Where The Truth Lies by Pat Conrad MD
There are different ways to lie. The most direct of course, is just an absolute falsehood, easily disproven. The more dangerous are the indirect lies, suppositions and insinuations along the lines of “Now I’m not saying my political opponent would actually beat his wife…” The indirect approach has been turned into a very profitable art form by the ABMS.
The American Board of Medical Specialties was given a huge cash cow by that damned Institute of Medicine study in 1999, and has been milking us ever since. Richard Hawkins, president and CEO of the ABMS, assures us the ABMS-enforced Maintenance of Certification is both an objective measure of physician worth, and that it improves patient care. Hawkins states that “physicians do not always accurately self-assess the areas of practice in which they may need improvement.” Hmm, sounds reasonable, even if earlier generations of doctors did a great job of keeping up all on their own. The non-profit Joint Commission on Accreditation of Healthcare Organizations was created to do good through standardization, and became a hugely expensive, punitive, self-serving body that now cannot be excised from hospitals no matter how idiotic or deleterious (remember to lock up that sterile water). The ABMS has provided a similar model, arguing for reasonable-sounding standardizations that rapidly became an extortion racket, backed up by self-serving proponents anxious to preserve their power and lucrative salaries gained off real doctors’ efforts (Hand washing module, anyone?).
“There is a substantial amount of evidence indicating that participation in a continuing certification process improves patient care.” Actually, the best you can argue is that the MOC is pushing more docs to practice the way they are told.
The ABMS touts a study of “improved asthma action plans” and a decline in exacerbations as a result of the MOC. They do NOT show that any decline in exacerbations is statistically significant against the larger population of physicians with pediatric asthma patients, only that those “participating” did better. No, I’m not against quality improvement. But when the CEO of the ABMS pushes a study that from their subordinate American Board of Family Medicine, I’m already more than skeptical. The federal government wants to mandate the Physician Quality Reporting System for all docs; the ABFM gins up a study that shows better blood sugar control when combining their Performance in Practice Modules with the government PQRS. So the ABFM forces doctors to pay for a PPM to measure quality; the government forces doctors to report “quality.” This measuring and reporting is combined in a study to satisfy both parties, then is pushed by the ABMS as purporting to improve health care. All of this is done to satisfy external organizations that can threaten the physician’s livelihood. None of it is done with any input from the individual patient, an afterthought whose best use is as the raw material for all of this quality. Argue with any of this and you hate quality.
And then the lies start slithering in.
“There is no evidence that the cost of participating in MOC is raising consumer health care costs…” Even if that is true, what about raising MY additional costs that I cannot pass along to the customer? Whether $5 or $5,000, it’s MY money – what gives you the right to pick my pocket? You imply that no one’s costs went up, and it took a fair amount of pricier, extra-hoppy IPA to wash out the taste of that last re-cert exam.
Hawkins claims that MOC doctors cost Medicare less per patient. The MOC requirement showed no statistical significance in the growth of the annual hospitalization rates, but claims an improved per beneficiary cost of $167/year, “a small reduction in the growth differences of costs for a cohort of Medicare beneficiaries.” Not the “total cost” as claimed by Hawkins, but he’s hoping you will read it that way. The study referenced here states: “Ambulatory care–sensitive hospitalizations are hospitalizations triggered by conditions thought to be potentially preventable through better access to and quality of outpatient care.” “Thought to be”…’potentially preventable”…”better access to and quality of”…these aren’t even objective terms, they are first-year med student slogans. Hawkins’ claim that this proves that MOC represents $5 billion in annual savings is as dumb and dishonest as the average statement from the average U.S. senator.
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“ABMS and its Member Boards rely on a highly trained and specialized workforce including psychometricians, assessment professionals, and medical educators to develop, evaluate, validate, and administer Board Certification programs…” Yes you fatuous ass, I remember that highly trained professional literally checking my pockets, and running a metal detector over be EVERY TIME I came back from taking a leak during the middle of that pointless re-cert exam. You want to use this MOC extortion to engender more public trust in physicians, when you can’t even trust them to go to the bathroom without cheating during a test so long and fast as to render cheating impossible even if it were open-Google.
Hawkins: “ABMS has a longstanding policy that Board Certification and MOC should not be a requirement for licensure…Board Certification is voluntary and physicians have alternatives to ABMS Board Certification.” Here again, he may not be telling a directly factual lie, but Hawkins you are lying your ass off by implication. The vast, vast majority of physicians take the MOC because they are forced to by the hospitals and insurance companies, that will not allow them to work in their facilities, or pay them without your extorted recertification. MOC may not be required for licensure, but letting it lapse means loss of employment, and you damn well know it. In fact, you rely on it for your extorted cushy income
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“It stands to reason that the greatest expenditure is in staff compensation, and its executive compensation is aligned with like non-profit organizations.” Just like the ABFM’s Dr. Puffer, who makes $800K/year without having to see patients?
Hawkins, I challenge you: if the MOC is really as beneficial and necessary as you claim, then physicians would WANT to take it and wouldn’t need to be forced. So have your lapdog subordinates like the ABIM and ABFM make MOC voluntary, and free. Make all board certifications lifelong, and you all truly work not for profit, but for the satisfaction of making us all better. Then have your subsidiary groups run some more studies on the MOC, participation rates, quality improvements, and money saved. If you need to make up the personal income, I hear there is a doctor shortage that is worsening. Maybe you could see some patients.
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I have been a physician for over 45 years. As I reflect on past, trying to make some sense of what we have become and what we now represent, I , distressingly, cannot imagine starting out on this journey again. Nothing brings those feelings of despair closer to home than the humiliating experience portrayed by Dr Vassallo in these comments.
When I quit the MOC they tried to claim that the improvement of physicians’ board scores over their careers was due to their requirements. I had just taken over a primary care practice where for the first time the charts contained all the consultants’ notes, and I was learning so much I told them it’s more likely from many years of seeing those.
And even traditional boards have one major flaw. As a patient, would you want your doctor to be right 75% of the time on some trivia that was never urgent and you’d probably have a specialist for or she could look up, or would you rather they knew 95% of what is essential to avoiding errors in primary care and all but the incompetent would find too easy? The idea of making a test hard enough so that the scores spread out over a wide range is for the purpose of ranking the test takers, not for ensuring competence. They didn’t even understand this feedback.
I took the IM MOC exam this Friday and can’t say I’m a happy about my experience. Forget the months of endless MKSAP questions (over 4000), and reduced patient care. The whole exam itself seemed like a maze of “I gotcha!”
I arrived to the test center, and had to be “buzzed” in though the main door. Once inside I had to show two forms of ID, and have my photo taken. I was instructed to place my belongings into a locker and proceed down a hallway.
At the end was a pleasant lady who scanned my palm, and then had me ensure that all my pockets were empty. From there I had to pull up my sleeves, and do a self pat down. Here’s the ridiculous part. I had a pretty good cold going, cough, congestion and nasal drainage. I had one of the travel packs of Kleenex with me. I was told that I couldn’t bring that in, that the testing center would have to provide the tissue during the exam! When I went to obtain a third tissue, I was told I could only have TWO TISSUES for the 120 minutes of the exam!
By the fourth hour my nose was running pretty good and the two tissues couldn’t keep up. I had to wave for some assistance, be escorted out and get swap out my used tissue for fresh ones. On my time!!
Now let’s get to the exam itself. For the first block it was pretty straight forward, pretty much what I expected. Then came blocks 2-4 where we got to use Uptodate for a resource. Sounds great! Right? Not so much. The answer choices were like splitting hairs. Now due to my “integrity pledge” I can’t point to specific questions, but I can tell you that there were two answer choices that would apply. I even confirmed this with Uptodate. I thought the whole point of the exam is to see if I am competent, not play medical nit picky.
There was a lot riding on this exam. I’m a solo practitioner, and have been informed by Blue Cross that if I don’t have it completed by August 2018 I will lose all BC contracts. This amounts to 50% of my practice. So I had a “little” pressure going in.
I haven’t slept well since the exam, and will be on pins and needles until the results are in. I may have to come up with a plan B if I fail. That may mean letting staff ago, and cutting ties with some long time patients. 255 Questions can erase 11 years of a practice that I have worked hard to build.
BTW I have one of the highest quality ratings in my P.O. and with BC. We are also PCMH certified.
Three words: Direct Primary Care