Wednesday, November 19, 2014

My Interview at AHA 2014 on ABIM's Maintenance of Certification Program

Thanks for C. Michael Gibson, MD for hosting an interview with me on my concerns with the American Board of Medical Specialties (ABMS) / American Board of Internal Medicine's Maintenance of Certification Program earlier today on his Clinical Trial Results website. A direct link to the interview is included here (if you're using a mobile phone, click the "Download video" link on the webpage).

As the physician groundswell of opposition to the ABMS's proprietary MOC program grows, physicians (especially younger physicians) must understand the complex forces that are intervening between the doctor and patient. The ABMS/ABIM Maintenance of Certification Program is just one of these forces. I encourage all doctors to educate themselves by reviewing the materials collected about MOC at changeboardrecert.com. It's an excellent resource from a variety of physician voices around the United States. Overseas doctors, too, should be aware that the ABIM is extending its tentacles there as well (video), all without any independently-verified evidence base upon which to impose their program as a physician quality or patient safety measure. Doctors must understand the importance of becoming more involved in preserving our profession by becoming more politically engaged.

It is interesting that the AMA just adopted the following new "Principles for MOC" in their press release of 10 Nov 2014:
The MOC principles will now include:
  • MOC should be based on evidence and designed to identify performance gaps and unmet needs, providing direction and guidance for improvement in physician performance and delivery of care.
  • The MOC process should be evaluated periodically to measure physician satisfaction, knowledge uptake, and intent to maintain or change practice.
  • MOC should be used as a tool for continuous improvement.
  • The MOC program should not be a mandated requirement for licensure, credentialing, payment, network participation or employment.
  • Actively practicing physicians should be well-represented on specialty boards developing MOC.
  • MOC activities and measurement should be relevant to clinical practice.
  • The MOC process should not be cost-prohibitive or present barriers to patient care. The policy encourages specialty boards to investigate alternative approaches to MOC and directs the AMA to report annually on the MOC process.
The American Board of Medical Specialties (ABMS) is the organization responsible for developing the MOC process. ABMS works with its 24 member boards in the ongoing evaluation and certification of physicians.

AMA policy supports physician accountability, life-long learning and self-assessment. The AMA will continue to work with the appropriate organizations to ensure the MOC process does not disrupt physician practice or reduce the capacity of the overall physician workforce. In June, the AMA and ABMS convened stakeholders in Chicago to discuss Part III of the MOC exam, focusing on the value of MOC Part III and innovative concepts that could potentially enhance or replace the current thinking around the secure exam requirement of MOC.
On first blush, this seems so promising. But we should appreciate that the ABMS and ABIM was an earlier spin-off of the AMA, making those of us familiar with these facts suspect.

Similarly, the Pennsylvania Medical Society, just released their "statement of principles" for MOC that sound eerily similar:
The Pennsylvania Medical Society is committed to lifelong learning, cognitive expertise, practice quality improvement, and adherence to the highest standards of medical practice. The Pennsylvania Medical Society supports a process of continuous learning and improvement based on evidence-based guidelines, national standards, and best practices, in combination with customized continuing education.

The Maintenance of Certification (MOC) process should be designed to identify performance gaps and unmet needs, providing direction and guidance for improvement in physician performance and delivery of care.

The Maintenance of Certification (MOC) process should be evaluated periodically to measure physician satisfaction, knowledge uptake and intent to maintain or change practice. Board certificates should have lifetime status, with Maintenance of Certification (MOC) used as a tool for continuous improvement.

The Maintenance of Certification (MOC) program should not be associated with hospital privileges, insurance reimbursements or network participation.

The Maintenance of Certification (MOC) program should not be required for Maintenance of Licensure (MOL).

Specialty boards, which develop Maintenance of Certification (MOC) standards, may approve curriculum, but should be independent from entities designing and delivering that curriculum, and should have no financial interest in the process.

A majority of specialty board members who are involved with the Maintenance of Certification (MOC) program should be actively practicing physicians directly engaged in patient care. Maintenance of Certification (MOC) activities and measurement should be relevant to real world clinical practice.

The Maintenance of Certification (MOC) process should not be cost prohibitive or present barriers to patient care.

While these "principles" from the AMA and the Pennsylvania Medical Society address many of physicians' concerns regarding these programs, both potentiate the concept of Maintenance of Certification (MOC), despite the many problems we've identified with this "program" to date (see here, here, here, and here for starters).
Neither of these "principles" insist on researching the unintended negative consequences of the MOC program on physicians should they fail to re-certify, especially since failure rates of this program is 22%.
So why have these two prominent organizations suddenly produced these two similar documents? Might it be to distance themselves from anti-trust concerns with MOC that continue to weave themselves through the courts? Might it be because they see the ABIM becoming irrelevant as more revelations of the management of these organizations comes to light? Might the AMA still want to perpetuate the loss of physician autonomy to gain favor with large hospital systems that are being created by our new health care law today?

We must wonder.

These are big issues. For young doctors overwhelmed with the realities of beginning practice, taking another test seems the easier option than confronting these realities. But all of us as treating doctors must not sit idly by as our autonomy is increasingly usurped and corrupted to benefit the system rather protecting the real health care needs of our patients.

-Wes

Monday, November 17, 2014

J. Rod Gimbel: Crowdsourcing a Consumer Safety Issue

The following is a guest post by J. Rod Gimbel, MD, a cardiac electrophysiologist from Knoxville, TN who has written extensively on the issue of electronic surveillance systems and electromagnetic interference with cardiac implantable electronic devices:
I’d like to express my appreciation for allowing me to guest post in this space.

This is about crowdsourcing a consumer safety issue; specifically the public safety of consumers who happen to have CIEDs (cardiac implantable electronic devices) such as pacemakers or implantable defibrillators (ICD). Nearly 2 million such consumers (patients) have CIEDs in the U.S. alone. As you know, these devices are susceptible to EMI (electromagnetic interference). Simply put, the lead(s) act like antennas and can pick up stray EMI from any number of sources and cause the device to malfunction by either withholding therapy (no pacing or ICD rescue therapy) or through delivery of inappropriate therapy (delivering pacing output or shocks where none is needed). Either situation can be life threatening.

One source of EMI that can affect a CIED patient is electronic article surveillance system (EAS). Such systems are widely used by retailers (ref) to deter and prevent store theft, a problem commonly referred to as “shrinkage”.

About 8 years ago, an ICD patient that I was caring for received inappropriate shocks from his ICD after being near an EAS system located in a big box retailer. A colleague of mine related a similar situation where a pacemaker dependent patient reported syncope in the proximity of an EAS system after her pacemaker inhibited in response to the EMI from the EAS system. These were two disturbing, potentially life threatening events. In hopes of raising awareness of this serious problem (EAS-CIED interaction), we generated a manuscript detailing the events that was published in 2007 in the Mayo Clinic Proceedings. Notably, the New York Times picked up the story. Others have published similar unfortunate misadventures between patients and EAS systems.

Several common sense recommendations have been made in this area; recommendations that preserve a retailer’s right to deter and reduce theft (a legitimate concern), but still protect CIED patients from adverse interactions with EAS systems. For instance, after receiving reports of several adverse events caused by EAS systems the Food and Drug Administration (FDA) issued a “Safety Communication” and noted:

  • Be aware that EAS systems may be hidden/camouflaged in entrances and exits where they are not readily visible in many commercial establishments.

  • Do not stay near the EAS system or metal detector longer than is necessary and do not lean against the system.
Beyond this, we and others also suggested:
  • Retailers should not "camouflage" the EAS pedestals with advertising as this may prevent customers with devices from recognizing the threat and may actually draw device patients toward the EAS pedestal.

  • Retailers should not place goods and services near the EAS systems that effectively encourage the patients to violate the "don't linger, don't lean" dictum that physicians tell patients who have devices.

It seems entirely reasonable to suggest a shared responsibility between medical device professionals, device patients, retailers, and EAS system manufacturers. It was hoped EAS manufactures and retailers would do their part and embrace these simple recommendations and help make retail spaces safe for those with implantable devices. Unfortunately, this does not seem to always be the case.

Figure 1: Bench to "relax" placed adjacent to a camouflaged EAS pedestal at big box retailer.
Figure 2: Chair to "relax" placed adjacent to EAS pedestal while patient waits for prescription to be filled at retail pharmacy store.
Figure 3: Complimentary coffee station where device patients might linger placed adjacent to EAS pedestal at big box retailer
These pictures were taken in the last several months around the country. Clearly, the juxtaposition of EAS systems and consumer areas may undermine the dictum “don’t linger, don’t lean” and leave device patients in harm’s way. Who then, is responsible for the safety of device patients in this situation?

Finally, perhaps in an attempt to thwart a determined and “informed shoplifter” who may employ several methods that might undermine the effectiveness of EAS systems, “there are also concerns that some installations are purposefully configured to exceed the rated specifications of the manufacturer, thereby exceeding tested and certified magnetic field levels.” This may increase further the risk of adverse reactions experienced by device patients when near EAS systems.

Now for the crowdsourcing part:

A presentation on this topic (CIED-EAS interactions) to an extra governmental regulatory group helping set standards for the device industry is to be given soon. This presentation will be to a number of interested parties including representatives of the EAS manufactures, device manufactures, and the FDA. As noted above, the “event rate” of these interactions is rather low, but as has been suggested significant under-reporting may obscure the true significance of the problem. It is surely recognize that not everyone has the time or inclination to write up adverse events for publication or inclusion in a database. Perhaps, some events go entirely unrecognized for what they really are, being passed off as “Oh, Mom passed out at the store today, but she’s OK now”.

With your help a strong presentation and case can be made emphasizing CIED-EAS interactions are an important public safety issue. Your voice and concerns can be heard. First off, send pictures where you see EAS systems placed in a manner that might endanger a device patient (like the ones shown above). Cell phone pictures are just fine. Second, if you are a health care provider or patient, please send any “events” that you may have experienced describing an adverse interaction between an EAS system and pacemakers and or ICDs. Please post the items here or send items of interest to J. Rod Gimbel, MD (gimbeljr@gmail.com). Your response is of course appreciated and in confidence and any presentation of the material provided will be anonymized. Upon completion of the presentation, a link will be posted here.
This is an important effort that Rod is undertaking on behalf of patients with CIEDs. I hope patients and health care providers will come forward with examples of EAS systems or EAS interference in their locales to assist him in this important consumer safety effort.

-Wes

Tuesday, November 11, 2014

Happy Veteran's Day

(Click image to enlarge)
Found this picture today in my basement from around 1996 when I has a staff cardiologist/cardiac electrophysiologist at the National Naval Medical Center, Bethesda, Maryland. There were so many great folks with whom I had the pleasure and honor to work beside, yet many of whom I've lost touch with, sadly.

It's fun to look back and see the the old cath lab equipment - including (dare I say it) the FILM canisters!  My, how far we've come!

Here's wishing all of these great doctors and corpsman a Happy Veteran's Day, wherever their paths have led them since. 

-Wes

Thursday, November 06, 2014

Excellent Sheep

"I was teaching a class at Yale on the literature of friendship. One day we got around to talking about the importance of being alone. The ability to engage in introspection, I suggested, is the essential precondition for living life of the mind, and the essential precondition for introspection is solitude. Many students took this in for a second - introspection, solitude, the life of the mind, things they had not been asked to think about before - then one of them said, with a dawning sense of self-awareness, "So are you saying that we're all just, like, really excellent sheep?"

All? Surely not. But after twenty-four years in the Ivy League - college at Columbia; a PhD at the same institution, including five years as a graduate instructor; and ten years, altogether, on the faculty at Yale - that was more or less how I had come to feel about it. The system manufactures students who are smart and talented and driven, yes, but also anxious, timid, and lost, with little intellectual curiosity and a stunted sense of purpose: trapped in a bubble of privilege, heading meekly in the same direction, great at what they're doing but with no idea why they're doing it. I published an essay that sketched out a few of these criticisms. Titled "The Disadvantages of an Elite Education," the article appeared in the American Scholar, a small literary quarterly. At best, I thought, it might get a few thousand readers.

Instead, it started to go viral almost the moment it came out. Within a few weeks, the piece had been viewed a hundred thousand times (with many times that number in the months and years to come). Apparently I'd touched a nerve. These were not just the grumblings of an ex-professor. As it turned out from the many emails I began to get, the vast majority from current students and recent graduates, I had evoked a widespread discontent among today's young high achievers - a sense that the system is cheating them out of a meaningful education, instilling them with values they rejected but couldn't somehow get beyond, and failing to equip them to contract their futures."
 - William Deresiewicz
"Excellent Sheep: The Miseducation of the American Elite and the Way to a Meaningful Life, Free Press, New York, 2014.
Sounds an awful lot like the concerns I hear from medical students, residents, and young physicians today, doesn't it? They are excellent test-takers, rule-followers, and lock-step thinkers, for these things help people succeed in medical school.  But add the burdens of seemingly insurmountable debt, regulatory testing and re-testing, and data entry mandates that mean more to their pay than actual visits to the bedside, I wonder how many our our new physicians will be willing to really work to evoke change on behalf of their patients rather than working with the system that drives them to do otherwise.

I worry when we're breeding really excellent sheep, I'd much rather they were breeding cowboys.

-Wes

Tuesday, October 28, 2014

The Wonders of Role Reversal

Another day, another pacemaker, at least so it seemed at first.

The usual greeting the patient, answering the last questions, consent signing, placement of the IV, EKG leads, prepping of the surgical site and initiation of the pre-operative antibiotics were all recent memories.  He laid there, smiling, knowing he'd made the right decision after years of struggling with his arrhythmia in other ways.  His heart was showing signs of slight weakening and his arrhythmias remained too fast despite a multitude of therapies, so he had agreed to proceed with placement of a biventricular pacemaker with later ablation of his AV node some weeks later after his surgical wound was well-healed.

The nurses and technicians in the room were wonderful, reassuring the patient as they moved him to the narrow procedural table.  More wires were connected to monitors and a blood pressure cuff placed. The instrument table laid ready, and the patient's choice of soft rock could be heard faintly in the background.  The pre-sedation note was completed and checklists reviewed.

Meanwhile, I donned by lead, bouffant hair net, headlamp, and face mask, then scrubbed for the procedure.  Shortly thereafter I turned to open the procedure room door with my backside and was quickly greeted to a hearty "Time Out!"  The patient's identity and procedure confirmed, I could see the patient smiling:

"We lawyers like to hear those things," he said.  (Yes, he was a lawyer.*)

"Nurse, make sure you give him a ton of sedation - he'll need it, okay?" I joked.  We laughed together at the thought.

"1 of Versed and 25 mcg of Fentanyl," the nurse shouted to the control room.

"1 and 25," the control room answered.

He and I had struggled together with his arrhythmia for years, finally agreeing that this option at this stage in his arrhythmia's progression would be best. 

I made my way to his side and once again prepped his chest with chlorhexidine prep sticks, letting each dry before the next was applied.   The surgical sight was then drapped to provide an island of an orange plastic film surrounded by a sea of blue paper covering.  Other drapes were secured and a pocket for instruments was made.  "Everybody have lead?" I asked.  The x-ray system was enabled, then the pacemaker system analyzer cable, a SiteRite ultrasound probe and Bovie pen made ready.   All was set to begin.

"Mr. Jones (not his real name), I'm going to start to numb your skin with the local anesthestic.  This will sting," I said.

"Okay..." as he braced himself for inpact.  Then:

"Come-on, doc, you can do better than that!..." as if to mock me, jokingly.

"Yes, I can, " I countered, then proceeded to administer more anesthetic to the area.  As the area became more anesthetized, his shoulder seemed to relax.  No doubt the Versed helped a bit, too.

I continued, locating the appropriate spot, then performing the incision.  He was unaware.  The pocket was created first, then I found the vein and placed the first lead without a problem.  Badda bing, badda boom.  Now for the next…

Then, out of the blue:

"Doc, I heard you're having a knee replacement ... "

"Just a partial, I hope ..."

"Hey, I just want to tell you.  It's the best thing I ever did. Listen, it's not as bad as you think, but there's quite a bit you have to be ready for…  Don't forget to preload the Miralax - that iron supplement before the procedure to slow you down and then the narcotics afterward to stop you up: it's a Machiavellian ploy by those orthopedic surgeons to assure your discomfort."

I chuckled as I thought about this.

"And whatever you do, take the pain medication before physical therapy.  I had a physical therapist threaten to fire me when I failed to take the pain medication 45 minutes before therapy.  And get rid of all those rugs.  It really helps to plan your trips when you get up.  Think about what you need and what you might need to limit your trips.  I'm telling you, this saved my life.  You know I'm writing a book about stuff like this... I'm waiting on the proof. Don't come back too soon.  Have you completed your FMLA forms yet?"

"What?"

"FMLA.  Look it up.  Loads of fun.  Anyhow, be nice to your wife - you're gonna need her.  Trust me on this..."

And on and on it went: patient treating doctor, until his pacemaker was done.  Then, finally, I had a chance to reciprocate:

"I'm closing."

"Thanks, doc, and good luck.  You're going to do fine."

-Wes


* ... yes, he gave me permission to tell this story.

Tuesday, October 21, 2014

Reviewing The Regulators

In 1990 the American Board of Medical Specialties (ABMS) and the American Board of Internal Medicine (ABIM) changed their requirements for physician board certification from a voluntary life-long designation and educational process to a time-limited designation lasting 10 years.  This decision to require repeated testing, the public was told, was based on data from a single highly flawed retrospective literature review that suggested physician competence deteriorates over time.  Despite this, over the ensuing years hospitals and insurance companies increasingly require physicians to be board certified for credentialing or billing purposes.  And as a result of changing the life-long designation of board certification to a temporary one, physicians were left with little choice but to pay for and participate in the ABMS/ABIM MOC program to practice their trade.

In 2005, the ABMS modified their re-certification requirements and created a program called "Maintenance of Certification" (MOC).  This program required completion of "Practice Improvement Modules" in addition to the completion of certain knowledge-base testing modules before a physician could sit for their secure re-certifying examination.  This decision to include "Practice Improvement Modules" was a unilateral one by the ABMS and its subsidiaries and was never scientifically challenged or validated by the independent physician community.

This year, the requirements for MOC changed again when all US physicians were now required to pay for and participate in the ABMS/ABIM MOC process every two years, in addition to re-taking their certifying examination every 10 years.  Because of the added cost and time requirements with the most recent change to the ABMS/ABIM  MOC process, physicians began questioning the MOC program's legitimacy as a means of assuring physician quality verses the ABIM's bottom line.  An online petition was signed by over 18,850 physicians asking to "recall the changes to MOC and to institute a simple pathway consisting of a recertification test every ten years."   In his response to this petition and to support the credibility of the MOC process, the President and CEO of the ABIM referred to the research conducted by the ABIM leadership and staff:

"There is a good deal of research demonstrating the value of MOC: from the validity of the examination, to the importance of independent assessments – clinicians are not good at evaluating their own weaknesses. All of this research drives and informs our program requirements and product development."  

Review of the ABIM’s "research" topics showed they cover a wide range of important clinical care issues including trust, teamwork, ethics, obligations of the Hippocratic Oath, characteristics of internal medicine physicians and their practices, teaching, staffing patterns, electronic health records, clinical skills, and the structure of medical homes. But closer inspection of much of this work shows it was not research, but rather opinion and editorial.  Much of the "research" resides behind expensive online paywalls free to the academic community, but expensive for the non-academic physician and public to review.  Given these realities, before casting aspersions on physicians' ability to evaluate their own weaknesses, it appears a review of the ABIM's "research" in regard to its clinical legitimacy is in order.

In 2014, the Center for Medicare and Medicaid Services (CMS) published the entire database of $77 billion dollars of payments made to US health care providers in 2012.  The data are easily reviewed using a website created by the Wall Street Journal.  In an effort to establish the credibility of the ABIM leadership and staff's journal publications as it pertains to the various aspects of medical practice they claim to actively monitor, each author published in the 2014 collection of journal articles published on the ABIM website was cross-referenced with their CMS 2012 Medicare provider payment data.

Methods

 The ABIM publishes journal articles authored by ABIM staff and leadership for the years 2000-2014 on its website.  The 31 articles published so far in 2014 were randomly selected for review. Each author of each paper was then compared to their 2012 Medicare payment data.  If the payment data for a particular author were non-zero, then the total number of inpatient and outpatient new and existing patient encounters were totaled to determine the total 2012 annual Medicare patient care encounters seen by the author.  Procedure counts were not added to this total of encounters, since the intent here was to "even the playing field" between "proceduralists" and hospital- or office-based clinicians in terms of the number of patient contact episodes they had each year.  In the event more than one physician author's first and last names were identical, the source article was reviewed to assure the proper physician data was obtained based on their city, state, or academic institution.

Authors designated as employees of ABIM, those with acknowledged conflicts of interest or those with non-academic or policy affiliations were also recorded. The average, median and standard deviation of 2012 Medicare payments and patient encounters were then calculated.

As a point of reference, the author of this blog post received a total of $163,184.55 in Medicare payments representing 529 patient encounters (298+75+13 established outpatient visits, 31 outpatient new visits, 82+14 initial hospital/inpatient care and 16 subsequent hospital care visits) according to the 2012 Medicare database. This number of encounters represented 1.5 days of outpatient clinic visits per week in 2012 (personal data) as well as inpatient patient care encounters payments received from Medicare patients. This encounter volume represented 42% of this author’s total number of clinical encounters billed in 2012 (personal data).

 Results

Thirty-one articles published by the ABIM staff and leadership in 2014 (so far) represented work by 150 authors.  Of the 31 articles published on the ABIM's website to date for 2014, ten of them (33%) were published solely by ABIM employees or leadership. Only 80 of the 150 authors held an MD degree.  The authors were a heterogeneous mix of US and non-US physicians, one veterinarian, nurses, students, statisticians, researchers, representatives from National Board of Medical Examiners, Center for Medicare and Medicaid Services, the Urban League, the Foundation for Advancement of International Medical Education and Research, Mathematica Policy Research, Inc., the National Collaborative for Improving Primary Care Through Industrial and Systems Engineering, the VA medical system, staff members of the American Board of Internal Medicine Foundation, and others from Consumer Reports Health.

Clinical Involvement

Of  physicians with an MD degree, the average 2012 Medicare payment amount was $18,196.97 ± $68,220.55 (median $0). Only thirty-seven of the 80 physician authors (46%) had Medicare payments paid to them in 2012.  Three authors had payments exceeding $100,000 in 2012 while the vast majority (30 of the 37) received under $25,000. This average payment amount corresponded to an average of 131 ± 308 patient encounters (median 0) for the entire year 2012.

If all of the authors were included in the analysis, the average 2012 Medicare payment was $9705.05 ± $50,502.95. The median Medicare payment to the authors published in 2014 to date was $0. The average number of patient encounters per year in 2014 was 70 ± 234. The median number of patient encounters in 2012 by the authors published to date was 0.

The entire spreadsheet (pdf) of the 2012 Medicare payment and encounter data by each author that published with ABIM leadership and staff in 2014 can be reviewed here.

 Discussion

This study is the first to cross-reference a portion of ABIM publishing authors to the 2012 Medicare provider payment database. While Medicare payment data might not represent the full workload of today's clinical physicians, it is the most complete database of US physician clinical work performed on patients in the United States published to date.

The ABMS/ABIM's Maintenance of Certification program has been criticized by many working physicians as onerous, expensive, time-consuming and a poor reflection of physician quality. In his response to physician concerns over the MOC process, the President and CEO of the ABIM stated:

"ABIM's mission is to enhance the quality of health care by certifying internists and subspecialists who demonstrate the knowledge, skills and attitudes essential for excellent patient care."

Dramatic changes to the health care landscape have occurred over the past five years.  If the mission of the ABIM is to truly certify internists who with “skills and attitudes essential for excellent patient care," we are left to question the legitimacy of recommendations made by physicians who no longer care for patients in today’s health care arena. The ABIM seems content with making recommendations to physicians while being woefully inxperienced about the challenges that face internists today.   In fact, the data presented in their work confirms that physician quality is being regulated by an unqualified body.

While some might argue that regimented study and time-consuming non-clinical data acquisitions are required to assure physician quality, it remains quite possible that such a dishonest and lopsided approach will backfire as physicians refuse to participate in this process or retire early from medicine just as more patients are entering our health care system. Burdening clinical physicians with unrealistic and unproven demands for non-clinical tasks detracts from needed patient care.  Recall that only three of the physicians included in the author list of ABIM's 2014 publications received over $100,000 of Medicare payments while 30 of 37 physicians in the published articles in 2014 received less than $25,000.   Might the recommendations and data that the ABIM is making available to hospital groups and insurance organizations be seriously flawed?

Even a cursory review of the background of the authors of several published works of the ABIM staff and leadership reviewed suggests a troubling narrative. For instance, one article included with the ABIM's 2014 list of journal articles is entitled "Internists' attitudes about assessing and maintaining clinical competence" (J General Int Med 2014; 29(4):608-614).  While this title might seem reassuring to the public that the ABIM is serious about their mission, their credibility becomes suspect when closer inspection of the background of the authors revealed only one of the six authors had any clinical encounters in 2012 and another author was a veterinarian. In another article entitled "Time to trust: longitudinal integrated clerkships and entrustable professional activities," (Academic Medicine, 89(2), pp 201-4) none of the authors received payments for patient care in 2012 and the authors acknowledge the ideas presented were provided by two political "think tanks."  Should these be the people we entrust to develop clerkship ideals and "entrustable professional activities" (whatever that is) for our future physicians?

We should note that despite fourteen years of articles on the ABIM's website, none of the ABIM’s "research" has ever evaluated any negative consequence of their MOC program.  Rather, these ABIM papers "drives and informs" additional unsubstantiated "program development" like a public relations firm. Without independent assessment of their practices, it remains completely possible that the MOC process causes more harm than benefit to actual patient care delivery as a result.

The Medicare payment data of ABIM authors also begs the question, how are the ABIM physicians and legislators spending their time?  It is apparent that most physician members of the ABIM are not involved in clinical care.  Given the conflicts of interest mentioned in the various citations, physician quality assurance is not the ABIM's priority.  Perhaps the physician members of the ABIM would have more credibility advising struggling doctor-employees on beefing up their curriculum vitae, earning consulting fees, perfecting public relations skills, and creating multiple income streams since their annual revenue take with their MOC program implementation went from $46,131,129 in 2010 to $55,625,925 in 2012 (Data from the 2011 and 2013 IRS Form 990 published on guidestar.org/).  Given these data, it is appears that the ABIM is more concerned about padding their resume to (1) create and air of legitimacy, (2) serve a political agenda, and (3) to provide a smoke screen for the high salaries of their board members.

Clearly, busy front-line full-time practicing physicians do not have the time for creating publishing mills or for scientifically meaningless survey collection.  Patients want capable practicing physician availability, not survey collectors. Assuring physician quality should not be about creating and funding a political action committee subservient to a political agenda, but rather understanding the challenges physicians face in their workplace and knowledge base and working collaboratively to offer continuous professional improvement.

Limitations

There are several limitations to this study.  First, because the CMS Medicare payment database does not capture work performed on patients under the age of 65, the database does not accurately reflect the total clinical work load a physician performs each year.  Physicians who do not accept Medicare for payment would not appear on this database.  However, since older patients commonly access our health care system more frequently as they age, it would be expected that internists writing policy for health care delivery would participate in the Medicare government program.  Second, the 2012 Medicare payment data reviewed does not correlate to the year the articles were published in the literature.  However, one would expect that experienced physicians who changed the testing requirements for MOC in 2014 would have recent direct patient care experience to appreciate the many factors that impact physicians today.  Finally, reviewing only one year's literature published on the ABIM's website might have introduced sampling bias.  Still, the sampling of the most recent year offers the advantage of reviewing articles that might affect upcoming policy decisions.

Conclusions

Physicians are not above proving their competence and establishing quality standards, especially if those standards are scientifically sound and transparent.  The legitimacy of the MOC process to assure physician quality should be called into question based on a careful literature review of the many conflicts exposed by this review and the limited recent clinical experience of those that contribute to their evidence base.  Citing numerous publications to legitimize the MOC program creates the illusion that this process of insuring quality care and has been vetted by actual scientific data.  Nothing could be further from the truth.

-Wes

What Signs Would Bureaucrats and Regulators Hold Up?



Nice to see front-line health care workers finding their voice.

I wonder what signs our health care bureaucrats and regulators would hold up?

-Wes

Thursday, September 25, 2014

The Last Reprogramming

He had called the other day to update me up on his condition.  He did not sound upset, but resolute.  "They offered me peritoneal dialysis," he said, "but I decided against it and figured I'd just let nature take its course.  The hospice people are so wonderful - I've got things all set here at home, but I have two questions.  What should I do about my warfarin?  You know, I just don't want to have a stroke.   And what I do about my defibrillator?"

We were colleagues once and grew to be friends later when life's circumstances brought us together. He, a revered senior neurologist and me, a relatively new doctor in town. I could remember overhearing his heated discussions about administrative snafus with colleagues in the hall, or watching a horde of residents and medical students following him into a patient's room to teach at the bedside.

"Of course he didn't want a stroke," I thought.

So we decided to keep the coumadin and let him continue his daily INR checks at home and to turn off just the tachyarrhythmia detections on his biventricular defibrillator.

"I'll come over tomorrow and we'll turn it off," I said.

There was a brief silence, perhaps because of momentary disbelief that I'd do such a thing.  Then he proceeded to give me detailed directions and landmarks to watch for on my way over.  "I'm sure I can find it," I said thanking him.

So the next afternoon after most of the day's events had finished, I grabbed the programmer and drove to his home.  It was an unusually beautiful day - mid 70's, sunny - as if Someone had wanted it that way. There in the yard, was his wife, wearing a large-brimmed hat and holding a hose while pretending to water the shrubs.  She came over to greet me: "Thanks so much for coming over," she said, "I know this means so much to him." Then she realized she was still holding the hose. "Oh, I'm so sorry, it's just that someone has to try to keep the place up," she said, voice cracking.

The "place," of course, was beautiful.  A majestic grande dame of a house - one I would later learn they had occupied for the past 44 years and bought when they were "just kids on the block."  It was meticulousy kept, stately.  I entered with his wife and noticed a shadowy figure two rooms away sitting at the edge of a mechanized hospital bed.  The bed was placed in what must have been his study with a large bay window with a couch next to it.  A reading lamp was over the head of the bed and the walls held books from the floor to ceiling with icons and statues, likely from other, more active time.

"Thanks for coming, Wes," he said, looking up.

"How are you feeling?" I asked, somewhat stupidly.

"Pretty good, considering everything.  See?  My legs aren't quite so swollen and my abrasions all have eschars on them," he noted as only a doctor could.

"Is there a plug nearby?" and he proceeded to point me the way so I could plug in the programmer to do my job while he explained the device to his wife.  The process was quick and I interrogated his defibrillator, then turned off the tachyarrhythmia detections, therapies and now needless alarms. "There, that didn't take long.  All done," I said.

There was a moment of silence as I sat with this man whom I known for so long.  Like a wise sage and hospitable host, it was clear he wanted to talk for a bit, so I slowed my exit.

"You know, I've always appreciated your frankness about my condition," he said. "You're a lot like me in many ways, I think.  You never overstepped, let me have control, to manage things like I wanted to, and I've always appreciated that," he said.

Embarassed by his frankness, I wondered what to say.  At a loss for words, I told him how much I enjoyed meeting his family, wife, daughters, and grand-daughters recently in the hospital.  He looked puzzled, forgetting. "You know, that day I brought my daughter in your room with them?"  His eyes brightened and his smile widened as he remembered. 

"Oh, yes! That was wonderful!  How fast times flies, doesn't it?" he said.

"You know, I wrote about that day in my blog," I mentioned, ".. and included some pictures of my daughter from 10 years ago - about what she thought about medicine - can I show you?"

"Of course!"

So I showed him the picture and we shared our thoughts about family.  Then, to make reading from my iPhone easier, I read him the post I'd written about that day.  We talked about family and what they meant to each of us.  And then he shared with me another nugget, that he grew to become a writer, too.

"You know, I spent some time and wrote an autobiography for my kids not too long ago - over a hundred pages - about everything I could remember - from my earliest years as a child, about my immigrant father and  American mother.  My father made it as a successful lawyer - came over from eastern Europe - I even know the ship - I remember the picture of him standing there with his hat..., and I wrote about my family, influential teachers in grade school, fellow professors, and people that I knew throughout the years - everything.  You should do that, too, you know.  I'm so glad I did.  I gave them to my kids and even made some some extra copies - maybe for the grandkids, in case they want it someday..."  He looked away to see his wife leave the room, trying not to be noticed as tears filled her eyes once more.   She didn't want to him to see her this way.

He stared down at the floor beneath his swollen feet, then continued.

"You know, it was therapeutic for me to write that autobiography.  After all, what we do is terribly isolating for the most part.  No one understands that.  Like you do your procedural stuff and I do my diagnosing.  We do most of it all alone, with no one else there.  Just the patient and the doctor.  Wonderful, to be sure, but isolating.  So many memories.  I guess it helped me to put some of those feelings and the thoughts I had about those I loved into words.  It's hard to capture it all..."

He looked up from the floor and stared in my eyes.  "Thank you," he said extending his hand.

I sat motionless for a bit digesting the gravity of his words, lost in them before I saw his hand.  Once I noticed, I lept up to shake it and gave him a long hug to his increasingly skeletal frame.  It was a brief moment to share together once more and one I now realized I had done too infrequently with other patients in a similar circumstance.  Here he was, an incredible man who'd given so much to his family, fellow colleagues and patients, now teaching me once more so much about life as a doctor, about grace, and about real love.  Just the two of us, isolated again, but as friends. 

With great reluctance I packed things up and found his wife on my way out.  "Thank you," she whispered with swollen eyes, "I just don't want him to be in pain." 

"He's going to be fine," I told her, "... perfectly fine, especially now. He's such a wonderful guy." She smiled and opened the door.

As I drove away I realized we probably won't see each other again - his remaining time here will be saved for others now. There were so many thoughts, so much to remember, so much still to learn. Perhaps because I'd been through something like this before I was more prepared - it's never easy - but I still felt okay about it all - not sad - confident that we did the right thing... 

... together.

-Wes