The ABFM Travesty

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All family doctors hate the burdens placed upon us by American Board of Family Medicine.  The testing is useless, the requirements are bogus and they are getting rich off our dime.  NO ONE likes them.  Recently, they sent out this letter to all family docs:

Dear Colleague,

I would like to take a brief moment to introduce myself. My name is Carlos Roberto Jaén and I currently serve as Chairman of the Department of Family and Community Medicine at the University of Texas Health Science Center at San Antonio. I also serve as Chair of the ABFM Board of Directors, and would like to introduce the other members of the Board of Directors:

Elizabeth G. Baxley, M.D. Greenville, NC
Diane K. Beebe, M.D. Jackson, MS
Laura M. Brooks, M.D. Lynchburg, VA
Alan K. David, M.D. Milwaukee, WI
Montgomery Douglas, M.D. Valhalla, NY
Joseph W. Gravel, Jr, M.D. North Reading, MA
Jimmy H. Hara, M.D. Los Angeles, CA
James Kennedy, M.D. Winter Park, CO
Jerry E. Kruse, M.D. Springfield, IL
Lorna Anne Lynn, M.D. Wynnewood, PA
Christine C. Matson, M.D. Norfolk, VA
David W. Mercer, M.D. Omaha, NE
Marcia J. Nielsen, PhD, MPH Lawrence, KS
Kailie R. Shaw, M.D. Tampa, FL
David E. Soper, M.D. Mt. Pleasant, SC
Keith L. Stelter, M.D. Mankato, MN
While your interactions with the ABFM may be largely related to certification, the non-profit ABFM has many purposes and goals. These objectives include: certification, research, leadership development, establishment of training standards, and collaboration with other organizations to promote the health of the public. The ABFM is not a membership organization. It is completely distinct from the membership organization for family physicians—the American Academy of Family Physicians (AAFP).

As a practicing family physician, I am acutely aware of the many pressures involved in your commitment to provide excellent family medicine. The numerous national, state, and local regulations continue to compete with our time with patients. As Board Chair, I hear from some family physicians that Maintenance of Certification (MC-FP) can be just one more of the distractions from practice. I want to address four frequently voiced concerns, and let you know what the ABFM is doing about these issues.

Issue 1: The MC-FP process is too time consuming.

From a historical perspective, the time required to maintain our certificate has not changed much. The self-reported time that the vast majority of family physicians take to complete a module is between 3 – 5 hours. The ABFM requires ONE module per year. So the time it should take to maintain your certificate is less than five hours per year. In the 1980s and 1990s, the ABFM required a chart review prior to sitting for the examination. From my own experience, this chart review took significantly more time to prepare than five hours.

For that 5-hour commitment per year, each physician gets CME credits upon completing a module. Because all of us desire to stay up-to-date with medicine, we all complete a number of CME activities each year. The ABFM module is online, self-directed, and can be completed bit-by-bit over the course of a year. And just in case you have some extenuating circumstances, the ABFM Stage process lets you complete the required modules anytime within the 3-year stage. If you procrastinate until December of the last Stage, it may take you about 15 hours to complete all of your modules. Completing one a year will avoid getting into a last minute bind. If for some reason you are taking significantly longer to complete a module, please contact our Support Center (877-223-7437, or [email protected]) for assistance. The support center agents can help you complete this online module in the most efficient manner.

Issue 2: The MC-FP process is too expensive.

Again, let’s look at this from a historical perspective. In 2004, the cost of the ABFM certification examination was $950. Over a seven-year timeframe, that works out approximately $135 per year. That expense was solely for the examination. An exam that previously was given in one of 20 hotels spread across the US on only one day per year. For those entering MC-FP in 2014, the cost is $200 per year (for nine years) plus $250 in year ten when the exam is taken for a total of $2050, or just over $200 per year. For that expense you get: (1) an extended certificate of 10 years (meaning fewer examinations over the course of a career and fewer external costs associated with taking the exam—study, travel, lodging, etc.), (2) included payment for your next examination (now given at over 300 test centers across the US and most of the world on one of 20 dates in either April or November), and (3) at least 100 CME credits (up to over 500 credits for no additional cost). The extra $65 per year does not even consider the cost of living increase over that 10-year period. In fact, once you have completed a three-year stage and paid the necessary fees, you may complete as many modules as you wish and obtain CME credit for each. We also allow for the prepayment of the process so that the total cost over the ten year period can be fixed and there is no risk of increasing prices. If you were part of the cohort that entered MC-FP in 2004, the annual fee paid for the process was $200 per year. The same as it is today.

In addition, the $200 per year MC-FP expense includes: update and regeneration of the examination questions, creation and update of the Part II SAMs, development and update of the Part IV QI activities, and support for approving externally developed activities (e.g., AAFP Metric, PCMH, self-directed QI activities).

The ABFM works hard to maintain the lowest possible fees for MC-FP, and the ABFM Board looks at the cost of MC-FP very closely. The Board of Directors is committed to providing the best service at the lowest possible cost to our physicians.

Issue 3: There is no evidence MC-FP works to improve care

When the MC-FP process was first developed, the ABFM committed itself to studying the process. We further committed to the family physicians that if the process did not show an empirical improvement in patient care, we would change the system. Beginning in 2006, we began collaborating with external colleagues to begin studying MC-FP. In 2012, we hired internal staff to conduct evidence-based research on MC-FP. The list of publications in peer-reviewed journals may be found here: www.theabfm.org/research/topic.aspx

To date, this growing body of evidence shows a positive relationship between maintenance of certification and patient outcomes. In addition to our own work, the American Board of Medical Specialties maintains a website for published articles across all specialties: evidencelibrary.abms.org

Issue 4: The Future of MC-FP

As you have heard before, the ABFM strategy is to move from an organization that simply measures knowledge to one that measures quality outcomes and helps family physicians deliver the best possible care to their patients. However, it will take some time and effort to reach this goal. In the meantime, we must work to continuously improve the assessment tools that we currently use.

While the ABFM remains aware that the first generation of MC-FP activities can always improve, the ABFM and its Board of Directors are committed to working toward a better system that is more integrated into what physicians do each day. An article from our most recent newsletter highlights two of these efforts to make your ongoing QI activities seamlessly integrate into the MC-FP requirements (www.theabfm.org/about/newslettersummer.aspx). In addition, your constructive feedback has led to many positive changes in the MC-FP process. Just this week we made over 40 updates to SAM questions. Nearly all of those updates were generated by comments made by family physicians regarding newer research in some aspect of medicine. We are continuously searching for ways to make the process more convenient for our physicians while also continuing to maintain its effectiveness.

Another newsletter article related to you our vision for the dynamic, real-time assessment of quality data from physician practices using technology that would constantly query the electronic health record (Winter 2012 — www.theabfm.org/about/newsletter.aspx). Doing so would allow us to assess practice data and repurpose it into quality dashboards that would allow you to continuously monitor and improve the quality of care that you deliver to your patients. We have embarked on the development of this next generation Part IV product this year, and while we know that it will take many years to develop this technology, we believe that it is the right thing to do to further promote your efforts to deliver excellent care.

The vast majority of family physicians continue to participate in MC-FP, and we continue to look for ways to make the process better. We have always encouraged your constructive feedback and will continue to work to make all of our products better. Thank you for all you do for the benefit of the patients and communities you serve.

Sincerely,

Carlos Roberto Jaén, MD

I read this and laughed.  Before I could rip them, someone sent me the letter they replied with.  It is perfect:

Dr. Jaen,

1- I am delighted that you chair both the San Antonio program and the ABFM. Don’t try to tell us that you have any idea about running a practice or a small business… or how to tell when we’re being hustled.

2- An honest organization that selects “…the establishment of training standards…” would de facto exclude itself from the sales of products required for certification. ABFM is prima facia dishonest in the way it has forced this entire invented product line onto unwary Family Docs.

3- Why are “…research, leadership development, … and collaboration with other organizations to promote the health of the public…” even a part of the ABFM mission? That is the role of membership organization as you insist that you are not. Mission creep is not tolerable where certification is enough.

4- Those of us who are voracious consumers of CME do not have time for fluff.. Your time estimate is self generous. It is also unjustifiable. After completing a 3 hour CME on pain management, I was then told that to get SAM credit, I would have to pay an additional $200 and spend 2-4 hours of my time doing a chart review to complete the SAM. Exactly how was that going to improve the care I give my patients? Swing and a Miss on cost and time. You can’t just impound my CME time as wholly owed to ABFM and call it even on time. You invented a new product line and then demanded it be purchased on penalty of losing certification. Not honest.

5- Yours is an entirely new time demand that is added on, not substituted, for those of us who wish to have a choice in CME purchases.

6- Cost. This a new cost. How dare you rave about your cost of doing business -developing questions and modules- as though it were some great feat? That is how business is done. I get the feeling that you have no idea about how to run a real business. Further, let us not get too wound up in the fact that testing -from the SAT to the MCAT to the ABFM- has changed in the form of testing centers. The simple fact that you are both requiring the specific CME selections and selling -as the only purveyor- the same selections, is wrong.

7- The evidence. Let us start with the fact that this behemoth was started with no evidence. Just required. And just happens to generate millions of dollars of revenue. Exactly who is going to believe that once established ABFM would fail to find it very successful? I read your take as “ABFM is gonna retool this shaft any way it has gotta to sell it”.

“To date, this growing body of evidence shows a positive relationship between maintenance of certification and patient outcomes.”

ok, let’s look-
Peterson et al – ‘incorporating MOC into residency training’ Swing and a Miss. That is training, not patient outcomes. It also suggests that you are degrading residency training into teaching to the test… not a proud time.

Galliher et al- from???JABFM??? really? you think this is a reasonable way to justify your product? Although I gotta admit, it does prove that Docs run though your modules learn how to toggle the right box on electronic records. As for ACTUAL patient out comes “…the association between activity undertaken and specific improvements is difficult to demonstrate.” Swing and a Miss

Lipner et al, CONCLUSIONS Certification boards should continuously try to improve their programs in response to feedback from stakeholders, changes in the way physicians practice, as well as the growth in the fields of measurement and technology. Keeping pace with these changes in a responsible and evidence-based way is important. Did you mean to say Patient Outcomes? Swing and a Miss. I’m starting to feel that this is just a bunch of fluff.

O’Neill et al, “…perform better on the ABFM certification…” You are not listening. Swing and a Miss.

Puffer et al, twice, only discus what sad little lemmings Family Docs are. Swing and a Miss. (twice)

O’Neill in press and Sumner et al are not available for review. You do not get the benefit of this huge doubt here.

Xierali et al is another lemmings article.

Yup, not a word about PATIENT OUTCOMES. This has all of the feel of a sham. I am assuming that you put your best evidence up front. Up front, I find no evidence.

In the future, I definitely see the ABFM working to maintain its grip on the very lucrative CME market.

I do not suspect that the public will be entirely tickled to hear that you, or any other entity is working towards a constant online monitoring of their most private medical information. The public has seen super security US government systems and hugely wealthy industry systems hacked with no arrests. There will be no confidence in this intrusion by self assured, self serving academics peddling their wares.

I am still not buying what you have to sell. You, sir Emperor, are nude.

Sincerely,
David D. Fitzpatrick MD

Nice job, Dave!!

 

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