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News: Internists Build War Chest against MOC

Sorelle, Ruth, MPH

doi: 10.1097/01.EEM.0000547210.36836.fe
News

Ms. SoRelle has been a medical and science writer for more than 40 years, previously at the University of Texas MD Anderson Cancer Center, the Houston Chronicle, and Baylor College of Medicine. She has received more than 60 awards, including the Texas Human Rights Foundation Award. She has been a contributor to EMN for more than 20 years.

A group of angry medical specialists is turning to social media to raise funds for legal research aimed at filing suit against the American Board of Internal Medicine, its foundation, and executives, perhaps spreading that scrutiny to others, with an eye toward bringing an end to maintenance of certification.

The efforts, spearheaded by Westby Fisher, MD, a cardiac electrophysiologist in the Chicago area, started a GoFundMe effort that has raised $117,662 of the needed $150,000 in two months. (http://bit.ly/2KXIHep.)

Dr. Fisher said he has decided not to recertify, partly because of the expense. “[T]he annual cost for an internist is $2,200 every 10 years right now. That's just the upfront cost,” he said. “It does not include time away from work, the time away from family, the study time that's required to pass. This is really difficult studying that has to be done because it's so massive.”

Internists have to know pretty much everything, he added, estimating that certification can total $22,000 every 10 years in direct and indirect costs.

Specialty pushback against maintenance of certification has affected most of the 24 medical specialties and the American Board of Medical Specialties, and ABMS has implemented changes to the program: alternatives to the every-10-years exam, including shorter assessments delivered periodically; providing immediate feedback on assessment questions; and allowing physicians to count existing improvement and research activities approved by hospitals and sponsors of ABMS programs.

A July survey by ABMS found that only 12 percent of physicians valued MOC. Forty-six percent said they had mixed feelings, and 41 percent said they did not value it. The survey was answered by 34,616 physicians, 1,373 nonphysician providers, and 403 members of the public. Cost topped the list of physician concerns at 58 percent, followed by being burdensome at 52 percent, and inability to measure clinical skills accurately at 48 percent. (http://bit.ly/2PfcHpn.)

What the ABMS survey did not reveal was the personal toll of MOC, Dr. Fisher said. An unpublished survey by Practicing Physicians of America (https://practicingphysician.org), for which Dr. Fisher serves as treasurer, found that 70 percent of 7,007 physicians and surgeons take part in MOC, and 8.3 percent of the subset of board certified physicians who participate in MOC had failed. More than 300 of the 394 physicians who failed reported psychological harm, with 56 percent becoming suicidal, depressed, anxious, or embarrassed, according to Dr. Fisher. Forty-four percent of those who failed said they were ashamed to share their failure with their hospitals. Twenty-three percent lost their hospital privileges, insurance panel payments, or job. Some had to move because of the failure, and 67 who failed planned to retire early.

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ABEM Revises Program

Pushback against MOC has led many certifying boards to revise their programs. The American Board of Emergency Medicine announced, for example, that emergency physicians will have the choice of taking the ConCert Examination or more frequent, one-hour-long tests that assess one or more specific content areas. They will have the opportunity to take the test again if they do not pass the first time. The cost of the new program is not yet available, but it will begin to be phased in in 2020.

Dr. Fisher said he and his group plan to “follow the money” to find where the American Board of Internal Medicine's MOC fees go. With the help of forensic accountant Charles Kroll, he said he found that the organization receives 97 percent of its revenue from practicing physicians—fees for initial certification and MOC. Mr. Kroll has posted his accounting on all 24 boards and ABMS at http://bit.ly/2wcBTV3.

John Held, the director of communications and brand management for the American Board of Internal Medicine, told EMN that Mr. Kroll's number was inaccurate. “In fiscal year 2017 ABIM revenue was $59,434,349 as reported on our 990. ABIM receives its funding from physicians, primarily through two sources—when they pay to take an assessment and an annual program fee. ABIM also received a small amount of investment income in 2017—$173,000—as well as $3.9 million in funding from the ABIM Foundation for initiatives related to enhance and improve internal systems and develop the new MOC program, he said.

“ABIM does not receive any funding from industry, such as device manufacturers or pharmaceutical companies,” Mr. Held said. “This is important because as an organization that believes deeply in professional self-regulation, ABIM needs to ensure its operations are independent of any outside influences.”

Frances M. Spring, the senior communications administrator for the American Board of Emergency Medicine, noted that most of its revenues come from certification, a total of $16,116,849 in the most recent fiscal report. She said Mr. Kroll's figures included portions from employee retirement plans that do not belong to the board. She also estimated that MOC costs have remained the same for the past five years. Lifelong Learning and Self-Assessment (LLSA) tests cost $100 each, four in a five-year period and $800 in the 10-year cycle, and the ConCert exam costs $1,850 for a total of $2,650 or $265 per year.

Addressing the controversial nature of MOC, she wrote: “CME is an inadequate replacement for continuing certification. Numerous studies have unequivocally demonstrated the inability for physicians to accurately self-assess their learning needs. Continuing certification by ABEM signifies that its physicians and medical specialists can objectively demonstrate that they are continuing to meet the standards in their specialties throughout their careers and are committed to improving patient care.” She noted that ABEM has never grandfathered in board-certified physicians and has always had a recertification program.

Dr. Fisher said his concerns about ABIM, however, are complicated by a lack of knowledge about how and why funds went to the ABIM foundation and real estate dealings that were not clear. Many of his concerns were aired in a 2015 article in Newsweek called “The Ugly Civil War in American Medicine.” (March 10, 2015; http://bit.ly/2BdlogY.)

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