Measuring the Quality of Doctors and Hospitals: When Is Good Enough, Good Enough?

In the past, neither hospitals nor practicing physicians were accustomed to being measured and judged. Aside from periodic inspections by the Joint Commission (for which they had years of notice and on which failures were rare), hospitals did not publicly report their quality data, and payment was based on volume, not performance.

Physicians endured an orgy of judgment during their formative years – in high school, college, medical school, and in residency and fellowship. But then it stopped, or at least it used to. At the tender age of 29 and having passed “the boards,” I remember the feeling of relief knowing that my professional work would never again be subject to the judgment of others.

In the past few years, all of that has changed, as society has found our healthcare “product” wanting and determined that the best way to spark improvement is to measure us, to report the measures publicly, and to pay differentially based on these measures. The strategy is sound, even if the measures are often not.

Hospitals and doctors, unaccustomed to being rated and ranked like resort hotels and American Idol contestants, are suffering from performance anxiety and feeling an intense desire to be left alone. But we also bristle at the possibility of misclassification: to be branded a “B” or a “C” when you’re really an “A” feels profoundly unjust.

In my role as chair of the ABIM this year, I am awed by the amount of time and expertise that goes into ensuring that the pass/fail decisions of the Board are valid and defensible (legally, if necessary). They are. But as new kinds of measures spring up, most of them lack the rigor of the verdicts of the certifying boards. For example, Medicare is now penalizing hospitals that have excessive numbers of readmissions. As Harvard’s Karen Joynt and Ashish Jha observed in 2012, there is considerable doubt that the 30-day readmission rate is a valid measure of quality, and clear evidence that its application leads to misclassifications – particularly for penalized hospitals whose sins are that they care for large numbers of poor patients or that they house teaching programs. Quite understandably, these hospitals cry “foul.”

Yet the Medicare fines have contributed to a falling number of readmissions nationally – from 19 percent in 2011 to 17.8 percent in 2012, which represents more than 100,000 patients spared an unpleasant and risky return trip to the hospital. While cause and effect is difficult to prove, it seems likely that hospitals’ responses to the Medicare program (better discharge planning, earlier follow-up appointments, enhanced communication with PCPs, post-discharge phone calls to patients) are playing a role. “Readmissions are not a good quality measure,” Jha observed in a recent blog, “but they may be a very good way to change the notion of accountability within the healthcare delivery system.” Medicare’s Jonathan Blum puts it more bluntly. “I’m personally comfortable with some imprecision to our measures,” he said, as long as the measures are contributing to the ultimate goal of reducing readmissions.

With Jha and seven other experts, I am an advisor to the Leapfrog Group’s effort to grade hospitals on patient safety. Using the best available publicly reported data, our panel recommended a set of measures and a weighting system that Leapfrog has used to assign patient safety letter grades to U.S. hospitals. The hospitals that have received “F’s” (25 out of the 2619 hospitals that received ratings) have been up in arms – I’ve received several calls from their representatives, livid about what they believe to be a vast injustice. Yet there is no question that these hospitals are working on improvement with a passion that, in many cases, was previously lacking.

Of course, before getting down to business, everyone’s first two responses to poor grades are to question the validity of the measures and to work on better coding. I know one hospital that received a stellar grade in the Consumer Reports ranking system (one of the several systems now out there), and responded by festooning the hospital lobby and halls with banners. A few months later, when they received a “C” from Leapfrog, their reaction was to inveigh against the methods. This, of course, is natural: we embrace the rankings we like and reject the ones we don’t. But it is largely unproductive.

At a recent conference on transparency, I heard Arnie Milstein, a national leader in assessment and a professor at Stanford, speak about the current state of quality measurement. He described the Los Angeles Health Department’s program that rates restaurants on cleanliness, and mandates that restaurants post large signs with their letter grades (A, B, or C) in their windows. According to Milstein, the measures “would not have passed the National Quality Forum,” the agency that vets healthcare quality measures for scientific rigor. Yet the results were strikingly positive: a 20 percent decrease in patients hospitalized for food poisoning. This raises the central question: “At what point are measures good enough?”

In a 2007 study, Milstein and colleagues asked 1,057 Americans about physician quality measures. Specifically, they wondered what level of potential inaccuracy people would accept before they would not want to see the results. About one in five respondents said that they would want to see a measure even if its rate of misclassification (calling a doctor fair when she is excellent, or vice versa) was as high as 20-50 percent. Another third would not tolerate that degree of uncertainty, but would want access to measures that might be as much as 5-20 percent inaccurate.

Milstein hypothesized that these results might be a manifestation of the public’s famous innumeracy: perhaps these folks didn’t really understand the hazards of relying on such flawed information. So he asked the same question of a group of PhD statisticians at a national meeting. If anything, they were even more tolerant of misclassification risk. “‘P equals less than 0.05’ was nowhere to be seen,” he quipped.

Why were experts and non-experts alike so accepting of misclassification? Milstein came to the conclusion that the measures that they were being offered were better than what they had, which was nothing. Moreover, they probably sensed that public reporting of such measures would not only help them make better choices as consumers, but would also spur the doctors to improve. “Measures can motivate or discriminate,” Yale’s Harlan Krumholz reminded us at the same meeting. And in most cases, they do a bit of both.

Does the public’s tolerance for misclassification give measurers – the ABIM, Leapfrog, or Medicare – a free ride on the “Ends-Justify-The-Means” Express? Absolutely not. Measurers need to do their honest best to produce measures with as much scientific integrity as possible, and commit themselves to improving the measures over time. Medicare’s decision to ditch their four-hour door-to-antibiotic time pneumonia measure in the face of evidence of misclassification and unanticipated consequences (antibiotics at triage for everyone with a cough) is a shining example of responding to feedback and new data. In a recent NEJM article, Joynt and Jha recommend a few simple changes, including taking into account patients’ socioeconomic status, that could improve the readmission measure. The trick is to adjust appropriately for such predictors without giving safety net and academic hospitals a pass, since these organizations undoubtedly vary in performance and many have room for improvement.

Now that I have been on both sides of the measurement equation, one thing that has become clear to me is this: Public reporting of quality measures not only improves the work of the measured, it improves the work of the measurer. Ultimately, a healthcare ecosystem in which reasonable measures help guide patient and purchaser choices will lead to improvements in both the quality of care and of the measures themselves. I believe we can look forward to an era of more accurate measures, measures that capture the right things (not just clinical quality but teamwork and communication skills, for example), and measures that are less burdensome to collect and analyze.

If there were a way of getting to this Nirvana without ever unfairly characterizing a physician or hospital as a “C” when she/it is really a “B+”, that would be splendid. Personally, I can’t see how we can manage that. Seen in that light, the question to ask is not, “Are the measures perfect?” (clearly, they’re not) but, “Is the risk of misclassification low enough and the value of public reporting and other policy responses high enough that the measure is good enough to use?” A second, equally important question follows: “Is the measurer committed to listening to the feedback of the public and profession and to responding to the emerging science in an effort to improve the measure over time?”

Measures that do not meet the first criteria should not be used. And organizations that do not meet the second should be ejected from the measurement and judgment business.

21 Responses to “Measuring the Quality of Doctors and Hospitals: When Is Good Enough, Good Enough?”

  1. Michael R Privitera MD MS April 1, 2013 at 12:34 pm #

    “Quality” can actually be a dangerous word, as few would quibble with the goal of improved quality, leaving providers and patients open to misdirected efforts that can be damaging. Hence “quality” is not challenged enough, especially by those not in the field that are sold a bill of goods that something is quality.
    First do no harm, should apply to quality indicators proposed–are we sure they will not have a negative impact? What we can call quality standards need to go through more rigor and I couldn’t agree more with Dr Wachter on the concern: “Is the measurer committed to listening to the feedback of the public and profession and to responding to the emerging science in an effort to improve the measure over time?” The definition of Quality of Care used by Carolyn Clancy (Director of Agency for Healthcare Research and Quality) in her statement to Congress was ”Getting the right care to the right patient at the right time—every time.” http://www.ahrq.gov/news/test031809.htm
    More rigor needs to be involved in defining the “right” care, appropriate to the patient in front of us, when needed, every time. We would serve the public interest, and be more efficient with time, money and staffing resources if we de-emphasize recertification and give life long learning credit by helping these trained individuals in-the-moment of patient contact have access to the best practice information available by the technologies we have now adopted?
    We are currently in early stages of adding these capabilities to medical record software. Use of these resources could be tracked as they are useful to the patient in front of us to get things right with the best evidenced based consideration possible.
    Too many business are thriving in the industry of “quality” improvement process and they aren’t been held to standards themselves, nor are profit streams being monitored. It seems we need to do a Kaizen method analysis of the whole healthcare system, get people in the room that do the work everyday together with leadership level individuals. There needs to be a reality check on what is reasonable to expect healthcare providers to do, as it can backfire on quality.
    In summary although not wishing for more buracracy than there is in healthcare, Dr Seuss was on to something with having the “bee watcher” being watched as well. Our quality efforts need to be examined for potential negative impact.

  2. wrs April 1, 2013 at 3:48 pm #

    One of the things that cracks me up is that there is now a measurement system for measurement systems (see the Informed Patient Institute). Make me wonder where this is all going to end up…

    Seems like there is a point where there should be an embargo on measurement. Try going home to your spouse and informing there will be new relationship metrics. That would probably be a really bad idea.

  3. ARCpoint Labs of South San Antonio April 1, 2013 at 10:23 pm #

    Having a system for work being reviewed is crucial in industry. It is even more important in the healthcare industry.

  4. Menoalittle April 2, 2013 at 2:52 am #

    Bob,

    You seem over enthused about these flawed measurement strategies. You guys are measuring everything but those of most importance to the patients’ safety, and you are not determining if outcomes are better.

    CMS did not measure how many patients’ radiographic infiltrates due to heart failure were teated with antibiotics within 4 hours of presenting with chest pain and shortness of breath.

    Thus, there should be a record with measures and public reporting by EHR vendor of all adverse events, deaths, injuries, system unavailability, near misses, and other hazards from EHRs, CPOE ( a supposed safety leap from the Leapfroggers), and the pages of CDS gibberish that pop up for remedial education every time a doc orders potassium.

    You and your safety mavens at UCSF should demand nothing less, and post it here.

    Best regards,

    Menoalittle

  5. Arvind Cavale April 2, 2013 at 5:08 pm #

    The fundamental issue I have is the effective conversion of a professional service involving science and art, into a commodity (or a product like you say) aided by agencies like the ABIM. A professional service cannot be appropriately “measured” by 3rd parties. They can only be evaluated as satisfactory or unsatisfactory by the recipients of the service. Therefore, all the so-called do-gooders out there (ABIM & Leapfrog included) should understand that they are doing more harm than good. Unfortunately, too many reputations and too much money is involved for anybody to acknowledge this truth.

  6. Jon April 2, 2013 at 6:31 pm #

    Based on the conclusions reached in “Measuring the Quality of Doctors and Hospitals: When Is Good Enough, Good Enough?”, the ABIM should itself be “ejected from the measurement and judgment business” because the ABIM, despite claims to the contrary by those on the ABIM payroll, is not “committed to listening to the feedback of the…profession”. In fact, the ABIM seems committed to ignoring the feedback of the profession it monitors. I have yet to meet, in the real world, a physician colleague who has participated in MOC who does not continue to find it deeply flawed, onerous, largely irrelevant, costly and unvalidated by rigorous scientific data conducted by independent researchers who have no conflict of interest (such as being on the payroll of the ABIM).

  7. Paul Kempen April 2, 2013 at 7:46 pm #

    The problem with costs in healthcare is that every company and administrative government agency wants a piece of the pie, either in cash or power. Care was very cheap when people went to the doctor or hospital and paid them for their services out of pocket and got reimbursed for any covered insurance.
    There was an up front discussion of the cost. Now costs mean nothing and the multitude of agents with their hands out has exploded. People getting “Free care” or after having paid the premium are ready to “take as much as they can get” have no incentive to do without “everything”. Hospital transfer from Hospice-no problem! Futile care? No problem. The ABIM and ABMS are all agents of restriction of trade by keeping out any foreign docs, keeping pay high and now we will be supplanted by nurses and other paraprofessional “providers”. This has been known for a very lo9ng time as is summarized from 1972 here:

    This excludes the costs and waste of time!

    First, the existence of numerous sharply defined specialties and subspecialties has resulted in overlapping jurisdiction among the boards, necessitating arbitration of the inevitable jurisdictional disputes.

    Second, the membership of the boards is unrepresentative. (all grandfathers!)

    Third, the members are not accountable for their decisions.

    Fourth, some requirements for certification are arbitrary Particularly objectionable is the requirement that an applicant for certification obtain references from certified men in his local community; this may enable a specialist who has already attained “diplomate” status to “blackball” a local competitor.”

    Fifth, the examination system is unnecessary and redundant to the residency programs, especially since some boards tend to pass almost every candidate while others fail 40 to 50 percent of their applicants.”‘

    Sixth, some boards deny or revoke the certificate without an explanation or hearing.”‘

    Seventh, the large number of autonomous boards has caused a lack of
    unity in educational policy and programs among specialty boards in
    contiguous fields and has contributed to the absence of an authoritative
    policymaking body responsible for supervising the development
    of graduate medical education in terms of the actual demands of medical
    care.

    The eighth criticism concerns the utility of certification. It
    could be an invaluable source of information concerning the qualifications
    of a medical specialist. Patient and doctor alike are frequently
    ill-prepared to determine the merits of self-proclaimed specialists; board
    certification might function as a guarantee that a specialist has advanced
    training in his chosen field. However, empirical studies of the quality of patient care have shown that the quality of care usually given by certified specialists is not superior to the care given by non-certified physicians.

    Ninth, with the rapid advance of medical technology, the boards
    typically have failed to require that member specialists keep abreast
    of developments. i.e. grandfathers/boardmembers pushing the agenda

    Tenth, the specialty certification system tends to increase the incomes of board-certified doctors by restricting hospital staff privileges to board-certified men, to the exclusion of general practitioners and non-certified specialists.

    From:Douglas A. Wallace, Occupational Licensing and Certification: Remedies for Denial, 14 Wm. & Mary L. Rev. 46 (1972), http://scholarship.law.wm.edu/wmlr/vol14/iss1/3

  8. Paul Kempen April 2, 2013 at 8:17 pm #

    “Physicians endured an orgy of judgment during their formative years – in high school, college, medical school, and in residency and fellowship. But then it stopped, or at least it used to. At the tender age of 29 and having passed “the boards,” I remember the feeling of relief knowing that my professional work would never again be subject to the judgment of others.”
    Well the Joke was on you Bob! Th ABMS continues to produce the regulatory capture including the PQRS-MOC CMS payments and the whole MOC program to force everyone to just keep bending over.
    Physicians never were shy of real parameters and meaningful measures-yes we all took our turns in the M+M conferences and have been continually undertaking lifelong learning. The problem is the nonsense of unproven and nonsensical parameters like the ABMS MOC program. We are adults and are used to adult education. Where does the ABMS get off to think they can PRESCRIBE to EVERYONE a program that will “do the job”. It is simply just more “compliance nonsense” which the government and insurances try to utilize to deny payment. It is a pity that academic physicians who like YOU Bob only infrequently actually treat patients try to justify their existence by promulgating these useless programs to insure their non-clincial existence on the backs of working physicians and without any validation or consideration from those being manipulated-that is exactly REGULATORY CAPTURE AT IT’S WORST.

  9. Bob Wachter April 3, 2013 at 5:12 am #

    Thanks for the comments. Not unexpectedly, my mention of ABIM has stimulated some more critiques of Maintenance of Certification. While all the opinions are welcome, I do want to correct a few incorrect statements.

    First of all, we do survey physicians who participate in the MOC process, and the Board of Directors reviews these results with great care. Here’s what we find:

    Of physicians who completed MOC, 79 percent would recommend it to other ABIM-certified physicians, and 85 percent say they plan to participate in MOC again. Sixty percent agree/strongly agree that participation in MOC made them a better physician and two-thirds agree/strongly agree that is was a valuable learning experience. Fifty-seven percent agree that the MOC examination was a fair assessment of clinical knowledge in their discipline (fifteen percent disagreed and 28 percent were neutral). This is likely to be a reflection of the fact that each examination covers a broad base of knowledge in a discipline, while many physicians have sub-, or even sub-sub-specialized. While we sympathize with the endocrinologist who only sees diabetes or the cardiologist who focuses on heart failure, as long as they are certified as an “endocrinologist” and a “cardiologist” (and that’s what patients see when they look them up) we need to be careful about narrowing the scope of their certification. This topic is a matter of active discussion at the Board, and it is possible that we will move toward allowing some focus within specialty certifications in the future – though I suspect that we will also require some “core” knowledge in the broader discipline.

    We also ask for feedback regarding our Practice Improvement Modules (PIMs). We do hear complaints regarding the value of PIMs and the time required to complete them. Nevertheless, three out of four physicians who complete PIMs report they changed their practice as a result of completing the PIM, and eight-one percent would recommend the PIM to a colleague. We have launched several efforts to improve the PIM process, including ones that will permit easier collection of data from EMRs, and creating a pathway for institutions that do high-quality QI work to be allowed to grant PIM credit to their physicians for work on appropriate projects.

    Finally, regarding Dr. Kempen’s comment that “the membership of the boards is unrepresentative (all grandfathers!),” it is true that the Board generally selects mid-career to senior physicians, including some whose background is primarily community-based practice, for Board membership. (Our soon-to-be CEO, former Board chair Rich Baron, was in a 7-person general internal medicine practice in Philadelphia for over two decades.) But once on the Board, every director (grandfather or not) is required to complete the MOC process within the first few years of service, and all of them do. (By the way, this issue will resolve itself over the next several years as physicians who were certified after 1990, when MOC began, begin taking the place of folks from my generation on future Boards.)

    We have many efforts that are aimed at improving the MOC process. While most are designed to make improvements in the short-term, I’ve also charged a high-level task force, chaired by Yale’s Harlan Krumholz and including leaders from medicine, assessment science, education, simulation, and policy, to take a hard look at our overall assessment process and recommend changes, potentially big ones, that will ensure that the MOC process is as up-to-date, relevant, user-friendly, and helpful as it can be. This group will report its findings and recommendations next year.

    • Michael R. Privitera MD, MS April 3, 2013 at 11:33 am #

      Dr Wachter,
      I can appreciate that most that participate in MOC have approval numbers as you mention. However, your denominator is composed of that either openly or tacitly approve of the process.Why not survey what percent of current Board Certified individuals approve of the MOC process, what they like and what people don’t like about it. It is not comforting to have someone from Yale ( all due respects to the individual) taking lead on this. This causes academic insulation from the real practice world–Ivory Tower effect.Actually if you look at the composition of the IOM “To Err is Human” article in 1999, they were either academics or CEO’s, far removed from the trenches. We all know we have to improve the healthcare system. What I have a strong problem with is autocratic role of the Boards without enough Grass Roots input, not enough patient input as to what it is they believe makes a good doctor. A good test taker is not a necessary and sufficient for a high “quality” physician. We all know this, but why is this delusion perpetuated? I can’t help but think that control, power, and money fly in the face of what is really needed and what could be COLLABORATIVELY attained, NOT autocratically.

  10. Arvind Cavale April 3, 2013 at 1:03 pm #

    It is admirable that you maintain this blog. But clearly you are propagating false statements, Bob. If your survey was accurate, can you release how many physicians actually responded to it and what methods were used to come to the conclusion you arrive at? We are currently conducting an unbiased survey of physicians across the country and have already had a big response. The results will be presented at a meeting in the Univ of Pennsylvania on April 20th. You and other ABIM leaders were invited, but every one of you declined the invitation. If ABIM leaders feel so strongly about MOC methods and outcomes, why is every one afraid to defend it. Following this meeting, there is a debate of the Benjamin Rush Society regarding the value of MOC to practicing physicians. Again, ABIM leaders refused to debate…does this not smell of hypocrisy?

    And, I just received this from ABIM yesterday….anything but user-friendly…
    What’s Changing?

    In 2014, ABIM and ABMS will begin reporting if you are “Meeting MOC Requirements.” To meet requirements, you will need to:

    Complete an MOC activity to earn ABIM MOC points between January 2014 and December 2015 (in two years and every two years thereafter).
    Earn a total of 100 ABIM MOC points and complete a patient survey and a patient safety module by December 2018 (in five years and every five years thereafter).
    What Does This Mean For You?

    Assuming your license is in good standing and your certification is current, you will continue to be certified for the length of your current certifications.

    If you are currently enrolled in MOC and your certification is valid, you will not need to do anything in January 2014. Continue participating and earning MOC points as you have been. You’ll be “Meeting MOC Requirements” in January and you will not owe any additional fees.
    If you are not currently enrolled in MOC and your certification is valid, you’ll be “Meeting MOC Requirements” in January 2014. However, you will need to activate your MOC program by March 31, 2014 to be reported as “Meeting MOC Requirements.” At that time, you will have the option of paying an annual program fee or pre-paying for 10 years.

    How can you truthfully defend this atrocious process, Bob?

  11. Paul Kempen April 3, 2013 at 2:51 pm #

    Dear Bob:
    I am quite sure that the individuals who have passed the Boards are all happy to provide positive reports on the matter-it is the “high” of passing as well as the advantage to exclude those who have not passed in practice around them. There is also the “inflation” from people scoring this stuff and we see this on resident evaluations consistently. How about data on the following direct from your files:
    What percentage of “Grandfathers” currently have chosen to recertify, are actively enrolled in MOC and why? (I saw 1% as the number)
    What percentage of Physicians with 10 year board certificates are enrolled in MOC? (is it really only 70%?)
    What percentage of ALL US physicians are certified as Lifelong (30%) and 10 year certificates 35% and NEVER (certified 30%)?
    How many are retiring early because they just don’t want to recertify?
    With failure rates of 10-25% on the boards, how many physicians will be excluded from practice when this become a requirement for license?
    How many times in YOUR life have you been asked if you are Board certified BY A PATIENT? I have NEVER been asked by a patient!

    Be sure to provide reference to your stats when you post them. Mine are from OHio State Medical Board publications and can be read at the following sites (esp last reference):

    Kempen PM: Why Do Patients Select and Stay with Their Doctor? Implications Regarding Board Certification and Maintenance of Certification and of Licensure (MOC/MOL). Journal of American Physicians and Surgeons Volume 17 Number 2 Summer 2012 P 53-56. http://www.jpands.org/vol17no2/kempen.pdf

    Kempen PM: Maintenance of Certification (MOC), Maintenance of Licensure (MOL),
    and Continuing Medical Education (CME): The Regulatory Capture of Medicine. Journal of American Physicians and Surgeons Volume 17 Number 3 Fall 2012 P 72-75. http://www.jpands.org/vol17no3/kempen.pdf

    Kempen PM: Successful Opposition to Maintenance of Licensure: the Ohio Experience as an Educational Template. Journal of American Physicians and Surgeons Volume 17 Number 4 Winter 2012 103-106. http://www.jpands.org/vol17no4/kempen.pdf

  12. Mt Doc April 3, 2013 at 4:39 pm #

    I am glad you are reviewing the current format and appplication of the boards. Giving a survey to the recipients may be misleading. To use an analogy, I recently recertified for ACLS and BLS, which certification I have to have to see patients in my facility. I responded to the survey afterwards affirmatively and responded that I felt this was a valuable experience. However, having that certification has nothing to do with my ability to care for patients in a code. It proves I can memorize algorithms, which change with each iteration of the course. The course even states that none of the medications used in the pulseless VT/Vfib alorithm have been shown to increase longterm survival over electroversion alone, nor have I seen any data that indicates that outcomes from codes from ACLS certified doctors are any better than for those who do not have this certification. I received training in handling tachyarrhythmias and bradycardia in medical school and residency and do this on a daily basis, but without that piece of paper I cannot practice in my institution. If the survey asked whether I thought the outcomes for my patients would be better for having gone through the certification process for the 15th time, I would have responded negatively. Finally, every crash cart I have seen and every ER has the algorithms posted or available for reference in a code. If these are available in real life why test as if they were not? For that matter, why test in the boards for this?

    On the IM boards, if I want to find the recent protocol for diagnosing pheochromocytoma I can look it up. What is important is if I recognise the disease entity as a possibility in the differential of the appropriate patient.

    Having only 57% of doctors responding that the boards are a fair assessment of knowlege is pretty darn poor. You really have your work cut out for you.

    As an aside, the British heart association has a video lasting less than 2 minutes demonstrating adult cpr which is funny, explicit and easy to remember. You can view it by googling “Vinnie Jones CPR”. We have a four hour course and a 57 page booklet dealing with the same thing. (In fairness, the BHS tape doesn’t deal with AED’s, the Heimlich maneuver or child/infant cpr but you get the idea.)

  13. ARCpoint Labs of Fort Lauderdale April 3, 2013 at 5:46 pm #

    It’s a little scary to think of all the restaurants that passed and shouldn’t have. It’s even scarier to think of healthcare businesses that should not pass.

  14. Marc S Frager MD April 3, 2013 at 6:33 pm #

    I believe the pass/fail decisions of the board are valid and defensible.But are they meaningful? And are they worth the expense of money and time?

  15. Jon April 3, 2013 at 8:06 pm #

    I would love to know who these doctors are who feel MOC is so helpful, would recommend it to others, etc, etc. I became board certified in IM, pulmonary and CC 20 years ago, I recertified in all three 10 years ago, and I recertified again in IM this past summer (theoretically, I should recertify in pulmonary in 2014 and CC In 2015, but that isn’t going to happen, BECAUSE I AM DONE WITH THIS NONSENSE). I passed all tests on the first try. I can honestly say, in 20 plus years of being involved in MOC, that no aspect of MOC has improved my medical skills, knowledge or my abiltiy to satisfy my patients in any way (still, I must be doing something right, as my office is packed with patients every day). Furthermore, my colleagues here in NY, and my medical friends/colleagues in places like Florida, Ohio, Los Angeles, etc, all feel the same way. The few colleagues I know who say they will likely do more MOC say so out of a sense of resignation that they have no choice, because of how they have been made to believe that MOC is necessary to be employed and get paid, NOT out of a sense of satisfaction at how well it meets their ongoing medical education needs. Just look at the posts above; the majority of them are highly critical of all things MOC. Go on medical media sites like Sermo and look at the posts on Boards and MOC; again, the majority (and I am talking hundreds of posts, not just a handful) are all highly negative and critical of MOC. So again, I ask, where and who are these MOC loving docs referenced in your statistics, because I cannot find any of them out here in small town USA, in the trenches of front-line medical care.

  16. Marc S Frager MD April 7, 2013 at 7:38 pm #

    If so many diplomates liked MOC so much, then what is all the furor about? Perhaps making diplomates take a survey before getting their MOC results biases the outcomes! But then, the ABIM doesn’t seem to mind forcing their processes on diplomates. While you may say MOC participation is “voluntary,” itis not truly voluntary without a statement that MOC participation should not be used to determine hospital privileges or insurance company participation. MOC is supposedly about more than marketing, right?

    Why not make MOC voluntary without conditions, and let the marketplace speak to participation rates. In all likelihood there will be no diminution in the quality of care, and care measures may well improve as diplomates have adequate time to pursue self-identified needs.

    While the ABIM is fond of saying internists are not very good at self-assessment, there is absolutely no data that the ABIM is any better. And while the ABIM almost gleefully points out that physician performance deteriorates with age ( a highly contentious conclusion), again there is no data that MOC improves the performance of aging physicians. Perhaps MOC participation can reverse the age-related decline in kidney function, bone mass, and muscle strength also!

  17. american behavioral clinics April 11, 2013 at 4:17 pm #

    This is a very interesting concept that now Hospitals and doctors are being rated and ranked like “resort hotels and American Idol contestants.”

  18. Greg Hall, MD May 4, 2013 at 5:28 pm #

    Seriously. You need to find your ‘inner physician’ and re-look at the entire board re-certification landscape. What is the motivation? Patient care or ABIM bottom line? Why does someone have to fail? Why does it have to be adversarial? Great leaders lead. Are you leading or following? Having this much bad karma from physicians cannot be good.

  19. kerry pay May 8, 2013 at 12:54 am #

    Rating doctors is good. I have been disabled since 2000 when my prominent back surgeon messed up my surgery and it became 8 hours instead of 4. He never told me the patient that anything went wrong. He also did not give much of a reason to my brother who was waiting. He just stated a “vein” was larger than normal. So this made a surgery which was to have been 4 hours become 8 hrs?
    I woke up 24 hrs later in massive pain and the nurses could not get the pain down with the drip I was on. I was crying histerically because crying is a release of emotions. My surgeon had to call my past pain physician to ask what to give me and he said that I have never responded to pain medications as normal people do. My body is completely different he stated. I was then told to use Oxycontin. Thank the Lord for this medication because it works!
    I don’t even respond to cocaine. This is why I know my body’s chemistry is totally different than regular people. Yet I have to go thru hoops to get this medication that keeps my pain in control from a surgeon who messed up my surgery. He damaged the nerve in my leg because I was unable to use or feel it for over 6 days in the hospital. My surgeon stated it would come back so I would be able to use my leg. The feeling came back with MASSIVE PAIN. I did not have this before the surgery. I also did not have any sleeping problems before this surgery either. After my surgery I was extremely tired and no one could tell me why I was so sleepy all day. For 10 years I kept on asking every doctor why I was unable to stay awake during the day and could not read the newspaper in the morning because I fell asleep. Every doctor was told I could not sleep longer than 60-120 minutes during the night and after 9 years I started to get morning headaches that were horrible. None of the doctors I saw trying to find the cause of this did anything. Not even a psychiatrist. Finally I remembered a that my primary care doctor had mentioned a sleep test but it had never been ordered. I asked a nurse to order the test.
    Found that I have severe obstructive sleep apnea that had not been treated all these years from when it started immediately after my surgery. My throat had been damaged as well as my leg. Now I have two disabilities and the severe obstructive sleep apnea is so bad no kind of CPAP will help. I also had two incompetent sleep doctors who did not listen to what I was telling them. Neither of these doctors referred me to an ENT to examine my nose or throat. My 5th primary care doctor agreed after I requested a consult and I finally got the examination. I was told only a tracheotomy would help because of everything the doctor discovered. I sent him a confirmation letter and when I returned to follow-up he didn’t even have a file or any of the two sleep studies he consulted that he was given. He then suggests a nasal surgery that he at my consult would not help and would be useless. I said I would think about it.
    My second sleep specialist refused to talk to the ENT and I have that conversation on voice recorder.
    This is how bad doctors have become in this country. I was shocked when I viewed all my medical records for the massive errors they contained as well as alterations that had been made as well so liability would not be found after I filed complaints.
    I voice record and send confirmation letters to maintain my own records because doctors today cannot write what actually happened and was discussed at any of my appointments.
    Doctors are not accountable anymore and it is a myth about frivolous law suits . No attorney would take my case because the doctors did not write anything that was discoverable. The federal government is paying for the bad medical care I have received from private doctors.
    Gladly to talk to anyone about all my past inept medical care. kerrypaymann@gmail.com leave me your phone number and I’ll call!

    • Jon May 9, 2013 at 3:04 am #

      A unfortunate story indeed, perhaps, but also extremely one-sided. So much of it makes no sense. Doctors flat out refusing to talk to one another? Doctors refusing to pursue basic tests, like a sleep study, for years? Very dubious story. From a patient apparently “immune ” to cocaine? Should we even trust a story by someone who admits to cocaine use? And sleep apnea “immune” to CPAP? Would love to know how much this patient weighs. Maybe this patient needs to take some responsibility for his/her own situation, lifestyle choices, etc. And even if all of these medical providers were so bad over so many years, does anyone really believe that something like MOC would have changed any of this? Not a chance.

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