment were caught completely off guard. None of them could imagine it happening. And even though larger and larger numbers of doctors weren't buying the propaganda of the Affordable Care Act (ACA) and MOC any longer, the AMA, heavily invested in the ACA construct, stuck to their plan to strong-arm physicians with these MOC "modifications" anyway.

Practicing doctors and their patients have been waking up to what the medical establishment have done to the middle class and the practice of medicine in America. We've been slow to catch on thanks to the realities and time required for this thing called patient care, but the reality is profound.

Thanks to Maintenance of Certification, practicing doctors are not so easily fooled any longer and with a new sheriff in town, the Machine might just have to go to an alternate Plan B in January 2017 or face some serious consequences.


Thursday, December 01, 2016

Knowing What We Don't Know

This week, Richard Baron, MD and Clarence H. Braddock, III, MD, MPH, both paid staff of the independent and unaccountable American Board of Internal Medicine (ABIM), received more (free?) advertising space in the New England Journal of Medicine to publish their perspective piece entitled "Knowing What We Don't Know - Improving Maintenance of Certification." While my readers are welcome to read the piece, rest assured there is nothing new there except more unsubstantiated excuses to prop up this expensive, wasteful, and corrupt enterprise.

I believe these authors should be very clear that physicians are quite aware of "Knowing What They Don't Know" about Maintenance of Certification (MOC), the ABIM, their collaborators at the American Board of Medical Specialties.

Here's what we don't know:

1) Who wants Maintenance of Certification so badly that Drs Baron and Braddock are allowed to publish their promotional piece in the New England Journal of Medicine after US physicians have overwhelmingly voted to end MOC immediately in the June 2016 AMA House of Delegates meeting? We can hypothesize many possibilities:

  • The New England Journal of Medicine itself, who stands to profit from their Knowledge+ educational product for MOC preparation.

  • The ACGME and its many members like the ABMS member boards, the AMA, the American Hospital Association (AHA), and Association of American Medical Colleges (AAMC) who stand to profit directly from the program and or by the anticompetitive practices it creates.

  • The multibillion dollar physician testing industry (Pearson, Prometric, etc.)

  • The major players in the US medical insurance industry (Blue Cross Blue Shield, Unitedhealthcare, Aetna, Cigna, etc.) who want to reduce their costs for expensive experienced physicians in lieu of physicians extenders, using the "National Committee on Quality Assurance" as their scapegoat?

  • Or perhaps, it's all of the above?

2) Why did the ABIM feel it could funnel $55 million of diplomate testing fees from 1989 to 1999 to fund its secretly-created (and undisclosed until 1999) ABIM Foundation?

3) Why has the IRS not investigated the repeated ABIM Foundation Form 990 tax fraud regarding the date and state of its Foundation's origin and the non-disclosed lobbying activities?

4) Why has the ABIM Foundation moved over $6.5 million of diplomate test fees offshore to the Cayman Islands in 2014?

5) Why were lawyers from ABIM's legal team, Ballard Spahr, and Ariel Benjamin Mannes (their two-time convicted felonious "Director of Investigations") allowed to accompany Federal Marshals during a home raid of two physicians homes that had developed an ACGME-accredited board review course? What agreement (monetary or otherwise) exists between the Dr. Rajender Arora (the director of the course) and the ABIM?

6) Why has the antitrust case filed by the Association of American Physicians and Surgeons against the ABIM, originally filed in New Jersey and then moved to the United States District Court for the Northern District of Illinois (Docket No. 1:14-CV-2705) on 4/23/2013, languished unaddressed in the Northern Illinois court docket since 7 Jan 2015?

These are just a few of the things practicing US physicians "Know What We Don't Know."

Rest assured, we won't rest until we find out and bring the corrupt MOC program to an end.


Tuesday, November 29, 2016

On Pediatricians' Golden Pond

Satellite view of the
American Board of Pediatrics' 2.8-acre Pond
Pediatricians in the United States can thank the American Board of Pediatrics (ABP) and their time-limited "Maintenance of Certification" (MOC) program for the purchase of their very own "Golden Pond."

Surely, US pediatricians need a 2.8 acre pond. Where else would they be able to sit and contemplate their past careers as academics as the sun sets slowly over the horizon? Everyone knows that when properly maintained, ponds provide a peaceful venue for a leisurely stroll or for the opportunity to toss a hook and bobber in search of a bluegill or large-mouth bass. No doubt these activities are critical pediatric health care quality and safety skills.  Thanks to the leadership and "medical professionalism" portrayed by the ABP leadership over the past 30 years or so, all US pediatricians can feel proud to know that every bit of their $1200 "continuous MOC" fee is going to the support of this worthy landmark.

Surely pediatricians worldwide know about the pond they purchased, don't they?

Perhaps not.

Ponds, you see, don't typically make the internet websites of the American Board of Medical Specialties member boards or IRS Form 990 tax forms (except as "land and buildings"). Few would think of lands and buildings as including a pond, but for the American Board of Pediatrics, it does. In fact, their pond (picture) rests on a consortium of properties adjacent to 111 Silver Cedar Ct, Chapel Hill, NC that span over 9.3 acres and comprises two separate buildings (201 Silver Cedar Ct is also owned by the ABP). Unfortunately, it's hard to imagine how a pond adds to the safety or quality of pediatric care in the United States. Instead, we can only surmise that a pond is an important asset to the American Board of Pediatrics because it improves their property value and provides important tax revenues and political influence to the state of North Carolina and beyond.

And who better to pay for that pond and annual taxes than unsuspecting US pediatricians increasingly forced to comply with Maintenance of Certification?

No one was supposed to know that the first recorded deed of these properties coincided in time with the creation of Maintenance of Certification, 1986, according to North Carolina real estate records. No one was supposed to know that as President and Advisor to the American Board of Pediatrics, James A. Stockman, III, MD, earned $1,307,415 in Fiscal year 2012 before his retirement package of another $2.4 million kicked in the next year, either.

And let's not forget the many cars that pediatric diplomates helped Dr. Stockman purchase during his tenure at the ABP.

Here are Dr. Stockman's own words, published in Pediatric Annals:
Dr. Shulman: If you had not chosen medicine, which field would you have chosen?

Dr. Stockman: I’d be a car salesman.

Dr. Shulman: I suppose that’s not a surprise. You are quite the collector of classic cars. Your wife once told me that during a 5-year period in Chicago you bought and sold 40 or 50 separate autos. And that was before eBay!

Dr. Stockman: Yes, my collection is very diverse. Among them are a ’56 Cadillac, a Sting Ray, a Triumph, and a twin turbo engine Porsche 911. I love driving them on all the country back roads here in North Carolina. There is life beyond academe!…
Life beyond academe indeed.

Especially when one considers that Maintenance of Certification (MOC) was Stockman's "most far-reaching  achievement" of his 20-year career with the American Board of Pediatrics (according to the well-funded Illinois-based American Academy of Pediatrics that has an extensive lobbying presence on Capitol Hill).


Monday, November 28, 2016

Staying Prepared at Christmas

Good Samaritan cardiologists never know when they (or someone else) might need 81 mg of aspirin  this holiday season.  Here are some fancy cufflinks (seen in clinic today) that every cardiologist should consider:


PS: I have no commercial interest in this gift idea. :)

Monday, November 21, 2016

Nickle and Dimed

The American Board of Anesthesia's heavily-promoted "MOCA Minute" had some not-too-flattering details exposed recently.

First, was this letter sent to a diplomate who had not purchased their MOC offering:

Second, was the cost and the requirement to renewed requirement for physicians to participate in previously-suspended Part IV of the ABMS MOC program:

Here's the math: $210 per anesthesia diplomate annually x 20,000 anesthesiology diplomates = $4.2 million EVERY YEAR.

That's $42 Million every 10 years.

That's $42 million to the ABA for a program that threatens to compromise an anesthesiologist's ability to practice.

That's $42 million to the ABA for a program that threatens an anesthesiologist's ability to earn revenues from insurance companies.

It doesn't matter if doctors pay one lump sum every 10 years (as internists can do), or break their fees into bits. Forcing them to pay to keep practicing is the problem. Such a program in the egalitarian United States will never fly. Why, then, do the American specialty boards continue to insist that physicians participate when there are simply no proof it adds value to patient care or safety?

Because we're letting them get away with this.

It's time for all practicing physicians to stop supporting the ABMS MOC program, especially when there's at least one better option.


Friday, November 11, 2016

More Insights to ABIM Board Certification Tests and Scoring

From a recent early-career physician who failed their certification board examination and is trying to understand why:*

Dr. Fisher,

I contacted ABIM today asking many questions about the initial certification exam and the scoring. 

As I've seen you mention, they claim to use the (modified) Angoff Method to set the cut score for passing. It involves a bunch of "experts" reading questions and estimating what percentage of "minimally competent" test-takers would answer correctly. They then average all experts' percentages for each question, and average the percentage for all questions, to achieve the minimum passing score. Apparently. No info on who the experts are. Also no definition of what a "minimally competent" test taker is.

That's a weird system, but it wasn't what I found most egregious. Without going into too much detail, there are 240 questions on test. By my answer report, based on number of missed questions, I got 74% correct. They have interviews with their president and examples online stating you need to get about 65% correct to pass. I blew that away and still failed. So, I called them. To start, they told me that at least 35 questions are "test questions" that end up being thrown out and neither count for or against you. So we are paying to be research subjects. And paying handsomely. Even if you throw out 35 questions, I still got 70% correct, so I asked how I could've failed if I was still well above the 65% threshold. They told me that not all tests are equivalent and essentially I may have had an easier version and needed to get more correct. So apparently someone could've missed more than I did but still passed if their test was arbitrarily deemed more difficult? 

I asked many questions about how this could even be considered an equitable way to grade a high stakes test, but got little response. They did offer to have a psychometric statistician call me. In 7-14 days.

Thanks for your time and for reading. What an arbitrary process. Also, they will not let me see my test or answers, nor can they show me what questions were thrown out. This being clouded in such secrecy just adds to the mistrust from physicians. How can we trust a test that's so arbitrary? Also, if I continue to fail (or am failed, depending on how you look at it), is the ABIM going to pay off my student loans? I've proven competence in residency and now fellowship training. I would argue I've proven competence on this very test too.
A few notes about this physician's observations.

ABIM has published several "abstracts" on their webpage about methods of psychometric testing. The first abstract, published in February 2011 an co-authored with a representative from the computerized testing firm PearsonVue, discusses "transitioning the board from linear computer-based test to an adaptive, multistage testlet-based examination" and their "experience 'selling' this change to leadership." In other words, it appears the method of scoring ABIM examinations made a change before February 2011 to IRT scoring. Secondly, it appears a member of PearsonVue and an ABIM non-physician helped "convince" the ABIM leadership why they should change methods. (On a side note for those interested, here's a not-so-"simple guide" to Item Response Theory.) The second abstract, published in April 2011, discusses a "transition from classical test theory (CTT) to item response theory (IRT) scoring." What prompted the change in scoring technique is uncertain, but it appears the method for scoring examinations for ABIM board examinations changed before early 2011. Importantly with this new technique, the pass rate cut-off appears to be determined AFTER the test is taken and may vary from individual to individual, as the doctor suggests in the email above.

For those interested, the 2005-2015 pass rates for initial ABIM board certification were as follows: 92% (2005), 91% (2006), 94% (2007), 91% (2008), 88% (2009), 87% (2010), 84% (2011), 85% (2012), 86% (2013), 87% (2014), 89% (2015). (source: the Internet archive and ABIM websites).

Was this change in examination methods responsible for the declining pass rates of physicians taking the ABIM certification examination noticed by program directors across the country in 2013? Or was this the way PearsonVue required the test be scored if PearsonVue's computerized test centers from  were used for scoring (making it a "win-win" for both organizations)? We are left to wonder. The  falling pass rate hypotheses considered even included the possibility that study methods of millennial physicians were less rigorous.  The New England Journal of Medicine's summary of the controversy tried to quell the outcry from millennials who were quick to respond. Even the American Board of Family Medicine's leadership felt compelled to explain their falling pass rates about the same time.

Isn't it interesting that no one ever entertained the possibility that a change in scoring method at the ABIM had occurred that might have caused the drop in pass rates? If true, the process of passing a physician's initial board certification is inconsistent between test takers since tests contain questions that are "weighted" differently for each diplomat and the process of determining pass rate cut-offs remain shrouded in secrecy.

It's time for the ABIM to stop hiding their "secret sauce" of test development, changes in test scoring, and test "security" processes and address this young physician's questions directly and honestly. Test scoring and the setting of pass rate cut-offs should be transparent and reproducible for any high stakes examination administered to US physicians, especially when this self-proclaimed "voluntary" testing and re-testing now affects all US physicians' ability to gain (and retain) employment.

Or is that too much to ask of folks that use physicians as research subjects without their consent, engage in illegal lobbying of Congress and "stakeholders" for their benefit, and delight in moving our testing fees offshore to the Caymans for their own benefit?


* Portions of the letter were edited to protect the physician's anonymity.