Friday, May 19, 2017

When JAMA Shows Who They Are

Front and back covers of the May 2nd, 2017 Issue of JAMA
on Physician Conflicts of Interest in Medicine
In the May 2nd issue of the Journal of the American Medical Association (JAMA), the American Medical Association (AMA) discusses the subject of physician conflicts of interest in medicine. This puts them at an interesting juncture when the editor-in-Chief and executive editor of JAMA failed to disclose their relationship with the AMA and the AMA's relationship with US physicians. The AMA still presents itself to the public and legislators as representing Americas' doctors, even though representing US physicians’ interests has not been their financial priority for many years. In fact, it is telling that their mission statement no longer includes the words doctor or physician. If they do represent US physicians as they often claim, then the AMA (and its publication JAMA) are rife with numerous conflicts of interest and public clarification of this fact is desperately needed.

Which is it?

In June 2016 at the invitation of the Pennsylvania Medical Society, concerns regarding the conflicts of interest inherent to the American Board of Medical Specialties’ (ABMS) Maintenance of Certification (MOC) program were brought before the interim national AMA House of Delegates meeting. The AMA and ABMS are co-member organizations of the Accreditation Council for Graduate Medical Education (ACGME) and each organization took interest. The room was full of concerned physician delegates who had taken time away from their practices to represent their colleagues, alongside the President and chief council of the AMA, senior executive officer of the American College of Physicians, and the President and CEO of the ABMS. These courageous practicing physician delegates issued a “vote of no confidence" in the American Board of Internal Medicine (ABIM) - the largest ABMS member board representing approximately 200,000 US physicians - during a national panel discussion. They later passed a resolution to end the ABMS MOC program, which is a laborious recertification process plaguing overburdened physicians across this nation. Unfortunately, the AMA leadership has yet to honor this resolution.

If the House of Delegates is little more than a figurehead that makes a mockery of representing practicing US physicians before the AMA, then the public, legislators, and participating physicians should be formally notified and the perceived conflict clarified. Likewise, when a physician notifies JAMA's Editor in Chief of ABMS authors that have consistently failed to disclose their affiliation with their own for-profit wholly-owned subsidiary ABMS Solutions, LLC in JAMA and elsewhere, a response and action addressing this specific conflict should occur.

However, if the AMA has chosen to serve as an independent business entity paying their journal's editor-in-chief (who also serves as their Senior Vice President) $687,290 while also earning $111.1 million from CPT code “royalties and credentialing services” and $20 million from advertisers, then there is no conflict and the editors can feel reassured their disclosures in JAMA were proper. The AMA is one of the largest nonprofit 501(c)(6) business leagues in the country and has accumulated assets of over $686 million for its purposes.

Publishing an entire journal issue dedicated to the topic of physician conflict of interest while failing to acknowledge their own conflicts with physicians threatens to render JAMA's coverage of this topic to little more than ethical "fake news." The onus is on the AMA to clarify their role and potential conflicts with working US physicians or as Maya Angelou once said, “When a person shows you who they are, believe them.”

Westby G. Fisher, MD
Director, Cardiac Electrophysiology
NorthShore University HealthSystem
Evanston, IL and
(unpaid) Treasurer and co-founder,
Practicing Physicians of America, Inc.

Thursday, May 18, 2017

Caption Contest: Twin Towers

Adjacent Towers in Chicago
(Click image to enlarge)
Okay internet: I need a clever caption for the above photo (note the building labels).

Have fun!


Friday, May 05, 2017


There is talk of quality in health care. There is talk of safety. Millions upon millions of dollars are spent on "quality and safety" in health care each year. After all, without "quality" and "safety," how can you have "value?"

Business people now call quality and safety "MIPS," "MOC," "MACRA," or "measures." To me, these are not quality, but rather very flawed attempts to define it. Acronyms and business strategies, no matter how well-meaning, can't define "quality" or "safety" or 'value" in health care. When it takes teams of consultants dispatched hospitals to explain how to make money with these new terms, that's called marketing, not "quality" or "safety."

The truth be known, "quality" is very difficult to define. That's because each of us brings a different perspective as to what defines health care "quality." A gruff neurosurgeon who is technically flawless in the operating room is likely perceived differently by the recipient of his services compared to his coworkers. Defining quality in medicine is like defining pornography - you just know it when you see it. The tricky thing about "quality," though, is that we often miss it when it lies right beneath our nose.

Last Friday I had the luxury of working with my favorite technician as we worked to install a pacemaker. For that short period of time, he was my wingman. I didn't really think about much. Neither did he. It was a quiet, pleasant moment as we complemented each others' skills: instruments assembled neatly on the table, soft music playing in the background, the ultrasound ready, a blade dispensed, a quiet whisper for another instrument that was already in his hand. A sheath, a suture, a steristrip, a gauze and Tegaderm - and a mutual respect that had quietly developed over our many years working together. A "quality" effort for sure.

Foolishly, I took it for granted.

I have been fortunate to work with great wingmen (and women, too) all my career. They know who they are. They never ask for accolades and are often embarrassed when they are passed along. They get up every day, report like clockwork to do their job, and do it really well. There is pride in their work because they know it matters. They treat others as they'd want to be treated themselves, and patients remember - maybe not their name - but their touch, their reassurance, their confidence, their kind words. I have learned you don't need an advanced degree to define "quality." Nor do you need a National Quality Forum or National Committee on Quality Assurance. It takes time and mutual respect to develop real quality, not checklists, metrics, or administrators.

So when the call came a few days ago that my wingman was sick - suddenly and unexpectedly - time stood still for all of us. This quiet, humble guy who knew the composer of every golden oldie that played in our lab. A guy who's stood at my side so many times, helped so many, now a patient himself. Why? Naively, I had convinced myself that things would always stay the same and only get better. Instead, life intervened and his vacation trip to California became a trip to the hospital - a scan - a serious cancer - and a life turned upside down in an instant.

Sometimes it takes tragedy to open our eyes and appreciate the small but important things we have. Sometimes it takes tragedy to help us acknowledge the real quality we have among our ranks. Quality metrics, by comparison, seem trite.

My wingman is back home now among family and friends. I went to check in on him and there he was smiling, with PICC line in place and chemo infusing. He spoke a bit and exchanged some pleasantries. As I turned to walk away, what did he say?

"Thank you, doc. It might be a while before I can come back."

Spoken like a typical wingman.

I thanked him back. "Take your time," I said. My response seemed so trivial compared to all he's done for me.

I returned to our lab and saw our closely-knit team working together on another difficult case - like flying in formation with one jet missing. The elephant in the room was standing there. We could feel it. No one said a word. They chose to focus instead.

Quality wingmen all.


Wednesday, May 03, 2017

What JAMA's Editors Failed to Disclose

"The lady doth protest too much, methinks."
- from Hamlet, by William Shakespeare

An entire journal dedicated to a discussion of conflicts of interest was published yesterday in the Journal of the American Medical Association (JAMA). There is remarkable irony when the executive editor and editor in chief of JAMA fail to disclose JAMA's ownership by the American Medical Assocation (AMA), a 501(c)(6) non-profit membership organization that has amassed assets worth $684,343,310 and has significant conflicts of interest of its own.

Caveat emptor, dear reader. Form 990's should not masquerade as scientific "disclosure."


Saturday, April 29, 2017

Texas: The Latest Front of the Ugly Civil War in American Medicine

The Alamo, 1894 (from Wikipedia)

The ugly civil war in American medicine continues, this time in Texas.

This civil war is not a war between the left-right politics of healthcare, as many would hope it be depicted. Rather, it is a war between an emerging left-right alliance that's building to topple health care's increasingly corporate state.

On one side of the civil war is the staid old guard of American health care, represented by the Accreditation Council for Graduate Medical Education: the American Medical Association (AMA), the American Hospital Association (AHA), the American Board of Medical Specialties (ABMS), the Federation of State Licensing Boards (FSMB), the National Board of Medical Examiners (NBME), the Association of American Medical Colleges (AAMC), the American Osteopathic Association (AOA), and the American Association of Colleges of Osteopathic Medicine (AACOM). These organizations have operated for years without appropriate accountability and oversight of their own.

On the other side are a whole host of smaller, disparate grass-roots organizations that have emerged independently and are coalescing under several common themes: (1) exposing and ending corruption/corporate greed by these unaccountable non-governmental organizations, (2) removing unnecessary and unwarranted regulatory intrusions into the practice of medicine, and (3) preserving a physician's right to work as their patient's primary health care advocate.

The fight against the onerous and expensive ABMS Maintenance of Certification (MOC) "continuous re-certification" requirement that was born of an insatiable thirst for physician testing and educational fees in the name of health care "quality," was the catalyst that finally sparked the war between these opposing forces.

This past week, anti-MOC legislation in Texas (SB 1148) that prohibits hospitals and health insurance companies from discriminating against physicians based solely on their ABMS maintenance of certification (MOC) status, passed 31-0 and now moves on to the House. No doubt corporate healthcare lobbyists are already knocking on Texas legislators'  doors to insist they either kill the upcoming anti-MOC House bill or modify it to favor their interests. One can only imagine the money being spent to do so.

If Texas House legislators votes are swayed by the current healthcare establishment's influence over their vote, they should remember a bit of Texas history, because that vote will be against Texas patients' best interest, too.

Remember the Alamo, dear legislators.


Tuesday, April 18, 2017

Teirstein: An Urgent Call to Action

This important email has been widely circulated today from Paul Teirstein, MD, President of the National Board of Physicians and Surgeons (NBPAS) and is an urgent call to action for practicing physicians. I urge all physicians to take a brief moment and contact your representative as Dr. Teirstein suggests. He's made the process as easy as possible:

Dear Colleague,

Several states now have anti-MOC legislation pending. Recently the Georgia legislature passed HB 165, similar to Oklahoma's SB 1148 which prohibits Maintenance of Certification (MOC) as a condition of licensure or reimbursement from third parties. However, the ABMS and its member boards have been heavily lobbying state legislators to defeat the pending bills in other states (click here to view ABMS lobbying materials). Those of us opposed to MOC must educate legislators in these states regarding how MOC requirements are onerous, expensive, have no proven benefit, and are forced on physicians by conflicted, self-appointed private ABMS member boards.

Here is how you can make a huge difference:

  1. This is going to take you a few minutes. I spend hundreds of uncompensated hours per year on this issue. Please take 5 minutes of your time to help yourself and our profession.

  2. This is your action item:

  3. Click here to effortlessly send a letter by email to your district's state representatives. You will be asked to "register" by entering in your name, email and address.  That's it.  From your address the system will pull your specific state bill and a letter tailored for your specific state representatives you can edit (if desired) and click to send to all your district's legislators.  We have made it as easy as possible for you.

  4. There are currently many states with strong anti-MOC legislation pending. If your state currently has no anti-MOC legislation pending, your letter will encourage your representatives to create anti-MOC legislation.

  5. If you are curious and want to view all the sample letters we have written by state, click here.

  6. Please spread the word. We have 18,000 email addresses of physician supporters but we need many more. This will not work without your help getting this message out. Forward this email to your colleagues, your patients, your med staff office for hospital wide distribution, your specialty organizations, your FB, Twitter, Linked In and other social media friends. (You can also refer them to the NBPAS Advocacy Webpage).

  7. To join the National Board of Physicians and Surgeons ( and obtain continuous certification based primarily on AACME accredited CME, click here.
Thank you for your help and support.


Paul Teirstein M.D.
National Board of Physicians and Surgeons (NBPAS)

Monday, April 17, 2017

For Texas Legislators: MOC's Myriad Conflicts of Interest

The American Board of Medical Specialties' (ABMS) Maintenance of Certification (MOC) proprietary continuing education program has a myriad of conflicts of interest. I thought I would assemble a partial list of some of them below:

1) The American Board of Internal Medicine (ABIM), the largest ABMS member board responsible for credentialing one-quarter of all US physicians, is increasingly in debt thanks to high salaries and expenses. Its latest 2015 Form 990 shows a NEGATIVE asset and fund balance of balance of $50,642,980.

2) The cost of for participating in the proprietary ABMS MOC program has grown far in excess of the rate of inflation (16.3 to 17.2% annually), without adding any appreciable change to the product delivered to physicians or the public.

3) The ABIM Foundation, which was reported as being created in 1999 on federal tax forms from 2008-2013, has a POSITIVE balance of $77,255,188 on its 2015 Form 990. Much of this balance was secretly transferred from the ABIM physician testing fees from 1990-1999, ten years before the organization was reportedly "created." Furthermore, the Foundation is domiciled in PA, not Iowa, as it was claimed from 1999-2013. With some of those funds, the ABIM purchased a $2.3 million condominium that came complete with a chauffeur-driven Mercedes S-class town car for itself in December 2007.

4) Christine Cassel, MD not only worked as President and CEO of the ABIM and its Foundation from 2004-2014, she also secretly served on the Board of Kaiser Foundation and Hospitals, earning $1,683,221. From 2008 through 2013, she also served on the Board of Directors at Premier, Inc, the largest US hospital procurement firm, earning 230,000 in case and stock in 2013. (Here's the breakdown of her take). None of these conflicts were ever disclosed until she was investigated by Propublica before becoming the President and CEO of the National Quality Forum. From 2010-2014, the ABIM paid a little-known company, CECity, Inc., over $5.5 million to process physician patient survey/practice improvement survey data. Shortly after Dr. Cassel left the ABIM, CECity, Inc was bought by Premier, Inc for $400 million in 2015.

5) Robert Wachter, MD served as a consultant and board member for IPC Hospitalist Company while working as Chairman of the Board of the ABIM/ABIM Foundation in 2014. IPC Hospitalist company was investigated for overbilling Medicare and Medicaid patients and paid $60 million to settle Medicare/Medicaid false claims act violations with the DOJ February 6, 2017.

6) The ABIM has been lobbying Congress for years, but such lobbying has never been disclosed to the public via Form 990 tax forms.

7) The adverse effects of MOC on physicians and patients have never been studied. Yet the ABIM has been conducting research on physicians (see here and here) without their consent or Institutional Review Board oversight, potentially in violation of Protection of Human Subject statutes of the Department of Health and Human Services.

8) The American Board of Medical Specialties (ABMS) and the American Hospital Association (AHA) are both member organizations of the Accreditation Council on Graduate Medical Education (ACGME). Maintenance of Certification (MOC) favors hospitals eager to limit competition.

9) Margaret E. O’Kane is founder and president of the National Committee for Quality Assurance (NCQA). Margaret E. O’Kane is founder and president of the National Committee for Quality Assurance (NCQA). The NCQA is responsible for credentialing insurance companies that must accept ABMS MOC as a condition if their credentialing under the Affordable Care Act. Ms. O'Kane is also a public board member of the American Board of Medical Specialties (ABMS) that actively promotes the ABMS MOC program that benefits the ABMS. In addition, Richard J. Baron, MD, the current President and CEO of the ABIM, served as member of the Standards Committee for the NCQA.

10) The ABMS sells credentialing information on physicians through its wholly-owned subsidiary, ABMS Solutions, LLC, a for-profit corporation based in Atlanta, Georgia.

11) The American Board of Family Medicine (ABFM), one of the ABMS member boards, holds ABFM Realty, LLC, a for-profit real estate company that manages commercial real estate and is funded almost entirely by physician testing fees.

12) The American Board of Pediatrics (ABP) has numerous real estate holdings surrounding its North Carolina address and contracted with its retired CEO, James A Stockman, III, MD to work 8 hours per week for $793,438 in 2014.

These are just a few of the conflicts inherent to the ABMS MOC product. Sadly, there have been many more throughout the years, including cozy relationships with major US academic institutions.


Friday, April 14, 2017

Dear Legislator

Physicians, consider providing the following letter (or a modified version) to every state legislator considering anti-MOC legislation.

Dear Legislator -

Across the country, bills are appearing in state House and Senate chambers regarding a trademarked  educational product owned by the American Board of Medical Specialties (ABMS) called Maintenance of Certification (MOC). No doubt a team of gray-suits representing the insurance companies and hospital systems in your area (aka, lobbyists) will be knocking on your door explaining why this program is so important to assuring the public that their physicians are of the highest quality and competency. They will insist that this proprietary physician continuing educational program is the only integrated system of physician education that assures quality educational content for doctors while also providing a multitude of practice improvement modules to assure the highest quality of care for patients.

Please don't be fooled. As your life-time certified ABMS Board certified doctor, I have seen the implementation of "continuous" MOC in 1990 and watched it grow into a cottage industry costing physicians nearly $1 billion and 32.7 million hours away from patients annually (over $23,000 per doctor every 10 years) without proven benefit to patient care. ABMS MOC product replicates Continuous Medical Education we already are required to do to maintain our license in each state and does not permit physicians the freedom to chose the education they need for their practice, but rather forces them to comply with an unnecessary, expensive, and repetitive mandated computer-testing exercise. Imagine having to retake your high school trigonometry final examination to continue to practice your trade today. This is the equivalent to what physicians must now endure every 10 years.

The ABMS MOC program grew from a financial need of the ABMS and their 24 member boards, especially the American Board of Internal Medicine (ABIM) which "certifies" one quarter of all US physicians. The  ABIM is currently $50.6 million dollars in debt (according to its most recently-available 2015 public tax returns) while their executives earn three- or four-times the salaries of the average working physician, enjoy complementary spousal air travel, and purchase luxury condominiums complete with chauffeur-driven town cars for themselves - all at working physicians' expense. They then sell our testing information for profit to ABMS Solutions, a for-profit corporation based in Georgia.

The ABMS and their lobbyists say that a computerized test or a continuous question-and-answer barrage fed to our cell phones or laptop computers is superior to direct patient care experience for maintaining our competency to practice. I would hope you can see through their propaganda.

Finally, the ABIM and the ABMS have been involved with highly irregular financial dealings, including falsifying tax forms and transferring many our our testing fees to the ABIM Foundation in the Cayman Islands. They also perform "research" on physicians and their practices without informed consent or Institutional Review Board oversight - potentially in violation of federal law.

For these reasons I would ask that you strongly reject the importance and value of the ABMS MOC program to practicing US physicians. We have carefully researched the financial and political dealings of this conglomerate of independent non-profit agencies that are pushing for MOC and would ask to have them investigated by the appropriate authorities, including the Federal Trade Commission and Internal Revenue Service before siding with their lobbyists' demands.

Such an action would be in the best interest of our patients and US healthcare, not the endless ABMS MOC testing of physicians who struggle to serve as patient advocates in our increasingly regulatory healthcare environment.

Your caring physician -

Wednesday, April 12, 2017

An American Sickness and the ABIM

Thanks to Elisabeth Rosenthal, MD for the mention of the ABIM/ABIM Foundation controversy in her new book, An American Sickness: How Healthcare Became Big Business and How You Can Take It Back.

Sadly, the financial troubles and numerous financial conflicts of interest at the ABIM persist for reasons Dr. Rosenthal articulates well: it's a "testing Ponzi scheme."


Monday, April 03, 2017

Attention Tennessee Physicians and Physicians Everywhere

Attention Tennessee physicians and beyond:
As you may be aware, the (anti-)Maintenance of Certification legislation (see House Bill HB 413) and Senate Bill (SB 298) is on the calendar on Tuesday at 1:30 p.m. in Senate Commerce and at 3:00 p.m. in House Health Subcommittee. This legislation is highly contested and being opposed by both hospitals and insurance companies. TMA is working hard to get this legislation passed, but they need your help!

We need you to come to the hearings on Tuesday to show legislators that PRACTICING physicians are firmly AGAINST making the unproven, time-consuming, and distracting ABMS Maintenance of Certification program a requirement to practice medicine in Tennessee. Having physicians in the hearings may mean the difference in what happens with this bill in the committees on Tuesday. As the bill is highly contested, the outcome is unknown. It may be amended and passed out, or it may be put off until next year. Without physicians in the hearings, they will not go well. The legislators need to see physicians present supporting this bill and following it closely.

When: Tuesday - Senate Commerce at 1:30pm in LP 12
House Health Subcommittee at 3:00pm in LP 30

If you have any questions about this or if you are able to attend, please let me know, and if you haven't already, please contact your representative and senator and let them know you support this bill.

Thank you for your help,


Nikki Ringenberg, MPA
Senior Director of Membership and Grants
Nashville Academy of Medicine
3301 West End Ave, Ste 100
Nashville, TN 37203
615-712-6236 office
615-712-6247 fax
It is time to turn your gaze away from that computer screen and rise up!

Practicing physicians' right to work is being compromised by the inclusion of the ABMS MOC requirement in state legislatures across the country.

Physicians need to alert their colleagues in Tennessee and elsewhere about this effort to restrict the practice of medicine by the American Board of Medical Specialties and Federation of State Licensing Boards. Practicing physicians are not against continuing education, but against the corruption that the ABMS Maintenance of Certification program represents and it's anti-trust implications it has to the practice of medicine.

It is time to save the practice of medicine and physicians' ability to act autonomously on behalf of our patients without the threat of unnecessary corporate intrusions into health care delivery.

There is not much time for us to mobilize. Please spread the word.


Addendum: Thanks to Meg Edison, MD for her letter to circulate:

Friday, March 31, 2017

ABIM Gets It Wrong Again

On Wednesday, the American Board of Internal Medicine (ABIM) quietly announced their much-anticipated "modifications" to their Maintenance of Certification program on their blog. As expected, rather than ending the MOC program, ABIM has decided to double down and justify their unproven process using an edited video of Skype sessions from their most fervent (paid) supporters.

The ABIM reportedly conducted invitation-only "listening sessions" accross the nation. On the basis of those sessions and months of focus groups and navel gazing, the ABIM unilaterally decided that an "open-book" examination that physicians must participate in every two years could serve as an "alternate pathway" to "maintain" a physician's (previously lifetime) Board certification. They then had the gall to say these were the changes we requested. They weren't.

In actuality, those "listening sessions"were invitation-only. (Yes, I applied to attend the one here in Chicago but was never granted an "invitation.") Selection bias of diplomates was the order of the day. And as their legal fees mount, ABIM has yet to mention what they plan to charge recertifying physicians for their new "pathway." Rest assured it will be plenty.

By now, practicing physicians understand what MOC is really about. It is NOT about making money, physician ongoing education, assuring physician competency, care quality, or patient safety.

MOC is about the control of physicians.

Control doctors and you control health care delivery. Control doctors and you can shape them to corporate ways. Don't like it, dear doctor? Then leave. We'll find someone else to take your place and your patients.

But replacing experienced physicians is not so easy. It takes years to gain credible experience in medicine. MOC is not about experience, it is about rote memorization and data entry. And what the ABIM doesn't get is referrals are still not always guided by who your employer is, as much as corporations and the government try to make it so with their consolidation attempts. They can "innovate" all the new ideas they want, but doctors are not fooled. Tie MOC to credentials or to insurance company payments if you want, but extortion is extortion, no matter how you color it. Because ABIM has not taken accountability for their serious financial transgressions and strongman tactics used to protect their monopoly, they will remain a pitiful example of corporate greed to practicing physicians (the people they claim to "help") and little else.

The Accreditation Council of Graduate Medical Education (ACCME) and their powerful member groups (The American Board of Medical Specialties, American Medical Association, American Hospital Association, the Council on Medical Subspecialty Societies and American Osteopathic Association) know billions of other reasons MOC is important, too. MOC generates about $2 billion in revenue annually for these organizations when one considers the endless board review classes and registration fees for their members. Condos, limo rides, first class airfare, gym memberships, and multimillion dollar golden parachutes are dependent on this program.  All done without proof of value to doctors OR their patients. All done without any assessments of MOC's potential harms. The fact that our bureaucratic academic leadership in medicine will not address the many problems uncovered on this blog's pages and what this means to patient care in America is more even concerning than the ABIM's missteps in my opinion.

Doctors have had it with the outright dishonesty and scandal that has plagued MOC from the beginning, especially when they're dealing with much more important life-and-death issues every day. The only realistic and honorable revision for MOC is to end it, or for every practicing physician to refuse to participate and allow MOC to wallow in it's own avarice and greed.


Tuesday, March 21, 2017

Fact Check on ABIM's Director of Investigations

On 9 February 2017, I received a note from the editor of Philadelphia Medicine magazine requesting that I respond to a letter they received from Sidney Baumgarten, Esq, a friend and counsel for Ariel Benjamin Mannes, the American Board of Internal Medicine (ABIM)'s Director of Investigations, whom I had mentioned in their publication dedicated to the ABIM that was released in December, 2016. Yesterday, Mr. Baumgarten's letter and my rebuttal appeared in the Spring 2017 issue (5 Mbytes) of Philadelphia Medicine magazine.

I have reproduced the contents of Mr. Baumgarten's original letter regarding Mr. Mannes and my rebuttal to his letter below:

December 27, 2016

Philadelphia Medicine Magazine
c/o Philadelphia County Medical Society
Alan J. Miceli, Editor
2100 Spring Garden St.
Philadelphia PA 19130

Dear Mr. Miceli,

I am writing this letter hoping that you will give it serious consideration and make it available to the members of the Society as well as those who read your publication.

I have been a friend and counsel to Ariel Benjamin Mannes, the Director of Investigations (formerly Test Security) at the American Board of Internal Medicine (ABIM), for many years. I must say, candidly, that with over 50 years of law practice I have never before seen the likes of the repeated attempts by Dr. Westby G. Fisher to malign a person based upon an 11-year old “blip” in his long and successful career of public trust. It is, to be sure, unconscionable, to be using invective to shame the ABIM and, along the way, destroying the career and good name of a very honest, competent person, I know that if a member physician were similarly treated you would be mounting the ramparts to obviate its harm to his/her career.

First, Mr. Mannes was a member of the DC Police Department with a very fine record of service. He had been on a leave of absence and was awaiting reinstatement to duty while working part time at a DC restaurant when the incident in question occurred. That night, Mr. Mannes intervened in an altercation and himself called the police for assistance and was in possession of a legally licensed handgun from Virginia where he lived, but not technically permitted then in DC. His arrest and conviction was solely for illegal possession of the weapon; one felony, not two as Dr. Fisher alleges.

Interestingly, Ben’s employment appeal was won and he was reinstated to the DC Police, and was ordered prior to the incident and was successfully reinstated, our legal view was that he was a de facto police officer at the time of the incident. It should also be noted that the very law Mr. Mannes plead guilty to was later declared unconstitutional by the Supreme Court.

Second, Ben had served with the US Department of Homeland Security on a TSA-led rail inspection team with a security clearance, even on the night of the incident. He had also held roles before moving to DC with the US Federal Protective Service in New York following the first World Trade Center bombing trials and the CAT Eyes program where he trained police instructors on anti-terrorism in multiple jurisdictions. Even after the aforementioned incident he worked as a contractor on homeland security technology initiatives in Los Angeles, Ohio and the Philadelphia region. In multiple instances, Mr. Mannes was able to assist me in my role as Chief of Staff of the Army Division of the New York Guard after 9/11. In fact, his intelligence gathering enabled us in New York to be forewarned of serious threats.

Third, because Ben was a resident of New York for many years, he was able to obtain a Certificate of Relief from Disabilities issued by the State of New York several years ago, which relieved him of any impediments to employment, etc. as a result of his plea and conviction.

Finally, our laws here in New York (where Mr. Mannes’ certificate was issued) prohibit discrimination against a person who has one criminal conviction. It is codified in our Human Rights Law and our Correction Law. Both are designed to prevent the stigma of one arrest from interfering with future employment.

As you can see, the one incident revealed nothing that would even suggest any form of dishonesty of other reason for the ABIM to reject his services. Mr. Mannes’ position was designed with a myriad of checks and balances and his casework, to include the one cited in your publication, have been upheld in courts of law on numerous occasions. Mr. Mannes is a consummate professional, active in the federal and local security community, who has made the appropriate disclosures in both his pre-employment background check at ABIM and the vetting process for appointments he has held since, to include his elected Governorship at Infragard, a public private partnership coordinated by the FBI.

To put it bluntly. Mr. Mannes is being unfairly pilloried to serve Dr. Fisher’s own differences with the ABIM. It is especially unseemly for the member of a highly respected profession to undertake the willful destruction of another human being for his own motives. Mr. Mannes has worked extremely hard over the last 11 years to undo the unfortunate incidents of one night and surely does not deserve to have his family, friends, and colleagues read disparaging, inaccurate things about him in the pages of your publication. I am sure Hippocrates would blush.


Sidney Baumgarten, Esq.
Former Deputy Mayor, City of New York
Brigadier General, NYG, Retired
Cc: Hoffman Publishing Group

* * *

Mr. Baumgarten's understanding of Mr. Mannes' background conflicts with publicly available information regarding Mr. Mannes' past. To the best of my knowledge and belief, Mr. Mannes' prior background, responsibilities, "intelligence gathering" tactics, access to ABIM diplomate personal information, law-enforcement connections, and salary at ABIM have never been disclosed to ABIM diplomates despite Mr. Mannes' important public role in the organization. Here is the response I sent to Phildelphia Medicine magazine regarding some of the verifiable facts I have found regarding his history (They requested I limit my response to 500 words):
"Contrary to what Sidney Baumgarten, Esq. claims, Ariel Benjamin Mannes does not have a 'fine record of service with the DC police department.' In 2003, Mannes admitted using his access as an officer to obtain Washington reporter Jason Cherkis's personal records and posting the information on a law enforcement website advocating reprisals. The disciplinary board decided unanimously to fire Mannes for conduct unbecoming, but took more than 55 days to notify him.

While on involuntary leave from D.C. Police pending investigation, Mannes began working for the TSA Railroad Division and moonlighted as a bouncer at the “Diva nightclub.” Mannes assaulted a Diva nightclub patron while carrying a loaded unregistered pistol and claiming he was a police officer. Mannes was charged with aggravated assault, impersonating a police officer, and carrying an unregistered firearm.

Per D.C. Court records (felony #006438), Mannes pleaded guilty on December 2005 to two charges from the nightclub incident: (a) impersonating a police officer and (b) carrying an unregistered firearm, and was sentenced to pay fines for each conviction and to probation. He lost his weapon and TSA employment because of this incident.

Police Chief Cathy Lanier was forced to rehire Mannes in November 2008 due solely to the notification issue, but then suspended him. The Department moved again to fire him because of his weapons charge.

Mannes lost his appeal of his two convictions on 10/21/2008, the same year he began working as Director of Test Security for the ABIM.

While at the ABIM, Mannes’ declaration before a federal judge was instrumental for the ABIM to obtain a temporary retraining and seizure order in ABIM’s investigation of the Arora Board Review (ABR) course on December 2, 2009. Mannes, ABIM lawyers, and U.S. Marshals seized materials from Dr. Arora’s home days later. Using emails from Arora’s computers, ABIM retaliated against 139 physicians and sued others and then issued a press release June 9, 2010 accusing physicians of unethical "brain dumping"  before due process could occur.

In summary, Mannes was disciplined by the D.C. Police for abusing his position of authority to access confidential information to retaliate against an innocent citizen. Such conduct was not acceptable to the DC Police, and yet it appears to be acceptable to ABIM while it falsely accuses physicians of acting unethically. ABIM's double standard should be exposed as long as it continues to harm physicians.
These kinds of threats and attempts to discredit me are a dark example of organized medicine's ethics today. It is also a stark example of the tactics members of the American Board of Internal Medicine (ABIM) will deploy to control the narrative about them.

I take no joy in disclosing the misdeeds of a fellow human being. While the writer of the letter to Philadelphia Medicine magazine seems to be concerned about his "friend and client" and describes his friend's past employment history as a mere "blip," he misses the point that 139 vulnerable physicians (and thousands more who received "letters of concern") had their entire careers threatened by the ABIM's strongman tactics using his "friend and client's" investigation techniques and connections. Those actions resulted in untold personal and professional anxiety, legal fees, and public humiliation before proper due process could occur. In many cases, physicians were forced to undergo ethics training and pay hefty fines to reinstate their board certification on the basis of the ABIM's felonious employee's carefully organized "investigation" so the leadership of the ABIM could maintain their monopoly, power, and lavish executive lifestyles. To then intimidate a person who tries to disclose the truth via a letter to a medical publication is a last-ditch tactic when there is no ground left to stand on.

Disclosing facts cannot be defined as "pillorying." In addition to the facts I outlined in my response to Mr. Baumgarten, it appears to me that Mr. Mannes used his experience with the Arora Board Review investigation to promote his test security techniques to the board members of the American Board of Medical Specialties (ABMS) in a course called "Building a Bulletproof Exam Integrity Case: Tools of the Trade" in 2012. Should physicians blindly permit the wanton breach of their civil liberties by individuals with Mr. Mannes' background and connections so other medical certifying boards can also profit using similar techniques?

Mr. Mannes had other conflicts of interest while an employee at ABIM: he worked for the test security firm, Caveon, teaching techniques of "responding to and investigating test-security incidents" to others. Mr. Mannes even created his own corporation, Exam Integrity Services, LLC, in Florida in 2015. How much more profit did Mr. Mannes hope to gain at the expense of ABIM's physician reprisals while working as their employee?

Recently, we have come to learn that the ABIM sued one physician more than two years after the statute of limitations had expired on the 2009 Arora Board Review copyright infringement case that Mr. Mannes investigated under the direction of ABIM officers. The court recently dismissed the claim after the physician (Dr. Salas Rushford) was forced to endure years of stress and expense inflicted by the ABIM. For reasons that are unclear, Mr. Mannes' deposition in that case (for which I serve as an expert witness on behalf of Dr. Salas Rushford) has been kept under seal to the public, yet the deposition of Dr. Salas Rushford has not. Why? It seems the ABIM is an entity that has grown disproportionate authority over physicians without any meaningful accountability or transparency, and which we now see can abuse its power to inflict untold harm against physicians who are trying to serve patients.

How, where, when, and why unaccountable physician certifying bodies can retaliate against or sue physicians by intruding upon their personal property and civil liberties on the basis of an unproven promise of assuring "patient safety and physician quality" is one of society's most delicate and grave decisions. Certainly ABIM knows this but seeks to reduce working physicians' many concerns about their conflicted financial and investigational activities to a name-calling problem. While I admire the cleverness of this strategy, the genie is out of the bottle. Their attempt to make their reality a personal issue against me is deceptive. Tens of thousands of US physicians have my same concerns and want answers from the ABIM and the American Board of Medical Specialties.  In addition, an entire state medical society has issued a vote of no confidence against the ABIM at the House of Delegates meeting in Chicago in June 2016, and the entire House of Delegates voted to end Maintenance of Certification (MOC) on the basis of lack of evidence of the need for MOC and the ABIM's financial and strongman actions. Despite this, the leadership of the American Medical Association has still not ended the ABMS Maintenance of Certification (MOC) program. Consequently, practicing physicians are mobilizing nationwide to enact state-level legislation to end the corrupt MOC program that is tied to hospital credentialing and the ability of physicians to receive insurance payments in many states and, therefore, to practice their trade.

French philosopher Foucault's work on power helps us understand why the physician certification industry, and Maintenance of Certification in particular, is so important to the US medical education system and for policy makers today:
Discipline, according to Foucault’s historical and philosophical analyses, is a form of power that tells people how to act by coaxing them to adjust themselves to what is ‘normal’. It is power in the form of correct training. Discipline does not strike down the subject at whom it is directed, in the way that sovereignty does. Discipline works more subtly, with an exquisite care even, in order to produce obedient people. Foucault famously called the obedient and normal products of discipline ‘docile subjects’.
Mr. Baumgarten's letter and the ABIM's strongman actions demonstate how the overreach of our US physician credentialing system can adversely affect the very people they pretend to protect: physicians and their patients. To limit a physicians' ability to think critically and care autonomously for their patients creates dangerous consequences for both caregivers and their patients. Health care administrators and policy makers would be wise to assure physicians continue to be able to speak independently and on behalf of their patients lest they fall prey to the same forces when they become patients themselves.

It is unacceptable to continue the half-truths and false representations of physician certification (and recertification's) value to our health care system. The ABIM and ABMS must take full accountability for their actions and reform the methods they are willing to employ to assure their revenues at the expense of the personal liberties of practicing physicians and stop using individuals like Mr. Mannes as their strongman and fall guy.


Friday, March 17, 2017

Federal Judge Dismisses ABIM Copyright Infringement Suit

Yesterday, US District Judge Katherine Hayden dismissed the instant copyright infringement action filed by the American Board of Internal Medicine (ABIM) against defendent Jaime Salas Rushford MD because the action was time-barred by its three-year statute of limitations.


The ruling stems from a December 2009 complaint filed by the ABIM against Rajender K. Arora who  conducted a live six-day board review course called the Arora Board Review (ABR) course in May 2009 in Livingston, NJ. Around that time, ABIM discovered test questions on ABR's website that ABIM suspected were copied from its prior examinations. ABIM filed their complaint that Arora, ABR, and an ABR employee, Anise Kachadourian, alleging a scheme through which "ABR unlawfully obtained ABIM's secure examination items by mobilizing course attendees to divuldge contents of the examination to defendents" in violation of federal copyright law. The December 2009 complaint also named 50 John Doe defendents "a presently unknown member of past and/or present candidates for Board Certification who have complied with this requests of defendents Arora and Kachadourian to provide secure, copyrighted examination content to Arora for further dissemination." (Note: the issue of ABIM claiming violations of copyright law are solely those of ABIM and were not addressed by the judge in her opinion, but rather the motion to dismiss was made taking everything the ABIM said was true and giving all the inferences they made in their favor.)

On the same day that it filed the December 2009 complaint, ABIM successfully obtained an ex parte order from the district court authorizing United States Federal Marshal to "break open and/or forcibly enter" the individual defendents' homes and seize, among other things, all communications with ABR's customers relating to infringement of ABIM's copyrighted examination. This action later led to national headlines in June 2010 that claimed "doctors cheated."

According to the ruling: "As a result of the seizure, ABIM obtained a trove of emails between Arora and various course attendees. The lawsuit against Arora was settled in June, 2010, and according to counsel, ABIM began instituting action against individual physicians whom ABIM deemed complicit with Arora and ABR. According to the complaint eventually filed in court, ABIM identified Jaime Salas Rushford in January 2012 as one of ABR's alledgedly complicit customers, when it linked him to an e-correspondence about August 2009 exam questions that was sent from the email address "" Salas allegedly began compiling detailed ABIM examination content that he got from colleagues who sat for the examination leading up to his own examination date 20 August 2009 and sent it to Arora using the email address."

ABIM then waited until October 2014 to file the current action against him in October 2014, even though they knew the identity of Salas Rushford in January 2012, eight months before the three-year statute of limitations for their action against Arora ended. (ABIM argued that the three-year statute of limitations did not begin until January 2012 when the identified Salas Rushford as the owner of the email address.) In fact, the judge noted "ABIM made an intentional decision not to bring suit against Salas within the applicable limitations period when the alledged facts clearly show it was capable of doing so." Judge Hayden goes on to say that "this lawsuit against Salas is a coda to the main thrust of ABIM's litigation efforts, apparently born of a second look at the decision ABIM made not to sue Salas when his name popped up in January 2012."

At the time Salas Rushford was sued by ABIM in 2014, he filed a counterclaim, not only against ABIM, but against Richard Baron, MD, Christine Cassel, MD, Lynn O. Langdon, Eric Holmbie, MD, and members of an alleged ABIM "Hearing Panel" comprised of David Coleman, MD, Joan M. Von Feldt, MD, and Naomi O'Grady, MD. He also included ABIM's insurance companies and Pearson Education Inc. in the counterclaim. That counterclaim now proceeds.


The implications of the decision by the Judge Hayden yesterday are signficiant for a large portion of practicing US physicians and for the the financial solvency of the ABIM. According to its most recently-available Fiscal Year 2015 federal tax forms, the ABIM has a deficit of $50,642,980. Currently, their website lists the ABIM's FY 2016 expenses at $62.5 million, $2.5 million more than their federal tax form disclosed for fiscal year 2015. Legal expenses are signficiantly contributing to these expenses, not just "strategic non-capitalized spending on infrastructure upgrades in anticipation of the launch of a new MOC assessment in 2018" as ABIM claims on its website.

How much higher can these expenses be allowed to go? Who shoulders these expenses?

Physicians do.

From 2000 to 2014, the cost of board certification has increased 244% (16.3%/year) from $795 to $1940 for general internists and 257% (17.2%/yr) from $995 to $2560 for specialists. This year, candidates sitting for their initial board certification in cardiac electrophysiology had to pay $2830 to register for their examination.

If things continue the way they are, the countersuit by Salas Rushford will be the least of the ABIM's legal and financial concerns as doctors come together to act collectively on their own behalf.


Disclaimer: I serve as an expert witness for Jaime Salas Rushford, MD and am a co-founder of Practicing Physicians of America, a physician advocacy organization.

Sunday, March 05, 2017

MOCA-Peds and Its Conflicts of Interest

The pediatric Maintenance of Certification (MOC) propaganda machine rolls on - this week in the JAMA Pediatrics.

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:
'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.


Saturday, March 04, 2017

TeamHealth: Medicine's "Big Short"

Remember Bob Wachter, MD, America's Most Influential Physician Executive in 2015?

Remember how he played Elvis and sang "Your Hospitalist Song" at Mandalay Casino while serving on the board of  IPC The Hospitalist Company in 2014?

Remember how Dr Wachter pivoted to "love" as a quality measure in the New York Times after leaving the American Board of Internal Medicine (ABIM) and after he quietly earned $210,586 in income, stock, and options with IPC Hospitalist Company in 2014, a portion of which was shared with his institution?

Remember how IPC Hospitalist was being investigated by the DOJ for Medicare fraud?

Remember how IPC Hospitalist Company was acquired by TeamHealth for a hefty profit anyway?

The DOJ's investigation completed and TeamHealth had a $60M judgement levied against it.

I went to look what happened to TeamHealth's stock price at the time of that announcement, but was surprised to see that TeamHealth had disappeared from the New York Stock Exchange.

It seems TeamHealth had been purchased by The Blackstone Group and became a private company just before the judgement was handed down.

* poof *

IPC Hospitalist Company. TeamHealth. All gone. All forgotten.

Welcome to US Medicine's mini-version of "The Big Short."


More here:

Friday, February 24, 2017

Bringing the ABMS MOC Program Before the FTC

Looks like the new Federal Trade Commission Chairwoman Maureen K. Ohlhausen might take an interest in the onerous and costly American Board of Medical Specialties' Maintenance of Certification (MOC) program:
Testifying on behalf of the FTC before the Subcommittee on Antitrust, Competition Policy and Consumer Rights, Commissioner Maureen K. Ohlhausen noted that while occupational licensing can help protect consumers from health and safety risks and support other valuable public policy goals, unwarranted restrictions can harm competition, leaving consumers with higher-priced, lower-quality, and less convenient services.

“From, a competition standpoint, occupational regulation can be especially worrisome when regulatory authority is delegated to a board composed of members of the occupation it regulates,” Commissioner Ohlhausen said.

According to the testimony, this type of board may make regulatory decisions that serve the private economic interests of its members and not the policies of the state (emphasis mine). Such decisions could result in occupational restrictions that discourage new entrants; deter competition among licensees and from providers in related fields; and suppress truthful, nondeceptive advertising, and innovative products or services that could challenge the status quo.

The testimony notes that while the principles of federalism embodied in the state action doctrine limit the reach of federal antitrust laws when a restraint on competition is imposed by a state, this does not mean that all state regulators are exempt from antitrust scrutiny. Through its enforcement and advocacy work, the Commission has helped to define the contours of the state action doctrine for actions taken by state boards composed of private actors – culminating in last year’s decision by the Supreme Court in North Carolina State Board of Dental Examiners v. FTC.

Tuesday, February 14, 2017

Why Didn't I Think of This?

What the public REALLY needs: a credentialer of the credentialers, based in Washington, DC!

These guys have it all: An Editorial Committee, an International Task Force, an External Stakeholder Development Task Force,  Public Member Development Task Force, Credentialing Careers Task Force, and Emerging Leaders Task Force - oh, and don't forget the Legal Action Fund to pay for hefty strongman tactics!

Sounds like the playbook for the American Board of Medical Specialties Maintenance of Certification (MOC) Program and the Accreditation Council for Graduate Medical Education, doesn't it?

Pure genius.

I feel so much safer now, don't you?


Monday, February 06, 2017

PPA Requests Congressional Hearing, IRS Investigation of MOC Program

The Library of Congress is a beautiful building in Washington DC. On the North wall of the Library of Congress Member's Room is a beautiful mosaic representing law:

It was the perfect setting to deliver the Practicing Physicians of America's debut message to Congress regarding the ABMS Maintenance of Certification program (pdf of slides) last Thursday:


Additional information: 

My earlier rebuttal to Richard Baron, MD, President and CEO of the American Board of Internal Medicine's, defense of MOC previously published in Medical Economics.

Anyone interested in downloading the Powerpoint of my presentation to use for educational or advocacy efforts can download the presentation here.

Practicing Physicians of America website.

Wednesday, February 01, 2017

Practicing Physicians of America: Taking the Stick

Shuzan, a Buddhist monk of the tenth century, once held up a bamboo stick before his disciples. "Call this a stick," he bellowed, "and you assert; call this not a stick, and you negate. Now, do not assert or negate, what would you call this stick? Speak! Speak!"

From out the ranks, a young monk ventured forth, grabbed the bamboo, and, breaking it in two, exclaimed to Shuzan, "What is this?"*

Wonder where I've been for the past several weeks?

Welcome to Practicing Physicians of America.

Thanks to everyone who has collaborated to make this dream become a reality in a remarkably short 12 days. We hope the momentum continues to grow. We have strong advisors and are commited to ending unproven bureaucratic intrusions that threaten our ability to practice our trade. There is still plenty to do as we work to create a new 501(c)(3) by practicing physicians for practicing physicians. This is a voluntary, grassroots effort.

There is strength in numbers and we're in Washington DC to kick it all off tomorrow (press release here). I hope EVERY practicing physician, irrespective of political loyalty, will join us in the work to end the bureaucratic intrusions that are threatening our ability to care for patients.  Please join us in this David vs Goliath fight.

We will have more in the coming days.


* From: An Introduction to Zen Buddhism, by D.T. Suzuki (Grove Press, 1964).

Sunday, January 22, 2017

Asking the Fox to Watch the Hen House

Why are we asking the fox to watch the ABIM/ABMS henhouse?

In November 2016, practicing physicians passed a resolution 607 at the AMA House of Delegates meeting requesting an independent audit of the ABIM.  As my prior post disclosed, the AMA is heavily vested in the ABMS MOC program as a member organization of the ACGME.

The response from the ABIM's corporate communications department was entirely predictable: see the ABIM website.

This is not an independent audit.

Would the ABIM like to explain why they changed auditors? We want to know for ourselves why there is a $13M shortfall this year. Might their investments in the Caymans have fallen short? Did they move those assets offshore to avoid potential tax consequences? Might they have made a few not-so-tiny errors on their behelf, like covering up the existence of the ABIM Foundation for 10 years and using $76M of our testing fees to create the ABIM Foundation by falsifying tax records?

There are a lot of questions to be answered. Why did the ABIM remove their website from the internet archive in 2014 if they were not trying to cover up their activities? Why wouldn't they release their tax forms to main stream media outlets when asked in 2013-2014, and why was the request for those documents only made available via the PA governor's press secretary?

No, the AMA can't bury this one.  Either they will hire an independent auditor approved by practicing physicians in America to review tax records from 1990 through the present, or we will be sure to ask the IRS and DOJ to join the investigation on our behalf.

Practicing physicians in America want the truth. All of it. And we will not rest until the activities performed by the ABIM with our finances withstand independent public scrutiny.


Friday, January 20, 2017

ABIM Stationary Sidebars: MOC and UCSF

I attended the University of California, San Francisco's (UCSF) electrophysiology program from 1993-1994. As I continue to explore the myriad of conflicts of interest inherent to the American Board of Medical Specialties (ABMS) Maintenance of Certification (MOC) program, it has come as quite a surprise to me that so many members of my alma mater (and the institution itself) were either passive or active participants in  the strongman tactics used by the American Board of Internal Medicine (ABIM) as a "message and deterrent" (as explained by former President and CEO of the ABIM, Christine Cassel, MD) to control the ABIM/ABMS monopoly on continuing medical education in the United States.

Let me explain.

In a retaliatory letter dated May 8, 2012, authored by Ms. Lynn Landon, the non-physician Chief Operating Officer of the ABIM at the time, Jaime Salas-Rushford, MD was accused of forwarding, prior to ever taking the ABIM Board certification exam, board review questions to the ABIM-certified instructor of the CME-accredited Arora Board Review course. About three years after the fact and after 139 others had already been sued or sanctioned for attending the same course (or at the very least, like a flashback to the McCarthy era, had warning letters "added to their file") this retaliatory letter declared that ABIM imposed an immediate, unlimited revocation of Board certification of Dr. Sala-Rushford and to "notify the Medical Board in every jurisdiction in which you are licensed" without due process.

On the stationary sidebar of that letter appear the names of the officers of the ABIM and it’s board members at the time: Chair Catherine R Lucey, MD, Chair-Elect Robert M Wachter, MD, Secretary-Treasurer Talmadge E King, MD, and President and CEO Christine Cassel, MD among others. Were these leaders listed in the sidebar mere figureheads of the ABIM when this occurred or were they ultimately responsible for the organizations' actions as their positions suggest?

It is remarkable that three of the above senior ABIM leaders were on staff at UCSF at the time. These same individuals now hold significant leadership positions at the USCF medical school. Dr. King serves as Dean of the UCSF Medical School since 26 May 2015, Dr. Lucey as the Vice Dean for Education, and Dr. Wachter serves as Professor and Chair of the Department of Medicine. In addition to their current academic positions at UCSF, these same individuals hold leadership in other organizations within the Accreditation Council for Graduate Medical Education (ACGME):
  • Dr. Lucey serves as an at-large board member of the American Board of Medical Specialties 2016-2017 and on the Board of Directors of the of the Association of American Medical Colleges (AAMC).

  • Dr. King has a long history of serving on the Board of Directors of the National Committee for Quality Assurance (NCQA) from 2010-2017 as an unpaid board member and currently works alongside the organization’s founder and President, Ms. Margaret E. O’Kane. Remember that NCQA, under Ms. O'Kane's direction, developed, maintained, and expanded the Healthcare Effectiveness Data and Information Set (HEDIS), the nation's most widely used quality measurement tool and has grown to a $50 million company with almost 300 employees. NCQA is also the main accreditor of recognized medical homes and one of two accrediting organizations permitted by federal law to accredit plans in the new health insurance exchange marketplaces that came online October 1, 2010, under the Affordable Care Act (ACA). Because the NCQA also credentials insurance providers as part of the ACA, one insurer quality metric they created requires physicians to "maintain" their certification via ABMS MOC programs if they want to receive payments from those insurers. Furthermore, the NCQA and the ABMS will continue to directly benefit from "quality" rules that they have put into place and lobbied Congress to enact laws such as the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). MACRA's Merit-based Incentive Performance is MOC on steroids (see comments to the final rule). While NCQA maintains the quality measurement tool that is used in MACRA to determine US physician pay based on their notion of care "value," much of the NCQA's own IRS 2015 Form 990 is redacted. Who is protecting our patients' interests when even the IRS allows this to occur?

  • Dr. Wachter has his own financial conflicts with MOC that also benefitted the UCSF. According to IRS Form 990's, in 2012 when the above sanction letter was issued, Dr. Wachter served as 'Director-Chair" of the ABIM earning $38,888 from the ABIM and $6,626 from the ABIM Foundation.

    While serving as "Director-Chair" of the ABIM and Director of the ABIM Foundation, Dr. Wachter was also simultaneously serving as Director of the IPC The Hospitalist Company, Inc, reportedly running a “leadership development course (at UCSF) for their practice group leaders.” Dr. Wachter's financial haul from his relationship with IPC was significant. He pocketed 1,355 shares of IPC stock valued at $50.68 on 1 Aug 2013 and another 2650 shares of stock valued at $58.50 on 2 January 2014. According to SEC filings, he earned $210,586 in 2014 ($ 108,000 as cash, $ 55,000 in stock and $ 47,526 in options). USCF benefitted from a fellowship grant with IPC brokered by Dr. Wachter that began sometime in 2010 or 2011 (Dr. Wachter's description of the program was published on his blog 18 November 2011.) On 17 June 2014, the Department of Justice filed suit against IPC Hospitalist Company alleging the company overbilled federal health insurance systems for physician evaluation and services. Nonetheless, it appears Dr. Wachter still received a stock option award of 2186 shares of IPC on 2 Jan 2015. Undeterred by the DOJ suit (or perhaps because of it), TeamHealth acquired IPC Hospitalist Company for hefty $80.25 per share on 23 Nov 2015, again profiting Dr. Wachter and UCSF (with whom he had a publicly-disclosed sharing agreement where he kept 80% and UCSF received 20% of this relationship). As of 17 Jan 2017, it appears a settlement agreement in the DOJ's suit against IPC The Hospitalist Company will be reached soon. In retrospect, watching Dr. Wachter doing an Elvis impersonation at Mandalay Casino in Las Vegas on behalf of corporate medicine at patients' expense with the tacit approval of the Dean of the UCSF Medical School reflects poorly on the University. These activities also serve to erode any remaining trust practicing physicians have on the unproven ABMS MOC program to serve in our patients' best interest.
It is remarkably coincidental that on 27 December 2012, an article appeared in the New England Journal of Medicine by one of Wachter’s colleagues at UCSF, Robert B. Baron, MD written in conjunction with John Iglehart, a “national correspondent” for the New England Journal of Medicine, explaining the controversy surrounding MOC and reinforcing the need for it. Dr. Robert Baron (no relation to Richard Baron, MD of the ABIM) never disclosed his simultaneous collegial associations with so many in leadership positions of the ABIM at the time, nor did either author mention the fact that the "NEJM Group" would be announced in March, 2013 to profit the Massachusetts Medical Society that included the launch of their Knowledge+ Maintenance of Certification “state-of-the-art adaptive learning” educational product April 16, 2014.

Who wouldn't want to join such a financial and reputational party bestowed upon these former ABIM leadership physicians? What medical center wouldn't like to benefit from the ABMS MOC system so many from UCSF have? How many other institutions are? Given what we now know about these colluding private organizations and their ethical and financial tactics, why haven't these respected leaders come forward to denounce the activities of the ABIM for which they served? Perhaps these leaders are fearful UCSF would lose their ACGME accreditation as a teaching institution eligible for additional Medicare training funds if they did. Or perhaps these individuals saw little risk of collateral damage to their professional reputation if ABIM used its strongman tactics against a small number of vulnerable, less prominent physician colleagues.

The irony of the ABIM requiring doctor clients of Arora Board Review subject to the sting operation organized by an undisclosed convicted felon to participate in “ethics” courses and pay additional fees to the ABIM before their board certification credential could be reinstated should be lost on no one.

According to USCF's own Faculty Code of Conduct: "The integrity of the faculty-student relationship is the foundation of the University’s educational mission. This relationship vests considerable trust in the faculty member, who, in turn, bears authority and accountability as mentor, educator, and evaluator. The unequal institutional power inherent in this relationship heightens the vulnerability of the student and the potential for coercion. The pedagogical relationship between faculty member and student must be protected from influences or activities that can interfere with learning consistent with the goals and ideals of the University." I would argue that the unequal institutional power carried by the ABIM (and other ABMS member boards) that can revoke a physician's ability to practice or earn a living on the basis of an unproven repeated testing is even larger and warrants even greater scrutiny.

It is clear that the complex financial interrelations of many tax-exempt private organizations that require the ABMS MOC credential have developed over the years to monopolize the physician continuing education process. In my opinion, it is far too coincidental that all of these physicians a single institution just happened to hold unelected leadership positions in so many of these interrelated private entities that financially benefit from MOC at the same time. I also believe the fact that another physician from the same institution published a manuscript in the New England Journal of Medicine while his colleagues stood to benefit politically and financially from their positions gives the appearance of collusion. I believe the UC Board of Regents, Attorney General of California, and/or even the Governor of California have a responsibility to investigate the use of public monies and academic positions to benefit these many non-governmental private entities that act outside of University responsibilities and act, as one independent journalist described them, "more akin to a protection racquet."

The ABMS Maintenance of Certification controversy and those culpable for its strongman tactics extends far further than just the ABIM. When respected leaders of the academic community fail to speak out about the irresponsible activities that occurred during their tenure with the organization, I believe they passively condone them. I suspect this is why we have heard little from other members of the academic community since the collusion extends to current board members of the NCQA, AAMC, ABMS, the New England Journal of Medicine, and other prominent academic institutions like UCSF.

Practicing US physicians voted to end the ABMS MOC program before the AMA House of Delegates meeting in June 2016 because of the unexplained financial dealings and the strongman tactics employed by the organization, yet it continues, even now. This no longer surprises us since the AMA is a member organization of the ACGME, too.

How high do the conflicts go in the US medical education system?

It is now clear they go all the way to the top. It is also clear why.

It's time for the AMA to shut the ABMS MOC program down as practicing US physicians have voted because it's doing more harm than good, not only to reputable practicing US physicians nationwide, but to their patients and academic institutions (like my alma mater) that purport to train and educate physicians to become ethical, hard-working, trustworthy doctors without fear of reprisal for educating themselves any way they choose.


Disclaimer: I serve as an expert witness on behalf of Jaime Salas-Rushford, MD.