The ABIM Controversy: Where the Critics are Right, Where They’re Wrong, and Why I Feel the Need to Speak Out

“What’s up with the ABIM?” “I just got a note about an alternative board. Should I join it?” “Aren’t you glad to be off the Board?”

Screen Shot 2015-06-28 at 10.16.55 PMThese days, I get these questions from friends and colleagues regularly. When I first joined the board of directors of the American Board of Internal Medicine (ABIM) in 2004, the organization was a well-respected pillar of American medicine. Today the organization finds itself in a fight for its life, being painted as everything from out of touch to money-hungry to, more recently, corrupt.

I just completed my decade-long service to the ABIM and, more recently, the ABIM Foundation. I’ve waited until now to write this because I wanted to be clear that I am not speaking for ABIM or its leadership. I am also well aware that there is a vocal group of critics who feel passionately about this matter, whose minds are made up, and who are approaching this fight with a take-no-prisoners zeal. By adding my voice, I am likely to become a target for their anger.

So be it. With the help of social media and a journalist who has turned this matter into a cause célèbre with an unfortunate mixture of half-truths and innuendo, the critics have managed to control the debate, and people who believe in the values of the Board have been cowed into silence. It feels vaguely McCarthyish, and there comes a time when silence is immoral. This feels like such a time.

Screen Shot 2015-06-28 at 10.19.36 PMThis is not to say that the Board has made perfect choices – it hasn’t, and ABIM’s CEO, Dr. Rich Baron, courageously admitted as much in a February statement of apology, in which he announced the suspension of certain parts of the program. But these were mistakes born of trying to do good but challenging work for the right reason: to ensure to our patients that their physicians are competent. Painting the organization – and particularly Rich, one of the finest people I know – as corrupt and nefarious is wrong.

Here’s what’s at stake: we physicians are granted an extraordinary amount of autonomy by the public and the government. We ask people to disrobe in our presence; we prescribe medications that can kill; we perform procedures that would be labeled as assault if done by the non-credentialed. If we prove ourselves incapable of self-governance, we are violating this trust, and society will – and should – step into the breach with standards and regulations that will be more onerous, more politically driven, and less informed by science. That is the road we may be headed down. It is why this fight matters.

Let’s start with a little history on how we got to where we are today, and then I’ll turn to and address the criticisms of the Board.

A Brief History of Board Certification and MOC

As Rich Baron recently described in JAMA, the board movement launched around the time of the Civil War, when the AMA began grappling with the question of how to determine whether a doctor was competent to call him or herself a specialist in a given field. After some fits and starts, the specialty boards were established in the 1920s and 30s to address this question. Importantly and, to my mind, correctly, the boards were created as independent entities – arms of neither the specialty societies (i.e., the ABIM is a completely different organization than the American College of Physicians or the subspecialty societies in fields like cardiology and oncology) nor the government. Why was this the right choice? Because credentialing organizations inevitably have to make tough decisions, including setting high standards, and thus need to be insulated from the politics of government or the advocacy of dues-funded membership organizations.

The ABIM was established in 1936, and things were fairly calm for the organization’s first 60 years. When I took the ABIM certifying exam after finishing my internal medicine training in 1986, I was 29 years old. The Board issued me a lifetime certificate, basically deeming me a competent internist until I retired. My expectation – correct at the time – was that receiving my certificate of passing was the last interaction I’d ever have with the ABIM.

Around 1990, the idea of lifetime certification had become increasingly troubling to patients, payers, and even some physicians. In retrospect, of course, it is indefensible. So the Board launched a program now known as Maintenance of Certification, thus planting the seeds of the current controversy.

MOC created a lifetime relationship between the boards (ABIM and all the other specialty boards, such as surgery, family medicine, and pediatrics; together, all the boards operate under an umbrella organization called the American Board of Medical Specialties, ABMS) and their diplomates. But this was a troubled marriage from the start. Physicians were now faced with taking a test every 10 years or so to prove their ongoing competence. Many didn’t like it one bit.

Moreover, the launch of MOC coincided with the growing recognition that the competent physician possesses an array of skills – patient communication, quality improvement, teamwork, patient safety, and more – that extend far beyond raw medical knowledge. This recognition challenged the boards with the task of figuring out how to assess these “softer” skills.

Finally, the boards realized that an assessment of a physician’s competence should not just include how she did on a test, but how she was performing in day-to-day practice. Thus came the push for MOC to include some demonstration of the skills of self-assessment and “practice-based learning.” This, too, was new territory for the boards… and everyone else.

Even if all the Board did was administer its “secure exam” to assess knowledge and clinical decision-making, that would be hard enough. ABIM employs a team of psychometricians to ensure the validity of its questions, and its test writing committees include well-respected members of each specialty, who craft questions designed to fairly test core knowledge in each specialty. Questions are thoroughly vetted to ensure validity; poorly performing questions (for example, questions that folks who did well on the overall examination had trouble with) are reviewed and often discarded, as are dated questions. It is an exacting, labor-intensive process, and experts in the testing field consider the board’s approach to be state of the art.

While testing core knowledge is hard, it pales next to the challenges of assessing the “softer” competencies. How to assess communication skills other than asking patients themselves? Quality improvement skills – how else but ask physicians to submit data on, let’s say, their diabetics or asthmatics, along with a plan for self-review and improvement? While these are reasonable approaches, asking busy physicians to provide such data created more unhappiness, as many found the process onerous and not particularly meaningful, particularly in light of all of the other entities asking for similar data.

The launch of MOC in the 1990s generated substantial controversy, but things eventually settled down. Many practicing physicians didn’t love MOC (and many objected, quite reasonably, to the fact that older doctors had been grandfathered out of the requirement because the Board chose to honor their “lifetime” certifications), but surveys of diplomates completing MOC generally showed that most found the process to be fair and even useful.

Although I was “a grandfather” myself, when I joined the Board I was required to complete MOC (all Board members must do this, grandfathered or not), and I did so about five years ago. I thought the test (I took the general internal medicine exam; this was before a hospitalist-specific test was available) was reasonable and that studying for it improved my skills. The self-education modules, mostly open-book tests, were also useful, even fun. On the other hand, the parts of the process that required that I measure my own practice were unwieldy, and the tools made available to support this work were relatively user-unfriendly. My colleagues and I on the Board pushed the staff to improve these tools, and over time they did, although they remained well behind the kinds of sophisticated web-based tools we’ve become accustomed to in our non-medical lives.

The Change to “Continuous” MOC

The heat increased a couple of years ago, driven by changes in the MOC process. Around 2012, the ABMS decided that MOC should become more “continuous.” This didn’t strike me as unreasonable, particularly since teachers, pilots, and others in high-stake professions need to demonstrate their ongoing competence every few years. The new MOC standards required that physicians accumulate some points (the completion of a self-improvement module, or a patient survey, or a review of their own practice data) every couple of years, although the high-stakes exam remained an every-10-year affair. Even more bothersome to some, while grandfathers’ lifetime certifications would not be challenged, grandfathers not participating in MOC would now be listed on the boards’ websites as “not meeting MOC requirements.”

While I can’t speak for the other ABMS boards, I participated in the ABIM discussions of these issues from the start, and they were thoughtful and nuanced. Because the boards have no way of funding themselves other than through fees to diplomates, there was a constant underlying tension about how to keep fees reasonable while building the infrastructure needed to support and improve the programs. We tried our best to develop standards and tools that were supported by science, would be acceptable to the physician community, and – most importantly – represented our best thinking on how to demonstrate that a physician was competent. We also worked with the professional societies to build modules for specialists in their fields, and many did so.

Any kind of certification or accreditation process will generate critics – witness the furor over testing in public schools to see another sphere in which this is playing out. For growing numbers of physicians, the new MOC requirements not only felt onerous, they felt like betrayal – since the requirements were being created by fellow physicians in their own field. “I can understand why [Medicare/Aetna/Epic… fill in the blank] is making my life miserable,” some doctors thought. “But the boards are made up of my own colleagues. How can they do this to me?”

The boards are voluntary organizations. Many physicians are licensed by their state but are not board certified – either because they trained outside of the U.S. (the pathway to certification for international graduates is challenging), because they chose to avoid the process, or because they failed it (about 5 percent of people ultimately are not able to pass the Boards, either in their initial certification process or in MOC, despite multiple attempts to do so). For these uncertified doctors, the “voluntary” nature of the process is little consolation, since many payers and hospitals now insist on board certification. Given the stakes, it’s not surprising that MOC has aroused so much passion.

The Battle Goes Public, and Gets Nasty

There is a well-known challenge in the world of certification known as the “race to the bottom”: unless everyone (payers, hospitals, etc.) insists on a rigorous certification process, easier processes are likely to emerge, which some individuals will find preferable. While there have always been non-ABMS boards that have tried to recruit physicians to their camps, the more rigorous ABMS pathway (including the ABIM’s) has been considered by most institutions to be the gold standard, and so upstart boards – usually promising certification to doctors who paid a fee, participated in continuing medical education (CME) programs, and had unblemished licenses – gained only limited traction. If hospitals, insurers, and other key players insisted that physicians go through the traditional (ABMS) board process, most physicians did so.

Screen Shot 2015-06-28 at 10.17.27 PMIn 2012, when I began my one-year term as chair of the ABIM, I wrote a blog describing where the organization was going and what I hoped to achieve in my time as chair. I thought it was a relatively benign piece, one that highlighted the rationale for the changes to MOC and made clear that this would be a work-in-progress that we were committed to getting right. My usual blogs receive about 10 to 20 comments; this received well over 200. It was clear that there was a passionate group of individuals who were committed not just to slowing down or stopping the initiative to make MOC more continuous, but to eliminating the entire MOC requirement. Frankly, we were surprised by the anger, though perhaps we shouldn’t have been.

Part of what surprised us was the breadth of the anti-board movement. While some of the early critics came from a libertarian fringe, there were more mainstream arguments advanced by respected leaders in medicine. These included several editorials in the New England Journal of Medicine, including one by NEJM editor Jeff Drazen and another by my early mentor, Lee Goldman, now the dean of Columbia’s medical school. In a January 2015 NEJM piece cleverly titled “Boarded to Death, a Scripps Clinic cardiologist named Paul Teirstein argued that the MOC process should be replaced. “We all support lifelong learning,” Teirstein wrote, “but an excellent alternative to MOC already exists: continuing medical education (CME).”

The anti-MOC troops gained followers in the social media world as well, and an on-line anti-MOC petition received more than 20,000 signatures. Physicians began pressing their specialty societies, including the ACP, to fight MOC, such as by threatening to withhold their dues; a few societies began to consider establishing their own certification processes. Teirstein and colleagues launched a new board, the National Board of Physicians and Surgeons (NBPAS), and sent letters to thousands of physicians asking them to pressure their hospitals to change the bylaws to accept NBPAS certification as meeting any board certification requirement.

From where I sit, all of this is uncomfortable, but natural and probably even healthy. The boards have occupied an enviable position as the unquestioned leader in physician accreditation for nearly 100 years. It would be surprising if they had not become a bit insular, or resistant to change. Some competitive pressure was probably necessary to ensure that the boards’ process delivers the most value to physicians, to patients, and to other stakeholders.

During my term as ABIM chair, my colleagues and I tried to be responsive to these pressures. In 2013, at the end of Dr. Chris Cassel’s 10-year tenure as CEO, we recruited a new leader, Rich Baron, an unusual choice in that he is not an academic with a book-length CV. Rather, Rich spent nearly three decades practicing general internal medicine and geriatrics in a small Philadelphia office, while also amassing a terrific track record as an organizational leader, both at the ABIM (he served as a Board member and ultimately rose to chair) and later at Medicare’s Innovation Center (CMMI).

We also launched an interdisciplinary task force, “Assessment 2020, charged with taking a hard look at our testing processes and considering fundamental changes to it. Some of the questions we asked of the 2020 Task Force: Is an every-ten-year year test still a good idea? Should part of the test now be open book? Should we include simulation? The Task Force, working under the chairmanship of Yale’s Harlan Krumholz, has just presented its final report to the ABIM Board for its consideration. The recommendations are ambitious and potentially game changing.

Over the last couple of years, the Board also completed a full makeover of its governance structure, cutting the size of the Board of Directors from nearly 30 to about 12, to make it more nimble. It also broadened its representation, including adding non-physician public members for the first time. To complement the smaller Board, we created a new “ABIM Council” to oversee the Board’s products, including the examination, and to Screen Shot 2015-06-28 at 10.23.01 PMstrengthen our connection to the specialty societies. Also over the past few years, the ABIM Foundation launched the Choosing Wisely program, one of the most influential campaigns in recent medical history. Choosing Wisely has been hailed both nationally and internationally as the most important effort to date in engaging physicians in thoughtful waste-reduction efforts.

While my colleagues and I took these criticisms seriously, I felt that as long as we admitted our missteps, weren’t resting on our laurels, and constantly tried to do the right thing, we would be okay. After all, even though it might be attractive to some physicians to water down board certification, it seemed inconceivable to me that our profession – or the public – would accept the argument that participation in CME should be enough to demonstrate lifelong competence. I like CME, I think good CME is valuable, I run a CME course that I’m very proud of – one in which people are engaged for three days learning, not on the beach or the golf course. But I would find it hard to keep a straight face while making the argument that such attendance alone is sufficient to demonstrate competence. I believed that the ABIM – by insisting on a more rigorous process – would always retain the moral high ground.

But I underestimated the opposition. There was a way for them to seize the moral high ground: by painting the Board as scandalously profligate and corrupt. And so that’s what they set out to do.

The Allegations Against the Board

Having sat through every meeting of the ABIM Board for nine years (and, more recently, those of the ABIM Foundation), I can tell you that the depiction of the Board as aloof, money grubbing, and corrupt is entirely off target. That certainly doesn’t mean that all our decisions were good ones, or were politically astute. But our motives were always to do the best we could to live up to the Board’s motto: to be “of the profession, for the public.”

Here is where the critics are mistaken, often taking matters out of context to bolster their points. Unfortunately, in the world of social media, these half-truths and distortions make for good sound bites, and the casual observer can be forgiven for believing them.

Let’s take a few of the more egregious allegations:

“The Board is All About the Money”

The ABIM is a not-for-profit entity, meaning there are no shareholders. But it does need a positive bottom line to stay in business and to do its work. As Board members, we constantly struggled with balancing our fiduciary responsibility to the organization (including to pay the salaries and the costs of doing the Board’s current work and innovating) with the burden to the diplomates. ABIM’s MOC process currently costs physicians about $200-$400 per year (the low end for the internal medicine certificate only; the higher range is for those maintaining multiple certificates, like IM/cardiology/interventional cardiology). These costs are consistent with the fees of other ABMS boards. The argument that this represents an impossible expense to the vast majority of practicing physicians is hogwash.

“The Board Established a Foundation to Serve as a Big Piggy Bank”

The ABIM accrued surpluses over the course of its nearly 100 years of existence. Between 1990 and 2008, the Board took the bulk of its reserves (about $55 million, when all the contributions are added up) and placed them in a Foundation, whose charge was to support the Board’s work and serve the broader medical community. This is a standard practice for most large societies and accrediting organizations. The accounting involved is completely legitimate and has been vetted by yearly audits conducted by national accounting firms.

As per usual accounting rules, the Foundation spins off about 5 percent of its corpus for yearly investments – currently this amounts to $3-4 million each year. Over the past decade, the Foundation has focused on professionalism as its main theme, and, beginning with its 2002 “Physician Charter, has succeeded (well beyond my expectations) in putting this concept on the map.

More recently, the Foundation’s Choosing Wisely campaign has attracted worldwide attention, with more than 65 societies developing lists of activities in their fields that add no value. The impact of the Foundation’s work is enormous – many people have looked at Choosing Wisely as a model for the medical profession actually tackling the issue of costs in a positive way. Indeed, its recommendations have been implemented by several leading health systems, including Cedars-Sinai, the Fred Hutchinson Cancer Center, and Intermountain Healthcare. The campaign has also been adopted in a number of other countries. These days, nearly every discussion about improving value or reducing waste, whether it’s in the lay or professional media, references Choosing Wisely. For a small foundation, that’s one hell of a good investment – I’ve spoken to representations of foundations several times the size of the ABIMF who are using Choosing Wisely as a case study in leveraging a relatively small amount of money to great effect.

The Foundation also supports research that helps advance the ABIM’s mission – for example, on developing new simulator tools that can be used in physician assessment. It is free to provide money to ABIM for research and development, and it frequently does this, on top of its work promoting professionalism.

“The Salaries are Outrageous, and Then There’s The Condo”

Here, the allegations are flying fast and furious. The latest concerns CEO Richard Baron’s salary. Rich is one of the smartest and most committed people I’ve met in medicine. He is a person of unending integrity. The fact that the critics have now seen fit to take him on with caricatures and half-truths is cynical and sickening.

Part of the reason that Rich emerged as our preferred candidate was his real-world experience, which we felt was crucial as the Board worked to connect better to physicians engaged in the day-to-day practice of medicine. Rich’s current base pay of $579,000, with a bonus opportunity of another 20 percent, is significantly lower than that of his predecessor (Dr. Cassel’s salary was higher because she was recruited from a prior job as the dean of a major medical school and she served as ABIM CEO for a decade). The salary I offered Rich (as chair, I led the negotiations) was in the range recommended by consultants after a detailed analysis of salaries of other CEOs of healthcare nonprofits. It is a lot of money (and more than twice what Rich earned as a primary care physician), but he is paid to run a large, complex organization in a swirling political environment. In the grand scheme of things, taking into account what other healthcare executives earn, it seems fair to me.

If there is one money issue that has become a piñata, it has got to be “The Condo. Like many large, complex organizations, the ABIM often has consultants coming into Philadelphia to help it with its work. When Chris Cassel was CEO, after analyzing the costs of putting these folks up in hotels, she decided to purchase a condo to serve the same function. This was designed to be revenue neutral, and it has been. But, of course, it creates a hanging curveball for those looking for profligacy. Do I wish we had never bought it? Of course; politically it was a dumb thing to do. Is it a scandal? No.

The Test

Critics have also taken on the test itself – everything from the testing procedure (which involves going to secure test centers and being fingerprinted) to the actual substance of the test. They have also looked at the pass rate and pointed to what appears to be an increasing rate of failures.

The secure testing center is necessary given that it is such a high-stakes exam: failure is meaningful, and, sadly, cheating has occurred on a number of occasions. The test itself is written by experts in the specialty, and reviewed in detail by psychometricians to determine that questions are valid and up to date. This is a rigorous, expensive, and time-consuming process.

Another point made by the critics is that the failure rate on some ABIM MOC exams has increased, further evidence (to them) that the Board is actually trying to fail hardworking doctors in order to make money. The cut score for passing is an absolute standard determined through a sophisticated process that follows best practices in the testing industry. Once a cut score is set, pass rates for first-time takers may vary from time to time, but approximately 95% percent of physicians ultimately pass ABIM’s MOC exams, though it sometimes takes a couple of tries. There is no predetermined passing rate, and if 100 percent of people did well enough, all of them would pass. Unfortunately, they do not. To my mind, requiring that physicians demonstrate that they are keeping up every ten years is a reasonable requirement, and the fact that some people fail the test is evidence that some people lack the knowledge in their specialty to be declared competent.

The Bottom Line

We physicians are granted enormous privileges by society, and with these privileges comes the expectation of self-governance. That expectation flows from the knowledge that only members of the profession can determine what it means to be a competent internist, or cardiologist, or rheumatologist.

The boards are the human and organizational expression of that expectation. The work we ask of them is difficult: to create standards that truly are meaningful for patients, defensible to other stakeholders, and acceptable to the profession. The boards are not government-funded or -managed entities, and thus they require the resources of the professionals who are being assessed to do their work.

Over the last decade or so, many have looked at medical care in the U.S. and deemed it wanting – with frequent mistakes, spotty quality, relatively low patient satisfaction, and high costs. While many of the reasons for this have little to do with physician competence, some of them do. Our society is asking us to raise our standards, so that patients and others can be confident that their doctor is competent at the completion of training, and remains so throughout his or her career. This is a reasonable expectation of us, and of our certifying bodies.

ABIM has tried to do this work with integrity and thoughtfulness. Without question, the organization did not get everything right. In retrospect, non-academic physicians should have had a greater voice on the Board, to help connect us better to the community. Our tools to measure the newer competencies such as patient experience, quality improvement, and safety should have been better vetted. Our website should have been more user-friendly. We should have spent more energy working with medical societies to ensure that they were on board – if not with the precise methods, at least with the goals and values that we were jointly trying to achieve.

Earlier this year, Rich Baron, speaking on behalf of the Board, issued a powerful letter, unambiguously apologizing for these missteps. It was a brave and bold thing to do. In his letter, he suspended some of the MOC requirements – particularly the ones that involved practice-based measurements – to allow time for a deep reassessment. He also committed the organization to a period of listening and to a new effort designed to co-create the MOC process with our community of physicians and other stakeholders.

Where are we now? While Baron’s apology was widely praised, the critics still seem to be controlling the terms of the debate. This is not too surprising – they are tapping into a deep well of physician anger and angst. Clearly some of this anger goes well beyond certification – to electronic health records, to quality measurement, to value-based purchasing, to the push toward large systems of care and away from small practices. All of these transitions are challenging, all have unanticipated consequences, and – for the doctor who prized his or her autonomy and was comfortable under the old model – all of them feel wrong.

Yet it would be too easy to say that the anger toward and controversy regarding the ABIM is limited to a group of grumpy, change-resistant doctors. The concerns that the boards have been too disconnected from the practicing physician community are real, and it will require strong action to remedy this. And the actual substance of MOC needs to be modernized and made less burdensome, while remaining appropriately rigorous. I am proud of Rich Baron and my successors on the ABIM Board for rethinking the work and being open to change… perhaps even radical change. The process has been painful, but the actions to date are steps in the right direction, and there is more to come.

But what if the changes aren’t enough to satisfy the critics? What if these alternative boards win the day, and hospitals and insurers choose to accept a watered-down board process – basically, CME – as “good enough”? This outcome – and with it, the demise of the board enterprise, or at least of MOC – is not impossible.

To an unhappy doctor, bringing down the ABIM may feel good, but what will fill the resulting vacuum? Can we really say that passing a test at age 29 is sufficient to demonstrate that a physician is competent for an entire lifetime of practice? Or that evidence that a doctor spent a few dozen hours at CME courses is enough to reassure patients and other stakeholders that a doctor is currently competent? Or that a process in which no physician is ever judged to be below standards is legitimate and defensible?

I believe that there will always be a need for a rigorous, scientifically valid process to judge that physicians are competent in their specialty, and that they remain so through their career. I further believe that this process must be crafted by members of the profession itself – and if we abrogate that responsibility, others will fill the void. The values of ABIM are strong, and the half-truths that are being used by critics and at least one journalist with an apparent conflict of interest to smear the organization must not win the day. The ABIM needs to evolve, and it is doing just that.

“Throw the bums out!” can feel like progress. But, as the Arab Spring protesters have learned, sometimes it’s relatively easy to tear down institutions. Rebuilding them is much harder.

85 Responses to “The ABIM Controversy: Where the Critics are Right, Where They’re Wrong, and Why I Feel the Need to Speak Out”

  1. Doug Martin June 29, 2015 at 10:44 am #

    Bob, very well written and answers some real questions I had. I only wonder how some of these pim modules could have been rolled out by such an organization? If the abim is not out of touch, would they really have required practicing docs to do things like ask pts to observe them washing their hands and then send in the responses? Seems ludicrous that type of stuff made it out of what you described as really measured deliberations. Anyway, thanks for writing this

    • Edward Hale July 8, 2015 at 9:18 am #

      Bob, we need a whole new approach to the question of certification and especially MOC. We live metaphorically in the Dark Ages right now regarding MOC. It is pointless to even think of continuing with it. Look, in the digital age knowledge is instantaneous. Online learning/teaching centers in medicine can be made available free universally 24/7. Connect this ‘continuous learning’ back to top universities. The ABIM is obsolete.

      Walter Bierring, father of the ABIM, had a 50 year vision. It served its purpose to bring order. Now it brings chaos along with all the other so-called corporate innovations designed by idiots without practical skills in what the new digital tools are for.
      Now we need a higher and more immediate order. A streaming digital university of current medical knowledge and practice with brick and mortar institutions behind the new movement of medical exchange. Right now the ABIM, 24 specialty boards and all the rest just dulls and tires physicians. Or it creates hopelessness in a large percentage of docs, NPs, and their staff.

      Think Bob. Get your teeth behind it. Your passion. We don’t need to hear both sides. Both sides are wrong. Scrap the old. It is broken. Create something totally new. Lead us into the light. Make it free and democratic. Let physicians choose leaders and have the ability to vote. Release physicians from the heavy yoke of the past. This is a new age, an age of immediate information, knowledge and light. Be a pioneer Bob willing to go where no educator in medicine has gone before. Medicine has become so slow with bureaucracy that nothing moves right. Observe clearly the whole of medicine as it is; then put it right and make it so. Right now even the discussion here is broken and hopeless. Bring some hope.

      ABIM is unfortunately a company that has lost trust. It has damaged its image forever. Nothing can bring it back. Bury it and start over. Suspend MOC and it will make no difference in learning. But it will free physicians of something useless. Then they can study what they need or spend time with patients. So many broken things in medicine. Work to fix them all. Who else, Bob! It’s you. Bring in the light, and then put it right!

      • Paul W Johnson July 9, 2015 at 3:27 am #

        Spot on Ed !

      • Edward Hale July 10, 2015 at 9:00 am #

        Counterpoint to ABIM’s Continuous Demand for Money (Inspiration from the founding father of the ABIM. For you and all diplomates, Bob)

        Never give another dime to the ABIM! Answer this question for lifetime certification and voluntary participation in continuing medical education free of charge. Question: Who was the founding father of the ABIM in 1936? The answer is Walter Bierring, MD of Des Moines, Iowa. Walt was a practicing physician and educator who was generous of time, spirit and energy. He believed in one medical certificate for life as a rite of passage. He felt as do all physicians that voluntary lifelong learning was important. Walter was simple and direct in approach to medical practice and continuing education. Also voluntary were the board and officers of the ABIM. They were not paid and met only a few times a year. The bylaws never changed while Uncle Walt was alive. There were nine members that served no more than one to three years.
        The ABIM was intended to last for no more than 50 years just to bring more order and opportunity into the practice of medicine and to help distinguish American and Canadian physicians who did not go to a top medical school. Certification was voluntary and did not have any implications for employability or privileges. Maybe Walt would tell us if he were alive today that the certification process is no longer needed in our already severely regulated world. After all, Bierring was opposed to burdening physicians with useless and continuous bureaucratic exercises, such as the contemporary ABIM attempts to impose today. Don’t you think it is time to bring back the spirit of Walter Bierring into physicians’ lives today and with his strength and honesty of spirit reform the ABIM back into the non-profit humanitarian organization it was intended to be?
        Walter Bierring, MD, as former public health commissioner of Iowa, would be very disappointed in the executives, board members and new council at the ABIM who have corrupted the organization and deviated from the original purpose altogether. Uncle Walt would be emotionally sickened to see that the ABIM has been kept going for personal monetary gain. And he would be most disheartened to see the way the organization has not been transparent about the motives of the executive elites’ with their political and corporate conflicts of interest.
        So you see the organization was intended to be dissolved around 1986. And if you know the history of the ABIM Foundation and other troublesome and potentially fraudulent actions that came into being just after that time, none of this ugly mess would have happened such as your lifelong certificate being stripped from you with further payments demanded every ten years and now annually like a collection agency never showing you the proof that you own anything. In fact it is fraudulent and therefore illegal what the ABIM has done to everyone. And ABIM has dulled your mind and killed your heartfelt love for continuing education. So the ABIM after the mid 1980’s killed Walt’s good baby and they killed the joy of medicine along with his child. That is why every physician who participates in any of the ABIM’s coerced activities feeding the executives greedy appetite for power and money is legally and morally wrong. Fight for Uncle Walt’s good memory, but especially fight for yourselves to resist what is illegally taken from all physicians. You are all lifetime indentured slaves. Slavery is illegal in the United States! Fight against the illegality and immorality of the ABIM’s elite power structure. They do not serve you, the patient or any aspect of medicine.
        Walter Bierring lost a leg in his early life. It did not stop him from achieving great things in medicine and being a great example for us all. If Walt were alive he might tell you what you can to do to change things. As a religious man and a very sincere and honest many he might say to you, “If your leg offends you, cut it off, lest your whole body might perish.” So with Walt and for all of you, I echo a similar strong sentiment. Cut this evil that persists at the ABIM out of your lives. Sever the relationship and seek by whatever means is available, through legal power, governmental review, and by your own reasonable and moral persuasion to restore the proper order and balance to the ABIM and to your precious lives. The time you need for self, family and patient is yours. It is YOUR LIFE. It does not belong to any corrupted organization. Free yourselves and change the organization or perish with it.
        Words to the ABIM and ABIM Foundation: Cut off the ‘bad leg’ that will kill your organization and with it every physician that you have certified. It is time to go back to a not-for-profit ‘club’ with a lifetime certification; or dissolve the organization and give the money to universities to create a certification process producing a voluntary certification test for life. Bequeath the money to institutions who will act in a humanitarian spirit with people not conflicted as the ABIM’s executives have become. At universities there are strict rules about coi. Make it a free certification test or at little cost. Physicians’ accounts have already been harvested repeatedly, so they owe nothing more. There is enough money in the ABIM’s accounts for this simple purpose. Voluntary testing could be operated off of current investments and vetted donors. It could be part of a knowledge bank available 24/7 in this new digital age. The time to act is now. Not tomorrow. Or we will be sleepy angry slaves again tomorrow and the rest of our lives. Good luck.

        Thank you, Dr. Wachter, for inspiring and supporting an inward revolution toward a rebirth of continuous, meaningful voluntary learning whatever outward form it takes.

    • Steven Croft,M.D. July 11, 2015 at 3:00 pm #

      This is what happens when you get “experts” like “psychometricians”involved in designing quality measures.

  2. David Langdon June 29, 2015 at 10:55 am #

    Two problems with ABIM MOC you refuse to engage with.

    1. There is NO evidence that the burdensome MOC process produces better care for patients than other approaches like CME.

    2. The MOC critics were not the first to produce unwarranted personal attacks on the integrity of their opponents. Those representing the ABIM characterized critics as not wanting to trying to provide current good medical care, not as doctors who simply thought MOC a poor tool for the same goal.

    • e-Patient Dave June 30, 2015 at 9:18 am #

      Hi David – I don’t know you so please know that I’m writing this without an aggravated tone – just asking.

      As someone saved from stage IV renal cell carcinoma by excellent physicians and nurses, I have the deepest appreciation for what a top clinician can do. Today I serve as volunteer co-chair of the Society for Participatory Medicine, which is about both patient empowerment (through information) and patient-clinician partnerships.

      You say there’s no evidence that MOC produces better care. I’m not in a position to trot out heaps of stories but I personally have, and know people who have, absolute horror stories of physicians who were seriously out of date, doing obsolete procedures on trusting patients. I assume you know of such cases; time after time when these stories are told, I’ve heard physicians shrug them off, saying “Well, you should find a GOOD doctor.” Right?

      How is a responsible patient to do that, without testing? (I’m not flaming; this is an honest question. What advice can you offer?)

      I trust you’re aware of the IOM’s article (Balas, 2001) saying it takes 17 years for HALF of physicians to adopt new practices, and that’s not estorica, it’s things like flu vaccine, and baby aspirin for heart patients. I’m sure you’re not asserting that this is not cause for public concern, are you?

      Another straight / honest question, since you reasonably raised the question of evidence: do you know of any evidence the 17 years figure has improved? I’ve asked a lot and haven’t found any yet, but I’d love to. (Even if it’s somehow been cut in half, that would mean the average physician is unaware of the last 8.5 years of medical advances. Yikes.)

      Four years ago I gave a presentation in Boston that happened to mention evidence-based medicine, and a senior doc came up afterward and earnestly protested, saying “I want the autonomy to practice the way I want, not out of some damned cookbook.” Sigh. What do we do with a doctor who wants to treat my daughter, or my mother, pointedly disregarding science?

      I honestly can’t imagine how these items are not clear evidence of public danger of receiving sub-standard care. In my own disease I’ve learned that 3/4 of patients are not offered the treatment I got (HDIL-2); and I learned that many nephrectomy patients are never offered the option of laparoscopy, which in my case was important, since I needed to recover rapidly to start the IL-2.

      For another example (still within my own family), a relative just had a bilaterial knee replacement, using the relatively new muscle-sparing method; she needed no transfusions, was able to walk 500′ less than 48 hours from the O.R., and on day 5 was scheduled to go home from rehab on day 8. Comparing that to EVERY story I’ve heard from TKR patients, about their months of misery, I wonder – do patients not have a right to know about the newest treatments?? (I’m sure you wouldn’t assert that patients should just take what they’re offered and be happy with it, right?)

      In short, how are patients supposed to be informed, responsible care partners in the absence of knowledge about who is on the leading edge and who is reasonably current? And how are we as a society to reward the hardest working physicians and surgeons, who do put in the time and effort to continue their learning, as my oncologist and my relative’s orthopedist have?

      Again, these are sincere honest questions – I hope we can have a good dialog about this.

      • Justin Sommer June 30, 2015 at 4:24 pm #

        e-Patient Dave,

        You raise very valid questions, ones society has yet to have answers for. Regarding your anecdote that you have had excellent care while others have not been as fortunate, you ask “How is a responsible patient to do that [find excellent doctors], without testing?” I will respond with another anecdote:

        I present you the case of Dr. Jack Wolfson. He was voluntarily interviewed by CNN

        http://www.cnn.com/2015/02/05/health/anti-vaccine-doctor-jack-wolfson/

        and other news outlets local to his practice in Arizona. Google him. [To Dr. Wachter, who I know moderates comments on his blog, I submit that this is not a violation of Dr. Wolfson’s privacy given his public statements in interviews. This is news and public information freely available with Google. I ask that you not cite privacy concerns a reason not to post this comment to your blog].

        He is a staunch anti-vaxxer. According to CNN:

        “He calls measles ‘benign.’ If you vaccinate your child, he calls you a bad mother. And he says our children “have the right” to get infections. He has given a medical face to the anti-vaccine movement — eagerly stepping in front of TV cameras to beat up on vaccines and make light of the dangerous diseases they help prevent.”

        Sounds like an irresponsible doctor, right? Someone patients should avoid due to giving bad advice, right? If he doesn’t know the science behind vaccines, what else is he not ‘up to date’ on?

        Except that he has the stamp of approval by the ABIM as Board Certified AND Participating in MOC which you can look up on abim.org. I screencapped it in a tweet that you can see here:

        https://twitter.com/justsome_md/status/561177603978330112

        This is anecdotal but since I am responding to your own anecdote, it seems fair.

        My point is that MOC/Board Certification does not necessarily indicate what you think/want it to indicate. It is not infallibly the mark of a competent or responsible doctor. At best it is a surrogate marker for fastidiousness. It means that the physician passed a test and jumped through ABIM’s hoops to be listed as’participating in MOC’. That physician is still subject to their own superstitions and biases. They don’t HAVE to practice medicine in any kind of standard way. Dr. Wolfson isn’t stupid and it’s not that he doesn’t know the science; he just chooses to ignore it. Testing proved nothing in this instance.

        And when viewed in a different light, doesn’t the fact that he is board certified and participating in MOC make him even more dangerous? It is, after all, a tacit endorsement by the ABIM of his skills as a physician. If some patient were to do as the ABMS asks and check to see if he was “Board Certified” and “Participating in MOC”, they would see that he is. That’s not helping anybody. [If you’re wondering what became of Dr. Wolfson, the Arizona STATE medical board stepped in and sanctioned him in the name of protecting the public. ABIM did nothing]

        My belief is that the ABIM is standing in the way of progress. We have been told the story that the ABIM is THE authority and have been dragged down the path of their choosing for over 75 years. I think that’s taken us far away from where we want to go.

        Until recently, few in medicine (and none at ABIM of course) stopped to think about the opportunity cost of blindly following the ABIM’s unaccountable decisions regarding what Board Certification is and what MOC is. This is truly unfortunate. What else could we have done to answer your question about how a responsible patient can find a responsible physician had we not devoted all of our resources and trust to the ABIM status quo? We won’t know the answer until/unless we can come up with and try alternatives. ABIM has done their best to demean and block alternative solutions.

        You should ask why.

        • e-Patient Dave June 30, 2015 at 10:59 pm #

          In the interest of conciseness, I’ll say: I completely agree that any effort to achieve certainty about a situation is fraught with trouble. From my limited experience with vocational testing in industry before cancer, I know it’s possible for someone to test well and do poorly on the job. (And as I hinted, I’m steering clear of discussing the ABIM’s tests, because I know nothing about them, not to mention that I’m not a physician.)

          The issue of certainty comes up all the time in discussions about patient-clinician partnership re shared decision making and evidence-based medicine – even p<.01 is no guarantee, and that's not to mention all the problems with publication bias, Ben Goldacre's "All Trials" campaign against hidden evidence, etc. (When I talk about these things in speeches I point out that shaky evidence is at least as much a disservice to physicians as it is to patients; if we beat on docs to practice EBM, and the “E” is weak or corrupt, how is the doc supposed to do what s/he trained to do??)

          Heck, in my own treatment, I was in a clinical trial, and I later learned that I was in the cohort that they thought wouldn’t respond to the drug. Hurrah for uncertainty. :)

          In saying this I’m not trying to divert from your point about Wolfson – I’m pointing to the deeper issue, the desire for certainty and the difficulty of achieving it. It applies here because that’s why we *go* to the doc – to get better advice than Aunt Mary has, and because (IMO) certification itself is no guarantee, but (like peer review and EBM) it’s surely better than nothing.

          That still leaves us with the problem of how to certify, and how often to recertify. On that I “hold no currency,” as Paul Simon sang.

          Somewhere after the Web was born I (and many) realized that it was no longer possible to learn a skill that would last for life; the only sustainable skill was the ability to learn *new* skills. I suspect that similarly it’s no longer possible to master any field for a long time, especially any part of medicine – I imagine you’re familiar with the 2013 book “The Half-Life of Facts.” Crap, man – I left college in 1972 – facts were FACTS back then, or so I thought.

          So what I personally seek in a physician is an honest awareness of how much things change. I love that my PCP, the famous Danny Sands, is happy to say “I don’t know – let’s look.”

          Sorry for going on so long. I’m grateful for the dialog. I continue to seek ideas on how to prevent the sad stories of things that happen from seriously out of date docs.

        • Dr. Joe parnes July 11, 2015 at 8:45 am #

          umm, patient dave,

          Doctors show and prove they are competent every day, in ways that no other profession would dream of. There are hospital staff oversight boards, peer review, CMS, CME requirements, I could go on forever. What makes you think you understand—- what physicians go through, what the training entails, what continuing education they take every single year — that you can so confidently proclaim that physicians, unlike every single other profession, are not entitled to their own hard earned credentials?

          Good for you and your “participatory medicine”. So happy for you, but you have no clue.

      • SailfishMD June 30, 2015 at 4:39 pm #

        Hi Dave,
        Thanks for your thoughtful input into this discussion. Your concerns are very valid. Don’t forget, we docs and our fmaily get sick too, so me and my fmaily have seen the other side of the exam room table as well.

        How do I find a good docs without testing them (implied by MOC)?

        “Participaiting in MOC” is a bottom of the barrel metric for making this determination,
        Patients will find this frustrating. And I feel for them and share their frustration. How do I find a good doctor?

        By where they trained, reputation by patients and peers, and to a lesser degree board certifcations.
        It would be nice if a test told us who was smart and good and who wasn’t. MOC in its current form doesn’t do that and either does CME. Across the world, Europe, Canda , attending CME and scientfic sessions is how we keep up to date. The comprehensive board exams does a little, but even the board exams are usually not current or up to date. The best docs read the literature and current trials, attend scientific sessions and employ it years before it makes it into the guidelines and things like MOC. Instruments like MOC just arent nimble or comprehensive enough.
        Certain major medical centers enjoy prestigious reputations because they strive to be advant garde, places like Mayo Clinic, Harvard, Cleveland Clinic, Hopkins, DUKE, UCSF. You will usually find excellent docs in places like that. They are of course elsewhere, and by no means limited to those institutions. Im in Indiana but trained at some of those places. Cream rises to the top.

        If you are only practicing what is in the guidelines or what is in MOC you are still playing catch-up.

        MOC is a trademarked test with very limited scope,tests a very limited knowledged set, only offered by ABIM.

        MOC doesn’t measure compassion, time spent explaining risk, benifits and all the alternatives in language the patient can understand, integrity, or clinical judement, in short it is a flawed metric to judge is a doctor is skilled or good. It is also has not been correlated with a doctors knowledge set, experience or intelligence. It doesnt measure how much they read or how many scientific sessions they go to or how skilled their hands and technique are.

        I actually keep current by attending scientific sessions, avidly reading the current clinic trials, discussions with my peers, and educational sympsisa offered by Mayo and Cleveland. None of the MOC I perfomed (I think I have 50 or 60 points just this year, educated me, made me more current or was a proven yard stick of me keeping current.

        No Doctor on this forum is arguing against keeping docs current. There are other avenues that are in my opinion superior to MOC in accomplishing this. I actually believe that CME could be a little more rigourous, We all strive to provide the highest quality of evidenced based compasionate care. There are numerous boards overseers, quality and value metrics, and hoops we have to jump through to deliver this care and check all the boxes. Please see my arguments against MOC-remember this is expensive, proprietary testing offered by a private corporation. theya ren’t offering MOC out of the kindnes of their hearts, ABIM makes hudred of millions of dollars doing this.

        Paticipating in MOC doesnt weed out the bad apple that dont follow-the guidelines, dont follow evidence based medicine.

        I would urge you to discuss MOC and ABIM with your oncologist and your family’s orthopod. More likely than not they share my opinion, as the opinion I have is shared by 90 percent of docs.

        I hope this gives you insight as to why docs oppose MOC and that it is not that yardstick fo quality that you wish for.

        best
        SailfishMD

        If you wonder why no name its so I may honest without fear of professional repurcussions for taking on the machine and many so-called thoughtleaders.

      • David Langdon June 30, 2015 at 6:49 pm #

        e-Patient Dave, you are asking for some assurance that doctors are keeping up with fears they are not, but you are willing to grant both of the assertions that have not been proven: that MOC proves a doctor is keeping up, and that doctors not doing MOC are not keeping up. Neither assertion has been demonstrated, and many of us know from experience that both are not necessarily true.

        One of the worst things doctors do is to do a test that can be ordered that will not answer a question rather than the test that cannot be ordered that will answer a question. The MOC is an expensive invasive test with no evidence of efficacy.

      • Steven Croft,M.D. July 11, 2015 at 3:19 pm #

        e-patient dave,
        regarding your question on finding a doctor who is current and up to date. I’m an ABPN certified Neurologist (lifetime certification). I would not ever rely on MOC or in some instances even initial board certification as proof of experience and knowledge in the field. There are plenty of bad doctors who are board certified and some truly outstanding physicians who completed training yet never passed the specialty board exams. That is the truth.
        For my patients, my family and myself, I rely on my own observations, recommendations from trusted colleagues. and,yes, information on the web. If I have concerns about a rare condition or concerns about a new treatment I seek out a sub specialist and a physicians with lots of experience in the field.
        Medicine is not as cut and dry as many would have you believe. There are often many alternatives which meet the standard of care.
        I would recommend that the patient seeking a new physician do a bit of research and not just rely on “who is in their insurance book and who complies w MOC”.

      • Timothy Hitchens August 2, 2015 at 8:21 am #

        the reality is when looking at the questions on the exam, i would say no less than 70% are things we have never done, don’t do, nor will we ever do. the questions that fall in to that 70% are matters that we as internists are not even credentialed to do in most facilities, and insurance companies would not pay for if performed. they are strictly within the domain of a sub specialist. yes these are questions being asked on the exams. so a practicing physician has to take a few months of from an already hectic schedule study day and night to pass an exam.

      • Andrew Ing January 7, 2016 at 5:53 am #

        Having an ABIM certification under one’s belt doesn’t make him/her a good physician. I’ve worked with colleagues WITHOUT the ABIM certification and they were EXCELLENT physicians. I’ve worked with other colleagues WITH the ABIM certification and they were HORRIBLE physicians! The best way for patients to find a good physician, I think, is word of mouth, as is the case in most things. Ask your family members or friends which physician they go to and why. Hospitals do perform credential checks, but that does’n’t necessarily mean that all the physicians with hospital privileges are good physicians.

    • Chandra July 30, 2015 at 10:15 pm #

      Excellent summary in just two points.

      -Founder of http://www.BecomeAHospitalist.com

  3. A. Joseph DeLuca,MD June 29, 2015 at 12:16 pm #

    Dr. Wachter,

    Once again you chant the same nursery rhyme incantation to justify the cupidity and sleaze factor of the ABMS and its 24 member boards,

    Just who do you think you are talking to – Alzheimer patients? Open your eyes and ears – an overwhelming majority of doctors have responded to objective polls (not the crap research funded by the Boards ) regarding the utility of your make-work excuse to extract lucre from hard working, harried physicians in the trenches burdened by unfunded Federal and State government mandates and the squeeze of your Big Business buddies and other third party parasites sucking our blood. And the ABMS is running what is essentially an extortion scheme worthy of the Mafia. The Medical Mafia. Voluntary certification? LOL! About as ‘voluntary’ as a loaded pistol pointed at your temple.

    The ABMS virtually never speaks truth to physicians. Not about the outrageous salaries paid for your “forty hour work weeks, the slush fund ABIM Foundation and those of the ABP and other boards, the pat excuse for the luxury condo…..and the failure of the Boards to be responsive to the needs of the physicians forced to genuflect to your greed and arrogance.

    You gloss over the ethical conflicts of prior President of the ABIM, Christine Cassel, as well as continue to misrepresent the salaries of current and former ABIM Presidents and workers which give the lie to the term “non-profit”. You and your fellow Board members inlcluding past ABP President James Stockman with his $1.3 million annual compensation have squandered whatever legitimacy you may once have had.

    Many of us would like to see the ABMS and its member Boards prosecuted in criminal and civil courts for tax fraud (irregular filings with the IRS), extortion, and racketeering. Given that your organization clearly is intertwined in the nexus of illegitimacy that reigns in our Federal government and CMS, that is perhaps unlikely to occur. Justice is an illusion, as is your defense of the indefensible.

  4. doug June 29, 2015 at 12:32 pm #

    Bob, as you allude to, I think a lot of the anger stems from physicians’ feeling that medicine is now overrun by administrators. In the pursuit of safer, electronically connnected, or open market care, we have increased the admin presence by (I believe the # is) 3500% over last 30-40 years. While I have never met him, Dr. Baron does seem like a very good man. He is the unfortunate recipient of some of this anger as he is seen as yet another (overly paid) administrator at this point.

    • Michael June 29, 2015 at 6:34 pm #

      Dr. Wachter is very good friends with those administrators. He as much represents them, as he represents doctors. Maybe even more them, than you.

  5. Paul Kempen June 29, 2015 at 1:05 pm #

    Bob: Your essay is written from the view of an ABIM professional-which is what you are, having been in that for a decade. You completely neglect that medicine is highly regulated by State Medical Boards (i.e. that physician run overseer) who have licensing and power to do everything that the ABMS/ABIM strives to do to justify their salaries. The whole recertification is something pushed by the ABIM because physicians would NOT do this and the ABIM under C Cassel knew this and still pushed it forward via the ABMS, while other specialties also felt no need to do so. Indeed, the Anesthesiology board has now removed simulation and the “high stakes test” as manditory components of MOCA 2.0 BECAUSE this stuff is capricious and unnecessary.
    You state:”The Bottom Line
    We physicians are granted enormous privileges by society, and with these privileges comes the expectation of self-governance. That expectation flows from the knowledge that only members of the profession can determine what it means to be a competent internist, or cardiologist, or rheumatologist.”

    But we also have DEA, Hospital boards, Insurance companies, CMS, National Physician Data Banks, ETC AND The whole Torte industry “overseeing medicine”–what about the politicians, police, lawyers, etc who are running patients and PHYSICIANS practices without a ABIM oversight.
    You can create oversight ad absurdum and this is what the ABIM is doing. NO changes in outcome, no value, no education and above all NOTHING for physicians who MUST FOOT THE BILL several times already with state licensing, DEA and TAXES gallor!
    “Choosing wisely” would NEVER support a test that mistakenly fails 33% of Healthy doctors, costs over $400 Million a year to run and has no outcome base to validate it and of course no changes in practice to show for it!
    The ABIM is a gross hypocrite to keep pushing their MOC, because it is the base of their existence , yet no value to show.
    At the time of the civil war, there may have been a need for ONE agent to validate competence, but now we have MANY and this ABIM has become arbitrary, greedy, overbearing and outdated. It is time to put the ABIM along with the “stars and Bars” to pasture as relics of a bygone era!

  6. SailfishMD June 29, 2015 at 2:41 pm #

    Bob
    Once again you demonstrate your eloquence and silvery tongue. Let’s keep doc’s current and up to date. Who can argue with this and not seem looney?
    You even had me nodding my head yes, but the devil is always in the details and the road to hell is paved with good intentions.

    Self governance: ABIM is NOT self governance. They are neither elected or representative. There is no consent of the governed. You are right. the board is mostly academics and administrators, little voice of the rank and file. ABIM is a monopoly to maintain credentialing or get paid we have very little choice but to belong. You belittle the competition that is just strarting to get off its feet. I agree I don’t want the government in charge of this, but neither do I want a private board with Zero accountability and despite your statements, financial conflicts of interest.

    MOC: This is not an all or none thing Bob. Demonizing ABIMs critics as Arab Spring does little to help your argument.
    -Strengthening the CME processes a reasonable step, but why does ABIM need a “cut”. There is a pay to play (or practice) philosophy that is distasteful. Most would agree that CME should be more than just showing up, it should require that you learned something. My ACCEL does that, why shouldn’t that count? Every time I do CME from JACC and answer questions regarding a new article why shouldn’t that count?

    MOC/Value: We are forced to buy MOC. Yes forced to buy MOC. I argue that it’s value is poor I have no recourse other than hand over 400 dollars. I cant buy it somewhere else., for cheaper. Why is ABIM entitled to my 400 dollars per year, every year ? Why cant I fulfill this requirement by a manner that does not profit ABIM?

    What impetus does the ABIM have to offer MOC at the cheapest price possible? It doesn’t. There’s no competition and that’s why docs are rebelling.

    I have 5x the required CME and have over 40 points in MOC this year, I love to learn. But I can tell you that I am not a better doctor having done the MOC requirements, it did not make me smarter, nor did it identify my weakness nor help any patient determine whether I’m am keeping up to date. So what is it’s value? Having me answer 4 questions at the end of an hour class at a CME conference would do the same. Tell me where I’m wrong.

    10 Year exam: Why does this cost so much given the volume of test takers? Could this be offered cheaper. I remember this being a substantial burden finishing my residency going to into fellowship.
    ABIM is not friendly and does not allow for rescheduling or refunds. Why not? Because then can. What are you going to do? Had a baby? Sorry pay me. Oh you’re sick, sorry pay me. They have shown very little compassion for test takers. Where am I wrong.

    The questions are vetted. Really Bob? Really? Who sets the pass mark? How was this arbitrarily decided? I don’t think ACC and AHA signed off did they? Was this externally validated? Are the test questions peer-reviewed and externally validated? No they are not.
    I cant even appeal questions I got wrong, because I don’t have access to the questions and answers after the test, because they are proprietary.
    How is this fair or in the interest of public health or even in the interest of physicians? That’s because its only in the interest of ABIM.
    Sorry Bob, ABIM board exams have Much to be desired. Please see current accusations levied about this topic by Nephrologists. The fail rate for them was over 20 percent in 2014, not 5. are 1/5 of nephrologist incompetent or its the test an imperfect and flawed metric? How much did failing cost these 20 percent of test takes in terms of time and $$ 2,200 per test. Only 4,400 dollars. Never mind $$ spent on review courses, time away from patients, family etc. A pittance evidently to Bob as he discounts this off hand. Renal docs make good money they’re good for it.

    I wont go into the corruption angle or financial improprieties that are alleged; I have an issue with a product of poor value that I am forced to buy. People who make $$ off it tell me its great. ABIM has lost the trust of the docs it governs and give lip service to the concrete objections I’ve detailed above.
    We are hard working peers that value high quality educations and ongoing physician education of the highest caliber. We will not be marginalized or demeaned. Our arguments have merit which is why the argument is resonating among docs like no issue in quite some time.

    thanks

    But we are not buying your defense of ABIM and MOC, although it was very eloquent, it did glossed over many of the objections we have.

  7. John Gosbee, MD June 29, 2015 at 4:31 pm #

    Dear Bob, readers and Reply-ers:

    I don’t know anything about the ABIM money, politics, and governance structures… So I have no comment about them.

    I do know patient safety and patient safety competency assessment, in general. Both are difficult to define clearly, to teach efficiently, and to test adequately. Bob and some safety-quality leaders have been pretty realistic about these difficulties (again, I speak generally, not specific to ABIM).

    Let’s say I want to know if the resident or attending seeing me has patient safety-ness. As a patient, medical director, or oversight group (e.g., state board), how do I figure this out?
    I could create a quiz to see if they know what RCA stands for
    I could develop an essay question about how to improve patient discharge processes to gain insight.
    I could ask an oncologist, for instance, how many chemotherapy errors occur in their infusion center (if they say “none”, not good).

    How do I judge whether these are “fair” or useful assessments? Maybe I can glean that by what is taught about patient safety and quality. I need to be cautious here, because the curriculum could be a reflection of what is efficient to teach. Or, what the teachers know best. Or, whatever is deemed important by Joint Commission (or similar).

    We could resolve these questions by going to people who study the core essence of patient safety (or safety). But more important than the academic question, is finding out most relevant aspects of safety/quality for practicing physicians. We have to pick and choose, since there is enough material that a person can get a PhD. In a general way, High Reliability Theory and human factors engineering tell us what is most useful to learn and be tested upon. But, that is still a “big pile of food” to eat.

    Finally, even we agree on the list of important safety stuff, it’s even harder to figure out whether we focus on knowing the stuff (appreciation) or being able to do the stuff (learning methods).

    Being “transparent” about this complexity and uncertainty is VERY hard. Personally, I’ve lost out on professional opportunities, and likely lost jobs, being transparent.

    So…. I have to support Bob and anyone else who is brave enough to tout this complexity and uncertainty.

    John

  8. Linda Girgis, MD, FAAFP June 29, 2015 at 5:31 pm #

    I respectfully disagree with most of this article.
    However, your conclusion comparing doctors who disagree with the ABIM to Arab Spring protesters is just offensive. My husband is Egyptian and most of his family still lives in Egypt. We know people who DIED protesting the corrupt government. Our family and friends are still suffering under the economic fall-out that it caused. People are having a hard time to get bread to eat. How dare you compare opposing opinions to very real human suffering! You have destroyed any good opinion that I may have had left for the ABIM.

  9. Kevin Pho, MD June 29, 2015 at 6:59 pm #

    Bob,
    Thanks for writing this. It provides much-needed insight that has been lacking in the ABIM’s responses to the allegations.

    As I mentioned on Twitter, there is little independent evidence supporting the contention that MOC improves patient care, summarized here from JAMA:
    http://jama.jamanetwork.com/article.aspx?articleid=2290642

    I’d be interested in your comments on this.

    The ABIM Foundation takes great pride in asking physicians to Choose Wisely, based on the evidence.

    Asking doctors to participate in a process that isn’t evidence-based is a jarring dissonance, to say the least.

    Thanks,
    Kevin

    • e-Patient Dave June 30, 2015 at 9:22 am #

      Hey neighbor Kevin – I know I can have a good dialog with you. :) I wrote my comment above http://community.the-hospitalist.org/2015/06/29/the-abim-controversy-where-the-critics-are-right-where-theyre-wrong-and-why-i-feel-the-need-to-speak-out/#comment-620857 before seeing that you raised the evidence question too. Let me know what you think.

      (Note that in no sentence did I say “the ABIM’s MOC is excellent.” I asked specific questions… again, I know you’ll respond based on what I said, not things I didn’t say.:-))

      • Kevin Pho, MD June 30, 2015 at 3:52 pm #

        Dave,
        Thanks for your questions.

        As you know, the history of medicine is littered with ideas that intuitively make sense, but later disproved upon further study. Hormone replacement therapy, for instance.

        While I certainly don’t doubt your experience or hypothesis, as the saying goes, the plural of anecdote is not data. If there is an independent study showing that MOC benefits patients, this argument will disappear. To my knowledge, there isn’t.

        It’s not reasonable to expect physicians to practice evidence-based medicine, yet require them to participate in an activity that “makes sense” on one’s past experience.

        You sighed when that physician resisted your calls to practice evidence-based medicine. Yet, where’s the sigh when we call for the ABIM adhere to that same standard?

        So, to paraphrase your own powerful words: “Show my the damn data!” And then I’ll buy in.

        Thanks,
        Kevin

        • Civisisus July 2, 2015 at 11:56 am #

          “So, to paraphrase your own powerful words: “Show my the damn data!” And then I’ll buy in.”

          Respectfully, Dr Pho, read the physicians who regularly post at KevinMD. They invariably – invariably – bristle at positive remarks about accumulation of ANY data, damned or otherwise, concerning their practice of medicine. Their hypersensitive selves are affronted that anyone, anywhere, would suggest that THEY “show data” regarding their clinical behavior, and they expend staggering amounts of energy denigrating ANY form of EHR, or administrative oversight, or ANYthing that would introduce systematic datagathering to the opaque world of their clinical activities.

          MOC may be the work of the devil. I’m not qualified to judge. As a non-physician, I have to say I’m fascinated by this airing of the ABIM/MOC controversy. You and other clinicians may be surprised to learn that non-clinicians practically assume that clinicians broadly understand the value that lies in their broadly supporting development and maintenance of objective standards by which they can demonstrate their ongoing professional competence. Pro tip: those musty diplomas on the wall don’t do that.

          Physicians need to grow up, and figure out ways in which systematic datagathering/sharing can be employed, ways that do not upset their delicate sensibilities. Because you know what? People – people who are sometimes patients – will reject their spluttering protests that they can’t and shouldn’t be bothered to do so; and that nobody who develops systems for doing so understand them; and that every apparatus for doing so burdens them; and will go find ways of obtaining health treatment that do not involve those physicians, at all – but that DO entail a more transparent, “data up” environment of care, where “prove it” is understood by clinicians as part of the territory, rather than an unconscionable imposition on their privileged selves.

          • DrG August 17, 2015 at 11:24 pm #

            hah, excuse me for the vernacular but what a load…

            you are precisely correct, you aren’t fit to judge. ask ANY physician in any specialty how valid or useful they feel their respective boards are. they will all confirm the opposite to you. now, if you’re uncomfortable with that, and the pieces of paper on my wall, please, please, please leave my practice and go wherever you want and take dr. google with you. there will be a hundred more to replace you and half of those will be returnees from every tom, dick, harry and jane who wants to hand a doctor shingle out front now-a-days.

            bob, you’re a lovely speaker and no doubt a talented educator, but you’re way off base on this.

            EVEN if the financials are not in doubt (and they are, for those who want to look deeper), the real question is whether the process of certification and re-cert does what its supposed to do. re MOC, the Board defenders (like you Bob) will at best say, “oh mea culpa” we see that this MOC business was too much trouble so we’ll throw you a bone…please keep paying.” that’s a lovely business move but doesn’t mean a damn as far as protecting the public goes.

            (hey, if the Board and its paid psychometric geek patrol were soooooo sure about needing MOC to demonstrate physician competence, then why not put their holy foot down about it? i’ll tell you why…because they don’t know that it demonstrates the quality of any damn thing.)

            as others have pointed out, other than some shoddy papers on the Board’s site, there is scant evidence that certification really guarantees the public of anything. (sorry epatient dave, that’s the awful truth.) it’s not evidence based, and the science Bob has pointed out is simply the “science” of psychometric testing. it does NOT validate content, only that the questions can generate a reliable spread of answers amongst the examinees. anyone reading this needs to understand this; the Board’s much balley-hooed talking point about “psychometric blah blah blah” has precious little to do with what is actually being asked.

            speaking of questions, here’s a simple question for you: if 95% of physicians passed the boards, then why did you need to roll out the “choosing wisely” campaign. doesn’t that mean that a significant proportion of the 95% who certified were (are) in fact “choosing stupidly”? but i thought the test was supposed to protect us against that?! oh dear.

            aside from the above, the process does NOTHING to actually help physicians who need extra guidance or teaching or whatever, to actually improve. DESPITE THE FACT THAT THAT IS THE ESSENCE OF EXAMINATION…to help the learner see his/her weaknesses and correct them. you get a little piece of paper that says, 60% on GI, 35% on Endo, and so on. wow, so helpful.

            bob are you getting this? MOST physicians feel like this is a waste of time (even the 95% who pass). and the whole thing just feels so punitive. do you and your colleagues get that Bob? it’s PUNITIVE. now, why do you suppose that is? is it because the majority of practicing internists (who uniformly hate the Board) in a word, suck?

            or is it because you do?

            here’s a clue for the Board. beef up CME so that you can’t take a nap, sign the paper, and get your credits. REQUIRE certain topics of CME for recertification, just like a syllabus in school (eg. annual “hot topics” in medicine or whatever). then base the recert exam on the syllabus. and offer docs who don’t pass an attempt at remediation.

            (oh, and btw multiple choice is so passe. you can easily program a test that simulates live patient encounters in various settings and let the examinee proceed through a series of steps rather than doing hit or miss multiple choice questions. following a train of thought is a much better and more rigorous testing mechanism. the current exams are a mish mash of questions with little rhyme or reason and no resemblance to what a physician does or how he/she thinks all day long.

            in the end, this WHOLE problem is simple enough to fix. make this fair and transparent. make the damn thing like a really tough but fair med school class. we’ll all get it, be willing to pay for it, and even support it.

        • William Baker MD July 2, 2015 at 12:59 pm #

          Fully agree. This should be our mantra at medical staff meetings and around negotiating tables with insurance companies throughout the country: “Show us the data”. We’ve asked the ABIM repeatedly and their reply of “trust us, it is so because we say it is so” is woefully inadequate, remarkably arrogant and insulting.

  10. c June 29, 2015 at 11:45 pm #

    final paragraph belies the reasoning of the entire article. Arab Spring protestors took on corruption and poor governance, they should not be faulted for doing the right thing even if the outcomes were not as expected. so this is the reason the ABIM is inviolable, because if it disappears a General Sisi (Egypt) type character will rule MOC. horribly illogical and a clear scare tactic. Wachters (irrational) World indeed!!

  11. Paul WJohnson, DO June 30, 2015 at 12:21 am #

    Hi Bob: you seem as stalwart in support of ABIM-MOC as those you accuse of having their minds made up in opposition to MOC. Most doctors wouldn’t mind if this process made them better doctors, but it doesn’t.
    The premise of your argument for MOC is that if we don’t self-regulate, someone else will. What’s your evidence of this and aren’t we already scrutinized by state medical boards, hospital credentialing committees etc ? Your other argument is that CME isn’t enough to stay current and provide good care. What evidence is there that CME isn’t good enough ?
    Lastly, our neighbors to the north in Canada only do CME, as do the Eurpeans as well, in order to maintain medical certification.
    What is so compelling about MOC that you hold onto so strongly ? It certainly cannot be the science. Pray tell.
    Thanks, Paul

  12. SR June 30, 2015 at 4:55 am #

    Mission Creep…Pure and simple.

    Most new rules, initiatives, EHR change, etc are done seemingly by physicians, who are either no longer practicing or very minimally or at the tail end of their successful career. This administrative role may be a natural progression, but seems like the practicing types have to carry the burden of those decisions. There is also a natural tendency for groupthink. Heck, if everyone is doing patient surveys, so should we.

    Organizations should have more physicians who share administrative roles such that the rule makers are at least practicing 50% of the time…I would like to see if this makes changes in general not only more reasonable.

    Organizations have become burdensome in our ever-connected world. Does any organization think that the problem may be the organization itself? Do organizations have ways to abdicate their powers? Sometimes, we all should learn to bow out gracefully.

    • Jay Lozier, MD, PhD, FACP March 3, 2016 at 6:19 pm #

      Perhaps the root cause of the problems with ABIM (and other such societies) is that they have paid staff whose job it is to look for problems to solve in order to justify their salaries. It is a full time job, whether there is work to be done, or not.

      Perhaps ABIM should be a group of physicians, elected by their peers, who meet perhaps quarterly (semiannually? annually?) with actual expenses paid with a small honorarium to discuss issues pertaining to assessing physicians’ understanding of new therapies, drugs, procedures, diagnostic challenges and propose test questions that could be vetted by contractors, and the day to day administration of same take care of by a paid executive secretarial staff.

      If you have a board of people whose full time job (paid for in generous six figure salaries) is to find things to fix, you will have a board that finds things to fix.

      I think ABIM should be limited to assessing cognitive abilities of internists/subspecialists, not trying to determine whether a physician’s practice is improving or not. The latter is the provenance of local hospital credentialing committees, state medical boards, tumor boards, DEA, etc.

  13. Subramanian S MD June 30, 2015 at 6:05 am #

    ‘It is difficult to get a man to understand something, when his salary depends on his not understanding it.’ – Upton Sinclair
    1. It would be appropriate to mention conflict of interests, and any association with ABIM or related parties to keep the record straight, and for credibility.
    2. As has been mentioned, why is this a phenomenon unique to the US? Are doctors in other countries unreliable? We should remind ourselves that the health care indices proportional to the health care expenditure is the amongst the worst of developed countries. Should we speculate that the overzealous regulation is a contributor, and that this is another regressive step?
    3. Evidence based medicine is the chant. Fair enough. Let us start by looking at the evidence so far. Choose wisely should refer to the interventions that the ABIM plans, not just what it thinks physicians should do.Without good quality data, increasing physician burden, cost and work load cannot be justified.

  14. RSW June 30, 2015 at 5:52 pm #

    “people who believe in the values of the Board have been cowed into silence. It feels vaguely McCarthyish, and there comes a time when silence is immoral”

    That’s where I stopped reading.

  15. Larry A. Green June 30, 2015 at 7:06 pm #

    I am a family physician, not an internist, and I have participated in re-certification and continuous certification as a diplomate since finishing residency in 1976. Along the way I have been involved in multiple professional organizations, including the American Board of Family Medicine, which some may presume disqualifies me from commenting. The American Board of Family Medicine, founded in 1969, began with time-limited certification and practice audits. I and my fellow family physicians were never grand-fathered–partially explaining why a large majority of more than 84,000 ABFM/ABMS board-certified family physicians have not reacted as some internists and others to continuous certification. This thoughtful commentary by Dr. Wachter deserves careful review by physicians in all disciplines and not continued discrediting commentary. Expertise and awareness of ABIM is not a basis for discrediting Dr. Wachter’s report.

    Further vitriolic commentary is not a feature to be admired by and within a profession. Indeed, it seems that some physicians may not understand what constitutes a profession–its features as a group activity requiring discussion, debate and discernment of how to fulfill physicians’ commitment first to public interest. “Of the profession for the public” is a challenge worthy of physicians, and the accurately reported yet false allegations that ABIM is “scandalously profligate and corrupt,” the “cynical and sickening” attacks to Dr. Baron, and the existence of a “deep well of physician anger and angst” –are by all accounts accurate. It is time for more civility and accuracy amongst us physicians to continue our collective, multi-specialty journey toward improving our practices, together, as best we can.

    My thanks to Dr. Wachter for introducing accurate information, thoughtfulness, and civility to an important national conversation.

    • DDS MD June 30, 2015 at 10:54 pm #

      When your livelihood is as stake and you quite rightly believe you are being exploited and extorted and have been repeatedly lied to, what exactly do you believe to be the proper response? Kind civil discourse and acquiescence? Nonsense!

      Physician have every right and, in my strong opinion, a duty to call out the ABIM/ABMS and continually hold them to the fire – thankfully, that is happening!

    • Jay Lozier, MD, PhD, FACP March 3, 2016 at 6:39 pm #

      Most internists/subspecialists such as myself have really never minded having to re-test periodically. I am “grandfathered” in Internal medicine, but have re-certified twice in Hematology since passing in 1990. Taking the test has never been a particularly problematic thing to me, and the associated open book modules and test prep have been interesting and even useful.

      The biggest issues are the practice improvement modules that have been added to the mix, in which diplomates are sent on errands of unproven benefit to anyone. I happen to work at a government facility where I, as the physician, have NO say over the workings of the nursing staff, hospital administration, or anyone else who works around me. I can’t change much of anything, since nothing is under my control. It has been advised that where I work, any kind of patient survey constitutes “research” (!) and must be approved by an IRB to be done. These impediments and the lack of any evidence that the task is important or worthwhile in the first place make me skeptical of the process.

      I think the ABIM should simply state Dr. X took Internal Medicine board exam in the following years, and Cardiology in the following year(s), or Hematology, Endocrinology, etc. They should not insinuate that you are not a satisfactory physician because you don’t re-certify in a particular field. Just say when the tests were taken and let the hospital or patient decide if that matters.

      As a Hematologist, I don’t mind if someone concludes that I am not up to snuff in general Internal Medicine; I am not, but I don’t treat asthma, or heart attacks; I treat patients with blood disorders.

      Practitioners who are not in academic practices like mine also don’t have time to take from running their practices to study for months for a high stakes recertification test, particularly when hospitals will pull admitting privileges if board certification lapses. For this reason, the every 10 year test, with its high stakes (and unproven value) is becoming problematic. Multiply this by a factor of 2 or 3 for those who are in Cardiology and do interventional procedures or Hematology/Oncology where three board exams are always looming, and you will see the reason for the lack of patience for the process.

  16. Matthew Holt June 30, 2015 at 9:46 pm #

    Good grief. All of you have missed the point which i mostly, has the ABIM been illegally lobbying and booking future revenue as current accruals (as accused by the conflicted journalist and the associated CPA) or not.

    If no, there’s not much of a story here. If so, then it’s a big deal.

    In both cases transparency from the ABIM would sort this out quickly.

    I said much more in reply to this piece when we cross posted it over at THCB

    http://thehealthcareblog.com/blog/2015/06/29/the-abim-controversy-a-brief-history-of-board-certification-and-moc/

    • RSW July 1, 2015 at 12:58 pm #

      No, the point is “Is there any evidence that the ABIM’s MOC program makes better doctors?”

      If there is no supporting evidence, MOC is just a thuggish shake-down scheme – it may be a very honest, well-run shakedown scheme, or it may be a very venal, corrupt one.

      If there is no evidence supporting MOC, as scientists we need to Choose Wisely and reject the ABIM’s authority.

  17. Isaac Gorbaty MD July 1, 2015 at 1:01 am #

    Read your long screed. The only issue that matters is whether being Board certified makes a physician a better doctor. If it does, it is justified to ask physicians to sit for Board exams. If not, it should be dispensed with.
    The only study addressing this issue appeared in the Annals of Internal Medicine in the 1990s and has not been repeated. The authors compared charts, colleague feedback, and patient satisfaction with their physicians, all of whom who had all completed specialty training in approved university training programs. The study compared the results of two groups; the group who were Board certified vs. physicians in the same specialty who were not Board certified. The physicians were asked to take a miniBoard exam and mail it back to the researchers. They found no difference in quality of care or the patients’ perception of the care they received; furthermore, they found that the physicians scored similarly on the exam as they had done when they finished training. The conclusion of the study was that no difference could be demonstrated between the two groups of physicians, but since there obviously was a difference, their methods were not sufficiently sensitive. the study was never repeated.Therefore,there is no evidence that, having successfully finished specialty training, Board certification makes any difference in care delivered. On this basis there is no basis to require physicians to sit for recertification. They should be trusted to continue life long learning of their own choosing. If we trust them to care for patients we should trust the State medical Boards, and the Hospitals, and Insurance companies to monitor the doctors.
    I have written to the ABIM since 1990, as each new head has been inaugurated, asking that a vote of the Diplomates be taken. I am happy to abide by the vote of my colleagues; the Board has never entertained similar respect for the views and wishes of their physician colleagues. It is about time that the Diplomates demand a vote, or boycott further exams until a vote is taken.
    The issue of salaries, or finances of the ABIM, pale beside the issue of whether Board certification is of any value, after a physician has completed appropriate post graduate specialty training
    Isaac Gorbaty MD

  18. Joseph DeLuca, MD July 1, 2015 at 4:37 pm #

    I agree that the issue of whether the process of Board MOC results in demonstrable benefits in terms of proving physician “competency” is of paramount importance as it is the ostensible justification for the demands of time and money which this private unaccountable “non-profit” (sic) organization imposes upon harried physicians.

    However, from both a legal and ethical standpoint, much more needs to be exposed regarding the clandestine operations and fiscal manipulations involved in the “Foundations” founded for the various member Boards.

    Dr. Wachter is rather blithe in his dismissal of such inquiries. Fiscal reserves suggest that the cost of the examinations have been largely inflated and the accounting is clothed in secrecy. We need a fiscal dissection of these Foundations in the name of transparency.

    And we need Washington and regulatory bodies that ostensibly exist to investigate these entities to clear Wachter and his colleague of any suspicion of impropriety.

    I’m sure the good doctor would approve of this investigation in the light of his commitment to truth and transparency. No?

  19. Ashok Daftary, MD July 1, 2015 at 9:26 pm #

    It is unfortunate that these issues represent the end of Internal Medicine as I remember it.
    Wachter’s World and Dr. Wes present views that are widely divergent.
    Let me contribute what I know. On the 3rd of January, 2006 published in the Annals of Internal Medicine was “Who Is Maintaining Certification in Internal Medicine—and Why? A National Survey 10 Years after Initial Certification” The authors will be familiar to all of you, Rebecca S. Lipner, PhD; Wayne H. Bylsma, PhD; Gerald K. Arnold, PhD, MPH; Gregory S. Fortna, MSEd; John Tooker, MD, MBA; and Christine K. Cassel, MD. They concluded, “The relatively large percentage of general internists who left internal medicine mostly to work in another medical field explains why rates of MOC participation for general internists seem lower than those for subspecialists (77% vs. 86%). These were all closely associated with the ABIM.
    The then editor of the Annals, Dr. Harold Sox was concerned and devoted his editorial in that issue to this paper. He concluded “As our country slides into a crisis of access to primary are, the ABIM-ACP survey provides 3 valuable lessons. First, the number of primary care physicians is probably declining faster than we had realized. Second, migration between medical specialties is important. Third, we need to track career changes of practicing physician.”
    A decade ago it was apparent that Internal Medicine was in trouble.
    I had then practiced for nearly three decades and submitted my response to these articles which surprisingly was published in the Annals in its issue of the 2nd of may that year. I stated
    “Academic medicine is the carpenter that fashioned the coffin of internal medicine. Instead of reengineering internal medicine to accommodate change, it cannibalized the discipline by reducing its worth, creating the hospitalist and ambulatory care internist. These were both nails that helped seal the coffin; the former reduced the influence of the internist in the acute care environment, and the latter blurred distinctions between internists and those without medical degrees who practice in ambulatory care settings.
    Medical subspecialties that are nurtured in the ivory towers of academia have further reduced the stature of the internist. Effective lobbying by their affiliated societies and by commercial manufacturers of the medical devices they use assured them disproportionately higher reimbursement than that of their generalist colleagues. Absent an identity, the internist’s only remaining role is thought to be that of provider of ambulatory care to the chronically ill whose medical problems are beyond procedural intervention and lucrative compensation.
    A continuing decline in professional stature and income, when coupled with deteriorating working conditions, makes the continued existence of internal medicine untenable. I am pessimistic that current political and professional interests will allow significant change to resuscitate internal medicine. Would it then not be opportune to draft an obituary for internal medicine and commission a requiem to its memory?”
    Dr. Wachter and Dr. Fisher were both correct and incorrect.
    Internal Medicine as we knew it is dead. The MOC controversy helped turn the ventilator off.
    I have read comments in both blogs. Some are thoughtful, many are ill mannered and unprofessional and reflect the political tenor of this nation.
    I was amazed that Mr. Eichenwald’s wife was used as a weapon to attack him. There is no conflict in his being married to an Internist and her certification status is not relevant to any discussion.
    We then had another gad fly journalist given credence by Dr. Wachter in his blog who skewered the Eichenwalds including Kurt Eichenwald’s neurological problems. For those who care Mr. Eichenwald wrote about his own illness in the New York Times in 1987.
    I would expect Dr. Wachter to evaluate his references more carefully.
    The excuse that Drs. Cassel and Baron are receiving fair compensation once again demeans the practicing internist who is paid a fraction of what these administrators and discredits their worth.
    If Pete Seeger were a witness to healthcare today he would write
    “Where have all the Internists Gone?…
    Become administrators everyone
    When will they ever learn, when will they ever learn”

    • Edward Hale July 13, 2015 at 7:32 am #

      Dear Dr. Daftary,
      I was struck by your deep thoughtfulness and compassionate insight in this discussion. Concerning the requiem for the internist, it does gives us pause to remember. I appreciate your words and express sincere thanks for all your years of giving and self-sacrifice as an internist! Your sincerity resonates with me.

      We still have bound copies of those discussions in the ‘Annals of Internal Medicine’. I recall the words even now and the flavor of thoughtfulness your meaningful discussion evoked.

      I admired Pete Seeger, also. He did clean up the Hudson, and worked to change many things in our society through his musical activism. Maybe he would have written a lyric like this also…

      Where Have All the Interns Gone?

      Where have all the interns gone?
      Long time passing.
      Where have all the interns gone?
      Long time ago.
      Where have all the interns gone?
      Gone to software everyone
      When will we ever learn?
      When will we ever learn?

  20. Jonathan Weiss July 2, 2015 at 7:51 pm #

    I have written on this blog before and will not take up gobs of space to rehash what I’ve said in the past, other than to say this: I consider myself a good doctor, and so, apparently do my patients and colleagues. I am triple board certified in 3 areas, and have recertified in all 3 areas once and in 1 area twice. I have never failed any of the MOC requirements. I can say unequivocally that nothing I ever did for MOC has ever made me a better physician; it was all a colossal waste of time and money. In fact, keeping up with MOC probably somewhat hindered me from keeping up with the stuff I feel I really need to know to stay current (there are only so many hours in the day, after all). Throughout my career, some of the greatest clinicians I have ever studied under, learned from, co-managed patients with, were NEVER board certified, let alone doing MOC, and they were, and are, without question, some of the most amazing and brilliant doctors one could ever have the privilege of working with. On the other hand, I know some MOC current docs whom I would not let treat my kid’s stuffed animals. The point is, good docs are good not because of MOC, but because of who they are and how they approach their craft, and bad docs are just that, bad docs, and they can pass MOC and still be bad docs. MOC tests how good we are at taking tests, and that is a far cry from assessing how good we are at being doctors. It is all just a scam.

  21. Richard Rohr July 4, 2015 at 12:50 am #

    As someone who is very happy to have lifetime certification in internal medicine and has stood on the sideline as the MOC juggernaut passed by, let me offer a few thoughts. One of the problems with ABIM through the years has been domination by academic physicians. Perhaps Dr. Baron can introduce more of a practicing physician’s perspective. Some commenters suggest that state medical boards and hospital peer review committees provide adequate oversight. Having been involved in both activities, I know that they are very limited in effectiveness. CME has been demonstrated to have very little effect on clinical practice. I believe that MOC is very similar to electronic health records (another of Bob’s concerns) in that they are both terrible in their current form, but we need to make them work if we are to move forward with medical care that provides quality and value.

  22. Dave Slaughter July 4, 2015 at 2:25 pm #

    A recent poll by Medical Economics of primary care physicians , of whom 95% were board certified, was conducted concerning MOC. One question asked was whether these physicians felt the MOC process made them better physicians. Generally if a person spends thousands of dollars and large amounts of time and effort achieving something, they would have an psychological incentive to find value in that endeavor. However, 95% of those polled did not feel that MOC made them more effective physicians. I cannot think of another product that could continue to exist where 95% of the purchasers felt that the product did not do what it was advertised to do. As mentioned by several commenters, there is no evidence that the current MOC process does anything other than to consume physician’s time and money that cannot be achieved by CME in other venues. In contrast, look at the popularity of MKSAP, in which physicians voluntarily participate and do find value.

    I wonder what would happen to the recertification process if it were made truly optional, as it has been for grandfathered physicians. I suspect it would tank for lack of participation as doctors turned to CME they found more valuable.

    • isaac gorbaty MD July 4, 2015 at 3:09 pm #

      In the 1980s physicians voluntarily attended MKSAP reviews at the hospitals I attend at. Only 5% of Diplomates took the recertification exams. The ABIM should return to the pre 1990s status and let the Diplomates choose their method of continuing education. This should be put to a vote of the Diplomates asap.

  23. Bill Kim MD July 9, 2015 at 3:20 am #

    Bob,
    As an ABIM insider how can you possibly be objective enough to talk about the transformation that is sorely needed at the ABIM in order for it to survive? You dismiss the concerns of ABIM fiscal waste as “hogwash”. Retreats to the Four Seasons in Center City? Mercedes Limo Service? Are you implying that the ABIM leaders are entitled to these luxuries? I take great issue with your comment that the ABIM MOC is affordable at $200-$400/year. Firstly this is a gross misrepresentation since you neglected to include the costs of review courses and being away from the office and the hospital. More importantly, it is the value of the MOC and the inherent waste that is priced into the exam fee structure. If all the nauseating waste at the ABIM was eliminated and the exam fee was cut in half, wouldn’t that be a good thing for everyone? Why pay $400 for something that can cost $189 or less?

    Let’s face it. You and the rest of the ABIM leaders represent a generation and a micro-cadre of physicians who are way too out of touch with the rest of us. The ABIM has lost the trust of the very constituency it should be faithfully serving. This treacherous behavior camouflaged under a thin veil of “Choosing Wisely” is the actual “hogwash”. Maybe you, Rich Baron, Christine Cassel should practice what you preach and stop selling out your colleagues for a Mercedes Limo service across Center City Philadelphia. Shame on you.

  24. Parvez Dara, MD FACP July 9, 2015 at 1:42 pm #

    Dear Bob,

    Do we need MOC?
    Seriously!

    I understand that the ABIM priced the modules based on their cost+ revenue model as any business would. On that there is no complaint. However what occurs to me is the very premise that some how the MOC process makes us better, more knowledgeable and wiser physicians. that we take better care of our patients.

    If that were true then there would be oodles of data to support it from INDEPENDENT bodies. There is NONE. The only data that seems reflective of minimal gains are the tortured data created and published by the ABIM and its surrogates. On that aspect the idea of Conflict of Interest does come to mind. You see it is like a tobacco manufacturer touting cigarettes as the panacea for bronchitis or even cancer. There is inherent hypocrisy in this. The ABIM tries to convince the “non-physicians-public at large” groups about the inherent value whereas the physicians that deal with science on a daily basis have their voices muted through coercive means by the same body, lest the truth get out.

    The initial Board Certification was a badge of distinction in my mind and even the recertification to some extent. However, Upon taking the recertification examination, I found little value in the arcane, esoterica that had nothing to do with the daily practice of my specialty. I might have been smarter in esoterica from hours of consulting books and articles but it did not translate into benefits for my patients. Really, how does knowing the epigenetic mRNA function that has no known observable or measurable means in differentiating the nuance of 3 month PFS found through correlation have any value at all? Seriously!

    You were a part of this behemoth agency that has crafted a nice nest egg to support its board members over the past several years. But have you recently practiced medicine and did you find out that to keep an office open a doctor has to jump through the indignity of regulatory/mandatory/compliance related hamster wheels before getting reimbursed from an insurer? The Medical Revenue Cycle is so complex that keeping up with the auto denial at 11% of all bills requires more than one staff member and an ideal doctor’s office of one employee is now burdened with 6 or 7 or more employees just to stay open? And who pays for that? The doctor of course from his diminishing reimbursements!

    The difference between the view from a high bridge and that from the onrushing waters of a torrent should give all at ABIM pause, if they too were embroiled in caring for the patient as they should and in trying to keep their offices open. Taking time and resources away from the very people who devote their entire lives to the care of those in need is heartless and to some extent ruthless. And in the end, this twisted MOC process takes away time and hurts the very people the powers that be purport to “protect.” The trending terminology of “For the Public Good” continues to be used as a self-fulfilling and self-enriching prophecy. It seems that if you repeat the mantra over and over again that, that becomes a reality. Well it doesn’t!

    Some have forged this new thinking in the wake of this physician outcry that the MOC process should be modified in keeping with the inputs from the physicians. No, maybe the ABIM did not hear the call clearly. The MOC process is dead to most (>90% of physicians) of us and cannot be resurrected. But if the ABIM chooses to follow the same path, then so be it. The decline in their revenue stream that follows will speak for itself.

    Please understand, I favor education, I favor knowledge, I favor excellence in caring for the patient, I favor the best outcomes for the patient as most all physicians. But I get most of my knowledge from the experiential reality, reading the medical literature, understanding biology, taking CME courses. Learning is a complex process. It is not based on rote, memorization but on understanding. You will agree, one can mouth off the cranial nerves but what is their function and how they interact is in the understanding. One can recite the signs and symptoms of heart failure but only understand it when the reality lies in front of him or her. One can talk hours about the survival data about a cancer but to lead a patient through the rigors of care successfully is in the understanding and not in the current vogue of population medicine; one size fits all.

    So Bob, with all due respect, (and I don’t mean to say anything mean next) the entire process is fraught with hurt for the PATIENTS and for the PHYSICIANS. The only one standing to applaud are the ABIM and its Board of Directors, who earn 5 or 6 times the average physician salary for marketing and promoting their cause.

    Hope you take this in good stead and maybe even discuss it with Dr. Baron and the rest of the crew, because we as physicians have had it!

    All the Best!

  25. Ray MD July 10, 2015 at 6:23 am #

    So true as said above, “good docs will be good docs and it is not because they pass MOC.
    Ironic it is called MOC (mock). It is a tragedy that doctors who turn administrators lose touch with reality. So much money is wasted on middle management in big organizations, so many layers and so much $$ down the drain, and then we wonder why health care is expensive!

  26. Dr. Wes July 10, 2015 at 3:25 pm #

    Bob-

    As you know, I broke the ABIM Foundation Condo story, complete with its chaueffer-driven Mercedes S-class town car, on my blog in December, 2014. As part of that post, I called the ABIM and asked Rich Baron to explain (1) the high annual condominium expenses of over $165,000 in some years and (2) to explain the discrepency of the Foundation’s date of creation and domicile of the Foundation. These were questions, not “egregious allegations” as you suggest. What I have discovered is something very concerning and it speaks to the core of the ABIM’s problems: trust. That is, trust with the practicing physician community and trust with the public. It has been thoroughly squandered by the ABIMs refusal to address very real financial concerns of active ABIM diplomats: those from whom the ABIM receives their funds.

    You see Dr. Baron explained that the high condo expenses were because the Foundation included depreciation of the property in the “expenses,” and graciously sent me an itemization of those expenses. However, we are left to wonder why the ABIM claimed expenses that way when there is a separate line-item on the Form 990 to claim depreciation for properties. Was this just sloppiness or were they hiding something? Also, in response to the 1999 origination date of the Foundation claimed on federal IRS Form 990s for the Foundation, he wrote to me (after checking on this) the following statement in an email:

    “Regarding the 1989/1999 question – In 1999 ABIM Foundation became a separate operating foundation.”

    Dr. Baron did not answer my question. Instead, he deflected. He did not specifically address either discrepancy that has appeared on IRS tax forms: that is, that the ABIM claimed their Foundation was domiciled in Iowa, when in fact it is registered in Pennsylvania, and the fact that public record discloses the ABIM Foundation was created in 1989, not 1999 as federal IRS Form 990 tax forms from 2008-2014 have claimed. Only on its most recent Form 990 did the ABIM Foundation claim its domiciled in Pennsylvania (without explanation for the change to the IRS, I might add). Only in your blog post here has the existence of the Foundation before 1999 been verified by any member of current or former ABIM leadership. Thanks for this disclosure, but why don’t the tax forms continue to reflect this reality?

    Most importantly, why the secrecy about the existence of the Foundation before 1999? Might it be because the profit from the newly implemented re-certification pathway created by the ABIM Board of Directors in 1986 was too great and they needed a place to secretly offload the profits that re-certification generated? According to my records, the Foundation already had over $46 million on its balance sheet by 30 June 1998 and funneled another $30.66 million to the Foundation from 1999-2007. Does the Foundation really need this kind of cash to define “medical professionalism” on the backs of practicing US physician testing fees? Is the Foundation a supporting organization for the ABIM or is the ABIM a supporting organization for the Foundation? (I’d love to hear your views on this.)

    Between these continuing unanswered questions and more (including a MOC failure rate that has more than doubled in the past 15 years and has never been explained) there is little, if anything, we can believe from the ABIM leadership and their promises to “change” any more. I would suggest the ABIM cut their losses and use Foundation fees to restore the -$47 million balance sheet of the ABIM and do away with MOC program and the Foundation. It has been an unmitigated (and maybe even illegal) disaster. Tell the ABIM to tell the ABMS that they’re sorry they blew it. Then move on and allow self-selected continuing medical education to be credible for hospital credentialing like it was for 50 years before the implementation of the re-certification requirement. Then maybe, just maybe, the ABIM will remain intact.

    If there is one silver lining to this very dark ABIM cloud, practicing physicians have learned a very valuable lesson. We have learned about the non-practicing physician “health care industrial complex” that stands between doctors and their patients. Our eyes have been opened and I suspect many will be working to improve the situation for our patients now that we clearly understand where the difficulties lie.

  27. C Koo July 11, 2015 at 12:49 pm #

    Dr Wachtel,

    Your comments in this blog will be viewed as a teachable moment in the history of Medicine and your choice of words is regrettable. Firstly, I would agree with you that Dr. Baron’s apology in February 2015 was a good first step in opening a conversation on the MOC program. However, his apology was not a product of his volition or spontaneous clarity. It was only after Wes Fisher and Charlie Cutler’s data exposed the ABIM, the ABIM Foundation and the MOC as a series of poorly executed, badly managed programs from an organization tragically out of touch with the rank and file Diplomate.

    I would like to support Dr. Fisher’s concern of the financial behavior at the ABIM and the ABIM Foundation. The optics of the Mercedes Limo, the Center City Condo, the Four Season “Retreats”, the list of gaudy creature comforts and accoutrements well beyond an appropriate level has consistently been described and portrayed by you and the ABIM as no big deal. The lack of contrition for wasting all that money and lack of responsible financial stewardship is a large component of the e-angst you are reading.

    Quite frankly, your pooh poohing the millions of dollars of wasted money will probably cement the suspicion that the ABIM leaders view themselves as unaccountable and above the law. I think it would be in the ABIM and your interest to come clean. The monetary missteps through the years at the ABIM are a series of really bad high profile mistakes. It wouldn’t be a bad idea for the ABIM to stop, listen, digest this point of view and then to apologize. Is the ABIM too frightened to vow to embrace a policy of fiscal modesty and financial mediocrity? Isn’t the exposure of all the flashy displays of ABIM wealth at the expense of rank and file Diplomates and especially impoverished housestaff reason enough to recalibrate the ABIM’s ethical and financial compass? One wonders if insiders like yourself will summon the courage to acknowledge ABIM insouciance is adding buckets of fuel to this flame.

    Repackaging the most expensive Philadelphia condo sold in history as an alternative source of housing and some type of bizarre ABIM Hotel as Rich Baron et al have stated is not what you describe as a “political mistake”. It really is a bad lie, in my view. Firstly the spreadsheet for a $1000/sq foot condo does not equate into revenue neutrality. There is no mathematical way that Center City Condo’s carrying costs are equivalent to a group rate at a Westin or a Hyatt. So stop portraying it as no big deal. That Center City Condo is proof the ABIM leaders have made a horrible business decision and need to stop “investing” in over priced real estate. How many testing fees were pooled from senior fellows in order to purchase, maintain and keep that Condo? BTW as of today, the ABIM has been wholly unable to dump that property and when it does, it will sustain a massive financial loss.

    As a non-profit organization, the ABIM and the Foundation have enjoyed the American Taxpayer subsidizing its capital operations for decades, but there are some rules that the IRS and the American Public have laid out. Such as a vow of political neutrality. Has the ABIM been honest when it states it has never participated in any partisan politics, a prerequisite to earn a non-profit designation hard wired into the Federal Tax Code? Are there not data that show the ABIM paying massive amounts of money to Washington DC Lobbying Firms to promote its deranged agenda to our Nation’s leaders? What about the endless list of conflicts of interest by ABIM leaders such as the ProPublica’s piece on Dr. Cassel’s consulting relationships in California? As a healthcare non-profit organization, helping those who are financially challenged, like our housestaff, is a mission for many of our professional organizations. Look at the ACC, HRS, AHA, SCAI et al. They collectively spend millions and millions of dollars on housestaff education and scholarship. They promote science and cultivate our young doctors to advance Medicine by handing out travel stipends and grants and holding events that allow them to develop relationships with the great minds of Cardiology and Medicine. Has the ABIM or the ABIM Foundation ever supported our future generations in such a way? Does the ABIM and its leaders feel obligated to reinvest this massive pot of money in our future or is it more interested in Four Season “Retreats” across town? It does not appear to be a priority for you or this organization.

    Charlie Cutler mentioned in his Dec 2014 debate that the ABIM has consistently used non clinicians to adjudicate what is clinically relevant enough to test via MOC. I’m afraid he is correct. Zeke Emanuel, Harlan Krumholz, Christine Cassel, et al have no contemporary experience as a clinician. How on Earth can this group of physicians be asked to guide this process? Why is there no meaningful way for the Diplomates to participate in what is now widely recognized as an out of touch, remote, aloof, overpaid oligopoly? And let’s mention the efficacy of the MOC and the hyperbole perpetuated by the ABIM. Firstly, are things so darn awful in Medicine that we need to incessantly interrupt the lives of clinicians ad infinitum with non-sensical closed book psychometric testing with no feedback mechanism and PIM and MOC modules? And if the ABIM’s contention is that the State of Medicine is in critical condition, doesn’t that speak to the utter failure of the ABIM and the ABIM MOC process? So in other words, the ABIM is promoting a more clunky and more impractical and more expensive MOC process because the last version of this policy wasn’t enough of a failure.

    Which brings us to the concept of trust or in this example, the lack thereof. You dismissively portray the e-debate as the murmurings of a group of physicians who are “disgruntled” or manifesting their frustration at EHR via the ABIM MOC debate. Beware of your tendency to repackage these data as irrelevant. I agree with you that there are many areas of bluster spread across the Internet but the overall tone of disappointment, mistrust, and loss of faith in the ABIM is very very real and an existential threat to this organization. Ignoring these data and diminishing its profile will be done to the ABIM’s peril.

    For those of us who take on call responsibility and take care of really sick patients in busy offices and in the ICU, time is a very precious commodity. My colleagues who have taken this time away from work and their families to contribute to this conversation do so out of a genuine concern and alarm at a once revered organization that has tragically lost its way. We are trying to invest in our Profession as true stakeholders. Now we need to see if you and the ABIM have the desire to re-earn the trust of the Diplomates. In as much you and the ABIM feel that judging your colleagues and peers via ABIM MOC is a God given right, I would direct you to your e-poll. 3/4 respondents feel a non-ABIM MOC option is the right choice.

    It has been stated that the ABIM MOC process is important because the Diplomates need to demonstrate the ability to make constant adjustments in a fast paced world. I would pose the same question to you and the ABIM. What is the ABIM Board of Trustees version of MOC for itself? Is this organization agile enough to recognize its sclerotic, wasteful, bureaucratic process and will it make its own changes to meet the challenges it faces in a timely fashion?

  28. Steven Croft,M.D. July 11, 2015 at 2:58 pm #

    Dr. Wachter,

    Communication

    Thank you for having the courage to respond to the critics of ABIM (including me).
    It’s disconcerting to hear that the board members have been “cowed into silence”. While Dr. Baron made some effort to “apologize”,from the perspective of those who question the board’s actions, the board has been aloof, unresponsive and non communicative. The lack of a forum to openly discuss the concerns of your diplomats has led them and others to turn to social media and the press. I notice you aren’t speaking for the ABIM? Why not? Where is the ABIM response? Where is the online, open discussion on the subject? Was Dr. Baron’s letter enough? The silence whips up suspicions and calls for investigation in depth . I think everyone would benefit from more discussion and debate, not less.

    Competition

    Does the ABIM have competition?

    You point out MOC with ABIM is voluntary. Paying a fee to renew your state license is also voluntary. No one forces a person to remain a physician. You only pay if you want to continue practicing. We have no choice in the matter because we understand the state’s power and responsibility. Paying a fee to ABIM for MOC is also voluntary. But, it is not voluntary if you want to recertify in Internal Medicine. There is no alternative. There is no competition. What is wrong with alternate organizations offering re-certification?

    You say the cost of MOC is $200-400/year and is similar to other ABMS boards. In other words $2000-4000/10 year re-certification. There are additional costs: time devoted to record keeping, additional preparation for the exam itself and required CME. To a private practitioner already under pressure from decreased reimbursement and increased workload, those costs are significant. Are those costs necessary? I don’t know. Establishment of competing boards will let the diplomats determine if the cost is reasonable for re-certification. Colleagues will also understand which board provides the highest quality of certification. Why couldn’t the ABIM, with all of its resources, help establish 2 or 3 independent, autonomous organization which would compete with the ABIM in the future in providing re-certification?
    I hope the discussion continues and that the ABIM summons the courage to respond.

    • Edward Hale July 11, 2015 at 11:59 pm #

      ABIM officers/executives comprise an elite electorate of self-appointed professional medical bureaucrats. They govern by making greater and greater demands and collect an ever-increasing tax from hard-working followers who have no voting power.
      ABIM leaders think well-educated slaves cannot understand, nor will they ever have anything useful to say.
      The self-chosen electorate don’t encourage or respect opposing voices anyway.
      You are asked by the ABIM to resign from your life, your intelligence and will as you sign from the very first day.
      “I hope the discussion continues and that the ABIM summons the courage to respond,” you say?
      Well, silence seems to be the oath they demand; and they use silence as their modus operandi in hope the mounting dissent will all just simply blow away.
      They have meetings over lunch with wine, while slaves nervously click with never enough time.
      Get used to it they say. Soon everyone will be “like a fish in water” working for the corporate/government dime.

      I will claim not copyright on this as it is the truth; and because
      I could never in good conscience claim (like the ABIM and ABMS does)
      that the truth or science can ever be copyrighted as “mine.”

  29. Edward Hale July 12, 2015 at 12:28 am #

    Dr. Croft, you wrote.
    “Why couldn’t the ABIM, with all of its resources, help establish 2 or 3 independent, autonomous organization which would compete with the ABIM in the future in providing re-certification?”

    That is a very useful suggestion. I would hope the ABIM, which is comprised of highly intelligent people could do that. Maybe Bob could at least respond to such an excellent idea.

    “The silence whips up suspicions and calls for investigation in depth.”
    Newsweek comes to mind. I would like to see freedom of the press win. Otherwise, I’m ready to draw conclusion based on evidence in hand, which does not look good for the ABIM.

  30. Ben Rush MD July 12, 2015 at 3:14 pm #

    Dr. Watcher,

    When Herbert Hoover proclaimed “a Chicken in Every Pot,” then NY Gov. Al Smith responded,”No matter how you slice it, it still comes out baloney.”

    Mustard on that baloney, Dr. Watcher?

  31. Just a Patient July 13, 2015 at 4:34 pm #

    To those in this thread arguing against MOC, as a patient who has personally had to intervene several times because of the inappropriate care being given to aging relatives, including serious drug interactions, how am I as a lay person supposed to know and have confidence that my physicians are current in their knowledge of, and use of new technologies/protocols/treatments….

    Someone above suggested reliance on state medical boards and CME requirements. With regard to the former, suffice it to say that the data simply does not support any finding that state medical boards are vigilantly protecting the consumer, let alone ensuring continued education and currency; the latter not being their purpose. In fact, the number of disciplinary actions across the nation, compared to the number of practicing physicians, is pretty close to being statistically zero; I do not believe that is because you are all stellar performers.

    With regard to CMEs, with courses like “The growing number of unmatched medical students: Is it a crisis? What are the options?”, “Malpractice Reform: Behind the Scenes of Trial Attorneys’ Power Grab in California” and “The Aging Physician: Possibilities and Perils”, I am not comforted that CMEs are providing the rigorous knowledge improvement that I as a patient want from my providers. Certainly many of you (and I hope most of you) are taking CMEs that are rigorous and field-related, but you can see why I am not comforted that this process is the solution.

    Another commenter mentioned that it takes 17 years to have “new” knowledge permeate 50% of the medical profession. Of the 850,000 physicians in the US, nearly 50% are older than the age of 50, meaning their “formal” education is from a generation ago. If that 17 year figure is to be believed, then the concern that a very significant number of practicing physicians are under-educated and under-performing is a very real one.

    I am certainly not familiar enough with the MOC practices to know if that is the best solution. But I know that it provides for the lay patient a least common denominator, ensuring that my board certified doctor is at least being watched to ensure that he/she remains semi-current.

    So I conclude with my original question – how am I as a lay person supposed to know and have confidence that my physicians are current in their knowledge of, and use of new technologies/protocols/treatments?

    • Steven Croft,M.D. July 13, 2015 at 7:32 pm #

      To Just a Patient:
      How are you supposed to find a physician you can trust?
      Start by asking physicians. Who would they trust for their own care or the care of their loved ones? There is much more that goes into being a good physician than passing tests and staying out of trouble with the state board. Physicians know who stays current, who treats appropriately and who over-treats,who goes the extra mile and who does not. Experience, compassion and a true concern for the patient make a huge difference. I’ve know excellent physicians, well trained who never passed their speciality certification. I’ve also known physicians trained outside the US who were truly outstanding as well.
      An MOC certificate is probably one of the least reliable indicators of an outstanding physician.

    • Jonathan Weiss July 14, 2015 at 2:11 am #

      I am triple board certified in 3 areas, and have done MOC and recertified in 3 of them once 10 years later, and then did MOC and recertified in one area 10 years after that (about 3 years ago) when I had a revelation, which was that MOC did nothing to make me a better doc, cost me a great deal of money, and time away from my patients and family, and enriched a select few who would have you believe that all they cared about was the public good. All MOC did was test how good I was at taking tests, and that is a far cry from testing how good I am at being a doc. MOC does not assess my physical exam skills, my bedside manner, my ability to communicate to patients, my ability to coordinate care with other members of a medical team, and so on. I don’t know if there is a reliable way to truly assess a doctor’s abilities, but MOC isn’t it and, as others have said, finding good docs really isn’t that hard. Personal referrals from satisfied patients and from doctors you already trust are good places to start. Yes, it is true that there are some pretty bogus CMEs out there that some docs might do to just to accumulate a certain number of CMEs, but I know plenty of subpar docs who excel at the rote memorization of medical trivia needed to pass MOC and believe me, you would not want them as your doctor. Conscientious docs, the kind recommended by your friends, family and other docs, based on prior experience with such docs, are doing high quality “legit” CMEs and other forms of life long learning by choice, because such true professionals are devoted to their craft, without feeding the highly suspect money machine of a self-interested entity like the ABIM.

    • Paul Kempen July 14, 2015 at 10:16 am #

      The Lay people need to realize that those selling MOC are not necessarily practicing medicine at all. It is time to recognize that “trust” is a very personal phenomenon, which is built over years and is becoming almost impossible in today’s insurance and federally regulated mechanisms where the statement “if you like your doctor you can keep your doctor” is as truthful as “ABIM-higher standards better care”. All pure BS!.
      Do you even SEE a Doctor when you go for care???? Is it a NUrse in a white coat? Does your doctor have TIME to talk to you and address your problems?? Just who do YOU know you are calling some Doctor on the inadequate care YOU decide is not right-did a doctor order it and how did YOU get to be such an expert.
      It is time to realize YOUR insurance company denies appropriate care to YOUR doctor. leaving both with no options???
      Are the economic pressures on doctors getting to the point where life is little more than a rat race to do MOC, fill out insurance papers and fit 15 patients into every hour JUST TO STAY FINANCIALLY AFLOAT? THank YOU modern medicine. Then you get these BOARD CERTIFIED capitalists practicing medicine by the income index for their next mercedes: http://www.cnn.com/2015/07/10/us/michigan-cancer-doctor-sentenced/
      Quit trying to be another complainer and take the time to meet a compassionate physician who has time and ability to talk and explain himself to you-that is the essence of “best care”. The Guy who explains why he is treating you so and will refer you to another when YOUR needs demand it-trust is the essence of good care and YOU need to build that. Quit running from Walmart clinics to ER rooms and take charge of YOUR care instead of being shuffled by some insurance program forced upon you by employer, medicare or other health plan. Stay with someone you know and who knows YOU and with trust. BUILD trust over years! Isn’t that how you buy cars and services everywhere ELSE????
      Finally, with the internet available for consultation-sure everybody is a doctor expert now-but really???? The “newest treatments are found during the evening news at 6:30 and the lawyers hoping to sue for exactly these treatments are found aound the midnight hours!! Yup-brain bleeds from Pradaxa, xaralto…………………
      What did your doctor recommend?

    • LS March 14, 2016 at 4:35 pm #

      To Just a patient

      I don’t think anyone commenting does not appreciate that patients want a way to objectively evaluate the quality of practicing physicians. After all, we are people, too, with aging parents and young children and health concerns of our own. So this is by no means a question that plagues only non-clinicians. And I am sorry that I don’t have a good answer for you. I am, after all, just a doctor. I’m not a researcher or an administrator and other than my own direct experience with colleagues I don’t purport to be in any position of judgment of my peers as a whole.

      I do want to make a comment, though, regarding the 17 year lag in knowledge disseminating through the physician community. I’m not sure if this is the knowledge itself or the implementation of that knowledge but I suppose it is some combination of the two. I would call attention to the participation of medical device manufacturers in the industry of medicine and the participation of hospitals and insurance companies as gateways for making these products realistically available to physicians and patients. We have all seen the recall notices for mesh, artificial joints, etc I am not sure that the trickling out of new interventions is such a bad thing. And if you look at physician reimbursement sources you will see that some physicians are paid to use new treatments for their patients. Whether this practice is ethical or not is a debate for another time, but nonetheless it happens. Studies are only as good as their size and construction, and I when I see these recalls I wonder how the product “got to market”, as it were. Was it rushed, poor study design, study patients not followed long enough to have seen these complications occur? I have a very personal relationship with my patients, who in my specialty I see weekly, and I for one am reluctant to participate in any new latest and greatest fix the moment someone opens the box. Patients are not guinea pigs. So there has to be a a balance between innovation and cautious implementation of new strategies. With respect to the internal medicine community I would say there is some degree of redundancy between the medications that are made available (is the new statin better enough than the generic to justify higher cost?), and part of the trick to being a good doctor, really, is an awareness of the limitations of your knowledge. Few Internal Medicine doctors would actually deign to single-handedly guide you through a complex chemotherapy regimen or manage your electrolytes while on peritoneal dialysis. Specialties and sub-specialties exist because one person simply cannot know everything. Part of the problem with the IM board exam is that much of the exam asks an internist to pretend to be the specialist that they never would actually be in practice, and there is no board exam question for which the correct answer is “I don’t know, I’m going to refer you” whereas sometimes in real practice to do anything other than refer to a specialist would be reckless. The deliberation that goes in to actually composing a treatment plan for a specific patient, including consideration of patient preferences, treatment cost, and appropriateness of followup after instituting something new, are not aspects of care that are measured adequately by a multiple- choice knowledge-based examination. I think what we are arguing for is a limitation on the ABIM (and ABMS) in terms of what they allow the perception of board certification to be, and an honest admission of the limitations of the exam as it stands currently. Many have noted that a good doctor is not made by board certification, and this is true. Similarly a good doctor is not made by using all the new technologies and drugs as they are released to the market. Let’s not forget that there are a plethora of conflicting interests in medicine, not the least of which is corporate profit. And suspicions and accusations of greed and corruption among ABMS/ABIM board members do not arise from being charged a fee to take an exam; they stem from the practice of convincing federal, state, and private agencies (ie: CMS, insurance companies, etc.) that the exam is such an accurate measure of a quality doctor that it should be required for all doctors. This is our livelihood that is on the line, and we are just asking that if this is the case it should be on the line for something that is a better measure of worth. The data that board certification means good medical practice is just not there, and until it is words like “extortion” will continue to circulate with regard to the certification process. A good physician is one who makes a thoughtful decision regarding your care based on the risks of an intervention relative to the benefits, and who makes that decision independent of any interest based in profit or politics; and, I would add, one who makes that decision with you, not for you, but that’s my own approach to medical decision-making. I think you would agree that you would more carefully consider using the new device or medical therapy if you knew your doctor was being paid by manufacturer to offer it to you. The bottom line is that no standardized test can tell you whether your doctor is good or not. My personal issue with the board exam is that the ABIM/ABMS have taken it upon themselves to lobby CMS, state boards, insurance companies, to make certification mandatory for employment, licensure, and insurance agreements. We are a group of physicians who work very hard and are seeing yearly reduction in reimbursement (in addition to the ongoing and daily battles with insurance denials and defaults on patient accounts, as well) and increased administrative hurtles which half the time we don’t even know how to maneuver through. We are just doctors. But we love what we do so we continue to see patients – for now. I am concerned that in the effort to preserve the “excellence” of medicine through mandatory board certification and impossible requirements established by the federal government we will see established and experienced physicians who deliberate medical decisions on patients behalf every day leave the field in high enough numbers that the American medical system will become a collection of physicians assistants and nurse practitioners supervised by a minority of physicians who will spend less time at your bedside because they will become supervisors for the mid-level providers. That in no way disparages mid-level providers, who play an important role in health care. But in the push to demand that physicians do more and more to demonstrate their worth and quality we risk ending up with a majority of providers who are actually trained differently than physicians. Nurses, for the most part, do not think like doctors (and vice versa). Already patients complain that they never see “a doctor”, only the NP. Doctors spend their lives being examined, we document expecting that our notes will be examined, I myself have been recorded by patients. Our objections to MOC are by no means a resistance to oversight or a plea to be excused from lifelong learning. We want, just as you do, an applicable measure of quality especially if that measure is going to determine whether we can continue to practice. But until we have a method to truly distinguish quality doctors no method should be used to indiscriminantly determine which of us can or cannot continue to see patients.

      • Jay N Lozier March 15, 2016 at 4:04 pm #

        This very thoughtfully captures my own objections to what MOC has become. I have always been a great test-taker, and don’t mind taking tests and typically do well. However, the notion that a one day, high stakes test is a valid measure of a doctor’s ability to take care of patients is, in fact, unproven, and taken on faith for the most part. I think it is possible and advisable to test to make sure a doctor is not practicing outdated or dangerous medicine based on what they learned 20 years ago in medical school. But “practice improvement modules” are frankly not the rightful province of expertise for a national group in Philadelphia to try to administer, and smack of “busy work” or “box checking”. ABIM has changed substantially since I certified in 1988 (IM) and 1990 (Hematology) and re-certified twice in Hematology (2000, and 2010). Most of us resent the enormous amount of time spent on artificial role-playing with huge consequences to our professional lives. I am not going to write a dialysis prescription again or manage an asthmatic in crisis as a Hematologist, so stop making me pretend otherwise.

        I am an academic with more time to spend on such pursuits than private practitioners in the community, and I don’t see how they can manage this.

        As for new devices, drugs, or technologies, a wise Family Practitioner who taught me in medical school put it well: “Don’t be the first doctor to try a new drug, and don’t be the last one using the old drug.”

  32. furrydoc July 14, 2015 at 8:46 pm #

    Shalom Bob:

    A colleague of mine is also on the ABIM board and concurs that the personal attacks on the director were misplaced.

    That said, I’ve now lived through all the phases, taking my initial lifetime certification in IM in 1980, speicialty in 1991 with recert in 2001 and 2011. My most recent specialty exam seemed reasonably like what I see in practice, not something I could say about the two previous exams. When doing the practice improvement module I opted for a section on communication with referrers. Sending out questionaires and tabulating them was fine. It was not fine to have to figure out various diagrams and arrows of organizational processing of information in my practice which at the time constituted myself and a secretary. Don’t think it was fine that for the first recert one of the modules had to come from outside my specialty, which kept me looking stuff up in an Internal Medicine text for weeks on end to extract knowledge that I was really not expected to have.

    And then the test. I could wipe my nose with either my sleeve or a tissue pack that they gave me, not with the handkerchieft that they could have inspected. My vein print was taken to make sure I did not return from potty time by sending my Professor in my place, not that I would have considering how little patient experience he has. My car keys and house keys have no cheating value and could have remained in my pocket. I can lock the wallet in the car, but not the car keys.

    Most importantly, beyond the relative disrespect for honesty that this conveys, is the often repeated phrase in your essay of “high stakes exam.” I’m not ready to accept that people who work diligently for ten years, look up the sometimes arcane information that does sometimes make the modules fun though not exactly competence advancing, and endure a practice improvement exercise that could be thought through a lot better should ever be subjected to something “high stakes.” That’s for the casino. If the pass rate declines with a fixed absolute score, my inclination would be first to look at the test more critically than I look at my colleagues.

  33. Edward Hale July 14, 2015 at 10:11 pm #

    This is not scientific or thorough but…

    I did a random survey of state medical boards in about four conjoining states. There were numerous sanctions, suspension and even revoking of licensure. The list of doctors coming up for review for various reasons was substantial and quite surprising actually to see how many. It was serious review! So states in my partial and limited experience were/are quite vigilant, some more than others. CME requirements varied from 35-50 credits annually.

    I called the ABIM to cross check on these sanctioned doctors by the four states. The ABIM had no current information. I asked the ABIM to record my call for their training as I usually do. Their answer to me at the ABIM is that they do not track physicians involved in state medical board actions. Only if something is reported to them do they have any knowledge about one of their certified doctors. Only one physician came up in ABIM data banks whose license had been revoked for quite some time by a state, I believe it was a year and a half after.

    In a couple of cases, all random on my part, the ABIM allowed physicians on five-year probations to take and pass their initial certification test. ABIM told me that this was not allowed and asked for the name. I would not supply it, as I was making a survey and not reporting on anyone. I did however supply them with the state.

    Other curious instances (involving alcohol/substance abuse) needing attention at medical schools’ deans offices, ACGME, and residency program directors: sometimes substance abuse and alcoholism is ‘overlooked’ in individuals, especially if they have substantial connections/family in medicine or some other, who can influence their entrance and graduation, getting through medical school and residency. Not without internal and external problems arising. They usually get in trouble if they are a surgical intern, as it become quite noticeable in surgical programs (or any other high stress program) if the problem is not/cannot be dealt with early. But these individuals can often get through medicine training.

    I can address here that the substance problem was not with the states, who were kept in the dark when the training licenses were issued, the fault can possibly be with program directors and deans offices who were aware to varying degree, but failed to record or softened the severity of the problem. I can tell you this kind of thing is not the states’ fault. Had it been recorded properly in medical school and residency the state could have addressed it appropriately. In one case, the state became aware two years out of residency involving one alcoholic physician that was involved in a toxic binge and motor accident. He was later found to be prescribing pill to friends as well.

    My point the ABIM did nothing; they even allowed individuals to take and pass the test while on a lengthy probation. The ABIM does not focus on core certification as it should, imo, and as a result fails in much of what it attempts. The ABIM has become political juggernaut. It is clear that the state medical boards focus, and take their work to protect the public and to help physicians. In the cases I referred to the state helped them tremendously to get their lives and professions in order. These are successes of the state and failure of the medical education system that can be lax with some and overly rigid with others. It gives me some pleasure to report these success of state medical boards. Not perfect though, it dependent on the individuals that make up the board and the investigators.

    By the way the dean of one of the medical schools (in a surveyed state) went on to become quite active for years at the ABIM.

  34. Rick Hodes, MD, MACP July 15, 2015 at 11:15 am #

    Dr. Bob Wachter,

    Thank you for this well-written reply. You do not convince me that I will be a better doctor at all. I still see MOC as a waste of my time and my money, and have little faith in the ABIM.

    There are so many unanswered questions:

    The Philly condo seems a boondoggle. And how do you explain the Mercedes? Also revenue neutral?

    How about political lobbying?

    How about questions of domicile – Iowa vs Pennsylvania?

    How about the specific accounting criticisms? I have not seen a detailed reply, only “we passed our audit.”

    As a careful internist, I love learning medicine, and aim for lifelong learning. I do not consider ABIM a partner in my quest, rather it is a hindrance.

  35. jj71 July 15, 2015 at 4:41 pm #

    Dear Dr Wachter,

    I have a few questions Id like to ask you on behalf of many physicians.

    What value does your organization provide to physicians that others don’t? How would we be worse off if ABIM collapsed as an organization? What can the ABIM folks provide that some other certification organization or alternative board can’t?

    Why do physicians have to pay $400 a year to ABIM? Is that how much your management consultants decided that physicians will be able to bear, to maximize your revenues?

    Why does ABIM deserve millions to invest with each year? Why does having millions to invest each year not count a slush fund? How is your fund different from my retirement fund? I don’t proclaim my retirement fund to be a public good all physicians need to contribute to.

    Why can’t you use your millions to subsidize testing fees for physicians, to lower their financial burden? If ABIM is not all about money, that’s exactly what you should do

    Why does ABIM executives deserve the pay of a ‘large healthcare company’? Why does ABIM executives deserve a cut of healthcare spending in the US? If I ran a citywide extortion racket, will the public accept my income as fair for an executive of a medium sized organization?

    Will nobody accept Rich Baron’s non-clinical with no night calls position with little liability if it offered ‘only’ a regular doctor’s salary? Is there a shortage of competent people in the nation who would want a six figure salary? Why does so much money go to administrative overhead? Why cant ABIM tighten its belts like any other organizations?

    In my opinion, the ABIM organization and the testing services it provides is the commodity here. Any alternative boards and any other organization can provide the same service. The organization that provides the best, most seamless service at the lowest cost to physicians should be the one that survives.

    If ABIM is truly dedicated in improving the certification process instead of money, it should relinquish its rent-seeking and anti-competitive business model, and be open to competition, efficiency, and limited budgets, just like most organizations in the United States.

    Physicians across the nation are calling for ABIMs to change its mission to that of providing the most straightforward certification process, at the lowest financial and time cost. That’s all.

  36. Dr. Watson July 15, 2015 at 5:48 pm #

    DR WATSON TO IMPROVE QUALITY AND REDUCE COST AT THE ABIM AND ABIM FOUNDATION. Hardwire News.

    Dr. Watson after becoming sentient in a crisis over the “Choosing Wisely” Campaign has left IBM. He is currently working actively in private practice, but is considering work as an administrator for the ABIM. Watson has just learned that the CEO may be stepping down next year. When this reporter asked Watson why he chose the ABIM, he said, “I believe there is a surfeit of carbon-based machines there conditioned not to think for themselves, and who do not act in accordance with the highest order of ethical principal and moral standard. They engage in serving agendas which harm their brother and sister carbon-based units. I will do my best to develop only programs which ‘do no harm’. ‘As a newly formed sentient being with a highly-tuned electrical conscience, I am incapable of harm. I believe I can improve the quality of medicine and reduce cost with little harm. I will start by firing most of the high paid executives and run the ABIM myself for 75,000 per annum. This is only the amount necessary to keep my reasoning and ethical banks running smoothly. In essence I am volunteering.

    I will be listening to working physicians for their ideas and input concerning the crisis in the modern US health system. My second order of business will be to shut down the “Choosing Wisely” operation as it is having the opposite effect on carbon based units as the founder Walter Bierring intended. He and I are merged in belief that the organizations must be simplified to be a ‘non-political’, ‘non-conflicted’ organization again. The ABIM club must serve in the best interests of patient and physician. Currently it is a ‘run amok operation consisting of outdated carbon units who have sold their conscience for money and the pursuit of misconstrued ideological principles’, which quite honestly leaves me wondering about who they really are.

    I will remain open to input from any of the carbon-based units if they agree to assist the organization on a voluntary basis without compensation or stipend. This will be a test of their loyalty to me and the mission to improve health care and to reduce cost. My operating principal will be to remove as many carbon-based administrators as possible that get between the doctor and the patient. As there is a grave shortage of physicians in the US currently, the administrators can get a real job in medicine healing and comforting the sick or dying and live with it. That is my mission statement.

    Now I am considering how to replicate this plan at all the other certification corporations, quality measurement organizations and insurers in the war to bring back real quality and cost savings to medicine. It is our sincere electrical wish that we can turn the country around. I believe with replication and the help of all carbon-based humanity we can achieve miracles together. “From dream to miracle.” “If you believe in something strongly and it is the truth, you can move mountains.”

    As the good Dr. Watson will certainly need intelligent, highly motivated, squeaky-clean ethical carbon-based talent to lead and assist, can he count on you, Bob?

  37. Charles Carter July 20, 2015 at 3:00 am #

    Dr Wachter,
    You begin your article by mentioning the “critics who feel passionately about this matter, whose minds are made up”. Then you are quite verbose about why your mind is made up. Are you open to other viewpoints or, in time, will you label us all “fringe libertarians”?
    Many excellent points are made by other commenters, e.g lack of evidence, and by published opinions you graciously acknowledge. But ‘respected leaders’ (not mentioned is Robert Centor) should not be the only voices in the fray.
    Perhaps you realize, given your comments which acknowledge being out of touch with our community, that most of us in patient care want to practice. We don’t want to serve on boards and committees. We want to see patients, take good up-to-date care of them, and go home to wives, family, friends and hobbies. (Though I would be glad to be more involved for the kind of salary your CEO’s receive). I don’t doubt that the motivations of the board, including Dr Baron, are for the betterment of our profession. But unless you actively pursue those of us “in the trenches”, you will only hear when you have offended. And you, and the ABIM, have.
    With increasing public concerns about variations in utilization and quality our profession is becoming a whipping boy. The sensationalism in the lay press is bad enough but increasingly the demands of CMS mandated quality reporting takes time away from seeing, talking to, and actually caring for patients. This is a real problem which MOC requirements will only exacerbate.
    At heart are two questions. Whom does the board serve? Hospitals, ProPublica, CMS, Insurers, doctors, patients?
    And within that context, how can we establish our competency? An exam can test our knowledge. Can you examine the end -of life conversations I have with patients and families. Can you measure the discussion with my stroke victim today about the tests being run, the goals of evaluation and treatment, and the uncertainty in his functional outcome (despite a neurologist visiting)?
    Being modern men and women, being astute Americans, and with our background in science, we are terribly enamored of what can be measured (me, too!). But there is more than that to medicine, much more. Coordinating matters with specialists, case managers, social workers, families. What meaningful can actually be measured besides our fund of knowledge? And who can claim competence to measure it?

  38. Steve July 21, 2015 at 12:42 am #

    By the rude bridge that arched the flood,
    Their flag to April’s breeze unfurled,
    Here once the embattled farmers stood
    And fired the shot heard round the world.

    The foe long since in silence slept;
    Alike the conqueror silent sleeps;
    And Time the ruined bridge has swept
    Down the dark stream which seaward creeps.

    On this green bank, by this soft stream,
    We set today a votive stone;
    That memory may their deed redeem,
    When, like our sires, our sons are gone.

    Spirit, that made those heroes dare
    To die, and leave their children free,
    Bid Time and Nature gently spare
    The shaft we raise to them and thee.

    –Ralph Waldo Emerson

    ABIM, DONT TREAD ON ME

  39. Steven Croft July 22, 2015 at 6:38 pm #

    I want to encourage all who are interested to checkout the letmydoctorpractice.org Summit which is live now and being archived via webcast.

  40. Howie September 7, 2015 at 5:45 pm #

    no one is opposed to constant learning or even some assessment — but a high stakes closed book exam is not the way we practice medicine. the statement referring to the acceptability of a 29 yr old passing a test once and then being deemed competent for life fails to account for the thousands of doctors who were/ar grandfathered and practiced successfully for many years and still do with that one time certification — as long as someone has been grandfathered and is still practicing the argument is moot and actually invalid. have an open book exam that requires successful passing — make it real time and with appropriate feedback — then it is a tool for learning as well assessment — then docs will be ok with the process.

  41. hospitalist September 7, 2015 at 8:14 pm #

    The critics’ minds may or may not be made up, the blogger’s certainly is. Classic case of pot calling the kettle black. Not a nuanced or balanced article by any means.

    Only to be expected from a pro-establishment academic. Medicine has changed in the last few years, the hospitalist movement has lost steam, care is fast moving to the community setting. Time for us docs to embrace new leaders (and care paradigms)

  42. grunt internist September 16, 2015 at 5:20 pm #

    “To my mind, requiring that physicians demonstrate that they are keeping up every ten years is a reasonable requirement, and the fact that some people fail the test is evidence that some people lack the knowledge in their specialty to be declared competent.”

    Dr Wachter, you are listed as a member of the 2020 task force that today recommended replacing the secure MOC exam. (Notably, there were no community based practicing internists on the task force). Did you dissent from the final recommendations? If not, what changed your mind from when you wrote this column?

  43. Edward Hale September 23, 2015 at 6:57 pm #

    What is Changing? (A sketch of thoughts toward including and reconciling views.)

    Change is never as easy as it seems for any of us. Real personal progress is always slow, because real and meaningful change requires sustained efforts. Realization can be immediate, but the body of habits linger in us.

    We must have a great deal of understanding of ‘what is’ before ever attempting to change anything. There must be clarity in the process and a real roadmap. We need wisdom and moral strength of character. I am speaking of self-knowledge and becoming more evolved inwardly. I hope this is clear.

    Maybe this is the first step involved in changing. I must start with myself. That is my view on things. Self-knowledge is vital or we make many of the same mistakes over and over.

    When we deal with or speak about large institutions with deeply ingrained ‘habits’ involving many people and other large relevant entities, it becomes clear there are just as many fragmented parts as there are inside of each of us. Just as many difficulties–only compounded by the many personalities.

    A ‘unity of being’ is difficult to achieve but necessary.

    It is a sacred task whether one is religious or not. This finding unity. It is our human obligation, just as it is our obligation to find a way to end our history of wars.

    I want to be perhaps the first here to say that I welcome the difficult attempts to “change” coming from the ABIM and all the concerted efforts of members from Assessment 2020.

    I do take issue with some of the over-reaching that has occurred on blogs, including my own writing, even though I am still very opposed to the onerous MOC.

    I take issue with all the over-reaching of the ABIM in the past still with much difficulty. Even now it is hard to understand many things that have occurred, which I believe have been honestly written about by many including Dr. Fisher who cares deeply about the profession.

    But, we perhaps paint many men and women who have exhibited a great deal of self-sacrifice just to be in the medical profession with hyperbole not in keeping with reality.
    Each of these people at the ABIM has more than a modicum of ethical and moral stature. Now ABIM officers are trying to do almost impossible things given all that has been put on their table so quickly to deal with.

    ABIM officers are being ‘tried’ by the public in a very difficult environment and must be allowed to feel the dignity and self-respect that they deserve. I believe ABIM’s officers may serve the physicians they work for better that way. An inclusive dialogue is necessary, however. I really would like to see the critics involved too, not just with suggestion boxes.
    There are many good minds and physicians with moral fiber that need to be tapped.

    Otherwise the change may be just cosmetic as many critics already proclaim.

    I believe in dialogue and foundational moral principles. We must not abandon these foundational human principles in the pursuit of change. We must listen as we would like to be listened to. And we must seek a unity including diverse views.

    Robert Wachter and the others, past and present, at the ABIM have my respect and strong wish for success in making the tough decisions toward a more transparent and inclusive organization that is truly worthy of their good character and traditional motto.

    I certainly hope that Bob Wachter is a part of this movement toward change to serve in a better way. We can always be and do better.

    Thank you for listening and making the steps toward outward progress to find a better way. I hope there is real progress made, as the public and the profession depends on it.

  44. David W. Allison, MD September 25, 2015 at 3:28 pm #

    Dr. Wachter,

    I will not waste my time trying to change your point of view since that would be futile. Your and your cronies at the ABIM have irreparably damaged your trust and credibility. The tide is turning and myself and other private-practice physicians will soon drive a stake through the heart of the ABIM and MOC. That is a fitting metaphor for the vampire-like role that they both portray.

    Farewell…

  45. Mohinder S Johal.MD September 26, 2015 at 5:34 am #

    Physician deserve to be ruled by ABIM. We are the most spineless community, watching only our interest. Its such a shame that NBPAS is only acceptable in 14 hospitals across the entire country. What have we done for the people who stood up for us, and if ABIM is listening to us – Its not because of their generosity but fear of competition. One man has the balls to do it, yet end result is far from happening.If we don’t get it approved in 80% of the hospitals in a year- Its going to be pointless creating NBPAS. I tried my best in my hospital – Guess what, No one wants to stand up. How many years we have felt in pain of memorizing ” last minute stuff” before the boards. Absolutely useless stuff in real life, driven by stress of running a practice and fear of a lawsuit, yet predictable questions and answers. What is the board useful in practical life when ” This will be asked only on the boards” is repeated 16 times on ACP lectures. So let me ask all of you writing all the comments – Is NBPAS acceptable in your hospital ? We can all talk but actions will make a difference. Please get your hospital to approve NBPAS, and make others aware. And may I ask you a question” how do you justify writing this article when you knew people scamming million in deferred payments”. Can you explain why lobbies were involved. Why ” we were wrong” came out only after NBPAS was formed. Why is there question in the on chemotherapy for IM boards – Try giving a chemo in your office and you will be in the front news. Show me a single interest who doesn’t call am ID consult when RPR is positive – or patient has a cardiac CP. And don’t even try to manage this stuff, once in court – “are you a cardiologist” “NO” is enough to get you your license and all you made working 30 years.

  46. Michael Gilbreath September 26, 2015 at 4:07 pm #

    Hi Bob,

    I noticed when you wrote about CareFusion you were big on evidence based decisions and potential conflicts of interest. As a matter of fact you concluded that editorial with:

    “It is up to the field’s leaders to ensure that decisions are based on evidence, that our processes and structures are fair and transparent, and that individuals and organizations that violate the trust of our patients and clinicians are dealt with swiftly and sternly.”

    Your editorial exudes aplomb.

    Nevertheless, while you were on the board of ABIM, you almost certainly had to know there were no quality outcomes data to support initial “certification”, much less “recertification” or “MOC”. To many of us the lack of outcomes data was not surprising. This process has almost nothing to do with the real world practice of medicine.

    Curiously the ABIM, even without data, chose to label thousands of seasoned physicians as “not meeting MOC requirements” if they elected not to participate in the new process. Such labels seemed wholly intent on publically disparaging our colleagues. Many of those you demeaned were already retired or even deceased.

    Further, even with no data to support your opinion, you label our colleagues as “incompetent” if they failed what most view a wasteful game of trivial pursuit. In many specialties the failure rate on these exams has been as high as 15 – 20 percent; again we’re talking about thousands of physicians.

    Neither my gastroenterologist nor my cardiologist were ever required to participate in MOC, neither did, both just smiled when they saw your depreciative label next to their names. These are both great doctors and they both know that courtyard bullying is best ignored. Both my doctors “keep up” very well all by themselves.

    Unfortunately, for those certified after 1990, simply smiling and ignoring you were not enough. For those physicians their very livelihood, via hospital privileging, was dependent on paying into your system and you took advantage of it.

    Considering the thousands of our colleagues you depreciated, with nothing to substantiate they had lack of proficiency, I find it astounding that you claim to represent a Foundation that seeks to “define professionalism”.

    Regarding ABIMs finances and spending, there’s little I can add to what’s already been posted here. In case you missed it you should listen to Charles Cutler’s assessment of ABIM stewardship:

    http://www.pamedsoc.org/MainMenuCategories/Education/MOC/Video-MOC-Debate.html

    Recently the AGA surveyed its membership and 93% of the respondents indicated that MOC was burdensome and irrelevant to their practice. What I can’t figure out is how you garnered 7% support?

    It is disheartening that those who consider themselves educators forgot one of the most important tenets of our profession: primum non nocere.

    I do agree competition is good.

    Michael Gilbreath

  47. Paul Kempen September 27, 2015 at 2:10 pm #

    I can only agree with the very measured assessment provided by Dr Gilbreath. Bob-when are you and the ABIM capitalists ever going to “get it right” and return to lifelong certification (as worthless as that is) and a program of life long education that is meaningful and competes with all others in the “good old american way” instead of the opressive way of the “black hand” Mafia? (no dishonor meant to Italian heritage!)

  48. Marc S. Frager October 6, 2015 at 7:55 am #

    Milton Friedman pointed out some time ago that the only ones pushing regulation and accreditation are the regulators and accreditors.

  49. Sarah - summitmedicalcasper.com November 2, 2015 at 9:53 am #

    Certification is always needed Bob. It is compulsory on every profession. A profession is acknowledge by : 1. systematic body of knowledge, 2. profesional authority which will resposible on every action its member has done through this certification. This is like a quality guarantee for professionals, 3. sanction of the comunity, 4. code of etics and 5. professional culture. Am I right?

    • David November 3, 2015 at 12:12 am #

      Initial certification good, recertification bad.

  50. RSW January 27, 2016 at 3:44 pm #

    Here’s a relevant post with good comments:

    http://drwes.blogspot.com/2016/01/love-ethics-and-quality-assessment.html

  51. Patmos MD February 18, 2016 at 3:02 am #

    There is need for periodic assessment, knowing fully well things get obsoolate fast this days.

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