MOC

Well, I won. Six years after I started down the very slow process to end forced MOC (Maintenance of Certification) in my state, it happened. On December 27, 2018 Michigan governor Rick Snyder signed HB 4134 and 4135 into law. The harm Blue Cross Blue Shield (BCBS) caused me and my patients will never happen to another pediatrician in Michigan.

I know. Crazy. I’m still in shock. It’s taken a while to process it enough to write about it.

So what happened? How did we go from “My MOC Failure” to victory in one year? From an outsider’s view, this signing was an abrupt end to MOC discrimination in Michigan, a nice neat Thanos Infinity War finger snap.

The inside reality was more Endgame: old and new friendships from all walks of medicine and politics coming together, devising a plan, racing against time to beat a powerful adversary, but sacrificing some good people along the way.

The Michigan legislation started six years ago in the Michigan State Medical Society (MSMS) House of Delegates, with some very simple resolutions opposing forced MOC. As physician awareness of MOC and its harm escalated over the years, so did the strength of the resolutions passed by the delegates, eventually culminating in a resolution to pursue legislative action. MSMS stepped up to the challenge, found sponsors, and legislation was introduced in 2015 to prevent hospitals and insurers from discriminating against doctors for not purchasing MOC.

The first committee hearing in 2016 was eye opening. The hospitals freaked out. The insurance companies freaked out. The American Board of Emergency Medicine, located in Michigan’s capitol, freaked out. Clearly, these organizations allow grandfathered doctors to practice without concern, yet went into full doomsday mode at the idea of younger doctors practicing without buying MOC.

And that was it. The bills died in committee.

So next legislative session, in 2017, the bills were re-written and we started again. This time, instead of trying to fight insurance companies and hospitals, we focused only on the insurance companies. The rationale being that hospital bylaws can theoretically be changed by doctors, but discriminatory insurer bylaws cannot.

So off we went to committee again, thinking we’d have smoother sailing.

But now the opposition was even more organized and vocal. As anticipated, BCBS opposed. But American Board of Medical Specialties sent in their big guns, the American Board of Emergency Medicine stacked the room with their board members to oppose, the American Board of Ob-Gyn and American Board of Orthopedic Surgery did the same.

The kick to the gut was a mother of a chronically ill child, who gave tear-jerking testimony in opposition to the bills “on behalf of parents”, but never disclosed she was with the American Board of Pediatrics Parent Advisory Council. It was madness.

And so the bills sat in committee again. In the committee’s eyes, physicians were divided: some wanted the bills and some didn’t. They didn’t see the clear conflict of interest with all opposition coming from those profiting from the monopoly.

The bills sat for over a year, and were set to expire at the end of 2018.

The 2018 midterm elections in Michigan divided our state government into a Republican legislature and Democrat governor, and our bill sponsor Dr. Ned Canfield decided to retire. The prospect of finding a new sponsor, re-educating a new legislature, and convincing a divided government to pass MOC reform…ugh…it was over.

But what about lame duck? With just a few weeks left in the legislative session, the impending leadership change had bills flying left and right. Could we squeak in under the wire, and more importantly, under the radar of the powerful ABMS friends?

One physician lawmaker said, “No way. Not possible. You’re too late. Try again next year”. The medical society didn’t have a lame duck strategy for the bills, and were skeptical. But to their credit, they got to work and quietly moved them forward.

The insurance bill was amended to appease BCBS, a big amendment: it would only apply to “primary care”, so pediatricians, internists, and family medicine. And to appease the hospitals, the package included joining the FSMB Interstate Licensure Compact, with some minor amendments to assure the compact pathway would be voluntary.

It was a crummy deal, but with days left before the legislative session’s end and the possibility of years before we had another shot, it was better than nothing. We took the deal.

Freed of opposition by BCBS and the hospitals, the amended bills sailed out of the house, passed unanimously through the Senate Health Policy Committee and then the full Senate. It happened so fast, ABMS and team were caught flat-footed. They couldn’t scramble their “A” team to testify in time, and their “B” team was eaten alive in committee. All the usual opposition by the Emergency Medicine Board fell flat, as the bill didn’t apply to them. It was beautiful.

But we compromised a lot for this little slice of freedom: we went from a bill to prevent MOC discrimination by hospitals and insurers for all specialties, to a bill that prevents MOC discrimination by insurers but only applies to pediatricians, internists, and family doctors. As BCBS was the only insurance company engaged in MOC discrimination, we did all that work to prevent one insurance company from requiring MOC for three specialty boards. And we joined the FSMB Interstate Licensure Compact (which requires MOC to get the initial license). Like I said, it was Endgame. We won, but we lost a lot.

Was it worth it? Well, for me, yeah. Pediatricians were chosen as “winners” in this bill. In Endgame vernacular, I wasn’t sacrificed over the cliff on Vormir. Was this by design, to get me to finally be quiet? Maybe. If so, it kinda worked.

I took care of my peeps. I feel bad for physicians in the remaining 21 specialty boards excluded from this legislation (well, not the ER docs, you get all the MOC you deserve as your colleagues nearly derailed the whole thing). But certainly not bad enough to turn down the deal when lawmakers offered it.

And winning after six years of late nights, early mornings, travel, flights, testimony, meetings, phone calls, blog posts, media interviews, lawmaker roundtables, inbox full of encouraging emails, and some threatening emails has left me a little tired out. When I started down this path, my son was in kindergarten. He’s a middle schooler now. This has been a long haul. I’m not going to be leading the charge for the surgeons, but more than happy to teach them how to do it.

We have a saying in medicine: See one, do one, teach one. What can I teach? There is a general recipe for success that applies everywhere: get your state medical society on board with a policy resolution, find a sponsor (most likely a physician lawmaker), write a bill, get it passed. There are some cautionary lessons that carry through in every state battle, and these truths were reinforced in Michigan.

I learned about the power and impotence of organized medicine. Straight up, the AMA is worthless in this fight. ABMS found their way from Chicago to Lansing to oppose the bills multiple times over many years. But the AMA, located just a block away from ABMS in Chicago? Not a peep. No support. Not even a letter. Your state medical society remains your single greatest ally to effect change.

I learned how much harm physicians in power can cause practicing physicians, and the shameful tactics they will use. At every hearing, physicians came to oppose MOC freedom. Without fail, a simple Google search showed these physicians were benefiting from the MOC industry.

You have to be prepared for heartbreak, intimidation, dirty tricks, and last minute ambush efforts. I watched this play out in Texas and Oklahoma, but I was still shocked in my own state. The mother used by the American Board of Pediatrics to mislead lawmakers was just appalling. (Not surprisingly, she was rewarded for her loyalty by a prime seat on the ABMS Stakeholder Council). In our final senate committee, the president of the Michigan College of Emergency Medicine showed up at the last minute, yelled at me, threatened to derail the legislation, even though it didn’t even apply to ER physicians. With so much money and power at stake, these behaviors are not surprising, but still hard to watch up close.

The part I can’t teach is the art of this process, as every state has their own organized medicine and political culture. You don’t know how it works until you jump in. I’ve had many people tell me there were certain “lucky breaks” I had in Michigan to make this easier: I’m a medical society delegate, I’m on my county medical society board, I had the Rebel.MD blog, my medical society cares, I understand the legislative process, I know politicians and their staff… as if those “lucky breaks” weren’t 100% by design and hard work.

It wasn’t by accident that I gave up my weekends every spring to be a medical society delegate, or evenings every month to be on my county medical society board, or countless hours building and maintaining Rebel.MD to get the message out. It wasn’t by accident that I met dozens of lawmakers in their offices and out in the community to discuss many issues, including MOC. This was pure hard work, not luck, not privilege. This is the stuff you can’t be taught and you can’t outsource. You just have to do it.

I’m a private practice pediatrician. I’m a serious nobody. I don’t have family or friends in high places. I didn’t know anything about organized medicine, politics, or website building until I did it. All the docs who helped in Michigan were new to this. The fact that we did this in Michigan with such an inexperienced rabble of docs without any resources, should be inspiration that this can happen in any state.

It takes time, but this can happen anywhere. Who knows, maybe even Illinois.

Whatever it takes, docs, whatever it takes.

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Oh, and here’s a photo of me and my hero, Dr. Ned Canfield, after the final senate hearing where his bills passed unanimously. I keep this on my desk in the office. He was a rock, the unsung soft-spoken hero of the MOC battle in Michigan. MOC freedom is his legacy, I am forever grateful.

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See how your state is doing with MOC legislation at www.stateofmoc.com.

It’s been a rough few weeks for physicians in this year’s first state battles against forced Maintenance of Certification. The good news is that 13 states now have pending legislation to limit the power of the ABMS over physicians. These bills are coming up in red states and blue states, sponsored by democrats and republicans alike. Maryland even has bipartisan sponsorship of their bill. The bad news is we physicians have a steep learning curve, as we’re finding out that hospitals, insurance companies, and the ABMS are incredibly powerful and organized in their lobbying efforts.

The past few weeks have produced disappointing but instructive failures in Oklahoma, Tennessee, and Florida. While heartbreaking to watch, there’s much to learn from these states as we all move forward. As testimony to the true grass-roots nature of the MOC battle, each of the 11 states are trying different legislative angles. There is no “template” being used. This is both exciting to see, and a bit nerve-wracking. The states are a “laboratory of democracy”, and this MOC battle demonstrates this, as each state tackles the issue in different ways that best suit their legislative climate.

Oklahoma stunned everyone last year when they passed the first Right to Care legislation protecting patients and their doctors from MOC red tape, in bipartisan fashion, without a hitch. Unfortunately, the language was not as tight as first thought, and hospitals found wiggle room to continue forcing MOC on some doctors while exempting “grandfathered” doctors. Oklahoma HB 1710 was introduced this year to clarify the language for hospitals.

The bill looked like a slam dunk. The hospitals didn’t seem to oppose it, the medical society didn’t even make it a priority for physicians to call prior to the vote. In the final 24 hours before the vote, the ABMS and the hospitals went on a lobbying and misinformation tirade, pouring incredible amounts of lobbying pressure and money upon the legislature. (ABMS and Hospital Talking Points Found Here.)

Physicians were caught off guard (because we work), and were completely flat footed to respond to such an outpouring of lobbying power and misleading information. In the end, HB 1710 failed miserably 71-22. Oklahoma’s MOC law from last summer still stands, but in legal limbo, likely needing an Attorney General’s guidance on what the law means.

The takeaway point here is that the ABMS will spare no expense to stop state legislation. The ABMS will ignore the rights of physician diplomates and will instead work together with hospitals and insurers and lobby for the “rights” of hospitals and insurers to force doctors to buy their MOC product. This is stunning mission creep on the part of ABMS and violates their claims upon the “voluntary” nature of MOC, but is not surprising given the money involved.

ABMS plus the 24 subspecialty boards currently have $1 billion in assets. This is a high-stakes game, and the lobbying effort in Oklahoma shows they will outspend us at every turn. They know we have real jobs, and can’t abandon patients and cancel surgery on short notice, so they will lobby last minute in ways we cannot. This means we need to start personal conversations with our lawmakers early and often about MOC. We can’t rely on medical society lobbyists, we need to make the calls ourselves and get our colleagues to call as well.

Tennessee started out very strong this session with an elegant MOC bill SB 298, sponsored by Senator Richard Briggs. If you don’t know who this guy is, just Google him. This is the guy you want sponsoring your MOC bill: Cardiothoracic surgeon, army trauma surgeon, Bronze star, the physician that treated ABC anchor Bob Woodruff when he was injured in a bomb blast in Iraq, —on and on, just a class act. The hospitals and insurers had such a fit and lobbied so hard against the bill, pushing delay upon delay, that the senate committee had to strip any mention of hospitals and insurers from the bill for it to move forward. The sad, impotent Tennessee bill now simply says that MOC can’t be required for a medical license. Which…it never has been required. In fact, MOC isn’t required for a medical license anywhere in the country. So Tennessee wrote a bill outlawing something imaginary.

The takeaway point here is that hospitals and insurers desperately want to force MOC on “their” doctors. I have no idea why, but they do. Perhaps it’s a way to control doctors, perhaps it’s just a marketing ploy, i.e. “all our doctors are board certified”. Perhaps it has something to do with NCQA making ABMS board certification a HEDIS measure (funny how that happens, when the president and founder of NCQA is also on the board of ABMS). But for true reform, we have to take on the hospitals and insurers. What good is a medical license if we can’t practice in a hospital or participate with insurance companies without being coerced to participate in ABMS MOC?

Comprehensive MOC legislation must have three components if it is to ensure MOC as a voluntary program: it must prohibit MOC from being required for a medical license as a preventive measure, but must also prohibit MOC from being required for hospital privileges and insurance reimbursement because this type of coercion, discrimination, and harm is happening now. If any of these three components are missing, physicians can still be forced to participate and pay in order to work: they will not be free.

For states that have to settle with legislation that only prohibits requiring MOC for a medical license, don’t settle for long. Keep pushing. Kentucky, Missouri, and North Carolina passed this type of limited legislation last year. Maryland, Rhode Island and now Tennessee are likely to pass this type of weak legislation this year. Don’t settle, keep pushing for more next year.

Florida. Oh Florida. I don’t even know what to say. The story of Florida’s MOC legislation is just plain bizarre, not quite Florida Man bizarre, but still…close. Florida had fantastic MOC legislation with SB 1354, it was comprehensive and beautiful. Then it went to committee and everything went sideways.

The health policy committee “amended” the legislation, by erasing every single word of the bill and replacing it with their own language directing the state to regulate the subspecialty boards, with a plan to control MOC rather than ensure its voluntary nature. The language now allows doctors to be forced to do MOC, so long as the board registers with the state, is a 501c3, has a brick and mortar building with full-time employees, requires ongoing “practice improvement modules”, charges no more than $500 every other year, and doesn’t require additional testing, plus whatever extra regulations the state wants to add at a later date. If a board does not comply with these requirements and get certified through the state of Florida, Florida doctors can no longer call themselves board certified in that specialty.

This tactic is so out of left field, I can’t make heads or tails of it. On one hand, I chuckle at the idea of the certifying boards having to comply with certification themselves. On the other hand, for boards that spend a little extra money complying, they will have the legitimacy of the state behind them. Like all forms of regulation, it always favors the “big dogs”. Despite public protests to the contrary, big corporations like regulation and often lobby for more regulation to stifle competition, knowing start-ups don’t have the funds to wade through the red tape. A situation like this with open-ended regulations will favor the well-funded boards under ABMS and their lobbying prowess and harm competition like NBPAS.

I don’t even know what the takeaway is from Florida, other than a need to stay vigilant. I’ll sit by with popcorn and watch what happens, but certainly wouldn’t encourage this method for other states until we see how the Florida experiment shakes out. The Florida legislation does not make doctors more free, it does not decrease the cost of healthcare, it does not increase access for patients, it does not decrease the regulatory power of the state. It takes a budget-neutral bill and creates new regulatory authority for the state with the expected budgetary bloat involved. But, it’s fascinating to watch from the outside.

My only piece of advice for doctors in Florida faced with this bill of uncertain impact…ask for one last amendment: the approved boards must provide peer reviewed data showing improved patient outcomes from their programs. As there is not a shred of evidence behind MOC, this simple amendment will stop this nonsense cold.

Going forward, I have most hope for Texas, Alaska, and Georgia to lead the way this year in real reform. Georgia has already passed their bill through the legislature and are only waiting for the governor to sign. Texas and Alaska have comprehensive MOC bills, and have similar personalities in their physicians and their legislature: they don’t like outsiders telling them what to do. I expect they will pass their bills this session without difficulty.

The ABMS, hospitals, and insurance companies have shown their hand. It’s our turn to take a good look at what has happened in Oklahoma, Tennessee, and Florida, do our M & M conference, and move forward smarter and more effective as a result of these pioneering states.

Right to Care legislation is right for patients and their physicians. We may not have the lobbying money or the power, but we are on the right side here. It sometimes feels like we’re a small disconnected group of physicians hashing this out in our own states, but we don’t have to fight alone. We can work together and learn from each other. Physicians in states that succeed can mentor physicians in states that are aspiring.

The AMA has been woefully silent on this issue, but Right to Care legislation is exactly AMA MOC policy put into state legislative form. This is not fringe, this is supported by the vast majority of physicians, our state medical societies and the AMA. Knowing this keeps me confident we will succeed.

Photo by SWoo

Update: Now 12 STATES! Maine has a bill heading to testimony on Tuesday, April 11!

Like many of my fellow pediatricians, today I read the three page letter written by American Board of Pediatrics CEO David Nichols.  It was a full day seeing patients and it took me nearly three hours to finish it. The letter was so upsetting I couldn’t handle reading it straight through. I’d start reading and my stomach would turn, I’d start to despair about the future of medicine, and I’d put the letter aside. Thankfully, it was a busy day and I was always rescued from this sadness with a patient. It’s summer, so that means sports physicals.  Today I saw lots of 14 year old girls, the same age as my oldest daughter, and it was fun. But between patients, I’d try to slog through more of the letter and the sadness would return…only to be rescued by a patient.

The emotional swing of my day is just one illustration of the stunning disconnect between the joy we find in being doctors and the soul-crushing work done to us by those in power. After carefully reading the letter, I had planned on writing a witty article making fun of the imaginary bell shaped curve and debunking Nichols’ whole straw man set-up. Now I realize it’s not worth it. Nichols’ letter is just one man’s desperate attempt to justify his million dollar salary. My sadness today was not with Nichols and the ABP, indeed I’m not even board certified through the ABP anymore, so what they say does not really impact me.

The real issue here is leaving medicine better than we found it. I can safely say the generations before me dropped the ball.  I’ve talked to many retired doctors and after chuckling “man I’m glad I got out”, there is a soft sadness and recognition of failure when they see the look on my face at those words.  They failed us.

Those in power now, like Nichols, are continuing to fail us.  At a certain point, even the $1.3 million dollar salary fades away late at night, and Nichols knows he’s made medicine worse for his fellow pediatricians. He’s taken our money, he’s driven good doctors into early retirement, he’s cost us jobs, promotions and pay.  He’s torn nursing physician mothers from their newborn babies, he’s forced physicians from the bedside of their own sick children and parents, he’s made physician cancer victims choose between taking a test to keep their job or taking care of their own health.  This is what the ABP Maintenance of Certification program and never-ending hoops are doing to us.

Nichols and the ABP are the perfect case study in how to ruin medicine and your fellow physicians.  From Nichols’ letter, it’s clear the ABP is not listening. Instead, the letter attempts to divert our attention and divide us.  Those of us who believe MOC is discriminatory, unjust, and an intrusion into the professional joy of the doctor-patient relationship are not just a “faction”, we are the majority.

The beauty of the MOC  fight is that it is also a perfect case study in how to make medicine better.  We are the majority, and we need to act that way.  We need to reject the whole premises and imaginary power of these boards.  We have to stop participating and let the program die away. This new generation of pediatricians graduating should be taking their boards for the first and last time. MOC stops with us.

As it stands, nine out of ten doctors do not recommend medical careers to their children. Those that do, do not recommend primary care.  This is a tragedy.  This world needs good doctors, and who better than the children of healers to carry on this calling?  There are so many things we do for our children to prepare their future, from teaching them to read to saving for college.  We need to take a hard look at the problems in medicine with them in mind. What can we do to make medicine a better career for them, how can we ease their way?

I can think of many toxic aspects of medicine, MOC is just one. I fight it because it’s an easy win. The tough ones on reimbursement and regulation are yet to come, but already we are seeing strong wins for those brave enough to challenge the whole system.  There are some bright spots, some really exciting bright spots in medicine.

Direct primary care, be still my heart!  The disruptors and innovators out there are almost too many to mention, Lee Gross of Epiphany Health, Josh Umbehr of Atlas MD, Ryan Neuhofel of Neucare,  I could go on and on. These docs are doing the impossible: after generations of rapidly deteriorating satisfaction in medicine as a career, they’ve actually created models that are better than the “golden age” of medicine. By meshing old school primary care with technology, they’re providing better quality care, better patient satisfaction, better physician satisfaction and decreased cost. It’s stunning. And it’s happening now.

When I see what these amazing docs are doing, how they are making medicine better for physicians and patients, when I step away and just spend time with my patients, all the babbling by Nichols and the ABP just looks pathetic, archaic, and irrelevant. Tonight, as I was thinking through all these issues and how I can improve my little corner of medicine, Zubin Damania posted this video, and I’m crying. This is exactly what I’m talking about. There is no question. I know where the real revolution in medicine is taking place and where our future lies. Let’s get to work building it.

Photo by Alex E. Proimos

Shhh. I think this is supposed to be a secret, but this Wednesday at the super-elite AMA House of Delegates meeting in Chicago, where only the mostly highly connected and AMA devoted doctors get to attend, they actually stood up for us.  It is now AMA policy that the AMA opposes mandatory ABMS recertification exams.

Crazy, right?  News of this random act of fortitude trickled out to us on Twitter by the small handful of delegates who very helpfully tweet updates for those of us on the outside.  But other than those little tweets, no word from the AMA on this incredibly good news.  This is HUGE folks! The AMA opposes ABMS recertification exams! It’s time for celebration, and press releases, and emails asking us to rejoin the AMA.  And yet, no word from the AMA.

It’s not listed in the Top 10 Stories from the AMA 2016 Meeting.  It’s not mentioned in the coverage of the MOC resolutions that passed. By looking at the AMA website and news coverage, the only MOC resolutions that passed were the typical mushy kind.  Here’s how the AMA reported their “newsworthy” MOC resolutions.  Hold on to your knickers, these are some groundbreaking resolutions.

“Delegates adopted policy to further these efforts, including:

• Examining the activities that medical specialty organizations have underway to review alternative pathways for board recertification
• Determining whether there is a need to establish criteria and construct a tool to evaluate whether alternative methods for board recertification are equivalent to established pathways
• Asking the American Board of Medical Specialties to encourage its member boards to review their MOC policies regarding the requirements for maintaining underlying primary or initial specialty board certification in addition to subspecialty board certification to allow physicians the option to focus on MOC activities most relevant to their practice.”

Whoa Nelly. And the AMA wonders why they’re bleeding membership. Nearly every doctor in the real world is saying “STOP MOC”. And the AMA flitters about asking for more studies and playing footsie with the ABMS. In defense of the authors, these resolutions probably started out strong. But once the board-member packed committees hacked them to impotent pieces, there’s no meat left.

So what about that resolution opposing ABMS testing?  Well, if you go to the AMA website and create a secure login and scroll through the hundreds of pages of amended resolutions from the nine reference committees, you’ll find…. Resolution 309 presented by Florida, California, Georgia, Pennsylvania, Washington, New York, & Virginia hidden in Reference Committee C.  The language is strong:

RESOLVED, That our American Medical Association call for the immediate end of any mandatory, recertifying examination by the American Board of Medical Specialties (ABMS) or other certifying organizations as part of the recertification process (Directive to Take Action);
and be it further
RESOLVED, That our AMA support a recertification process based on high quality, appropriate CME material directed by the AMA recognized specialty societies covering the physician’s practice area, in cooperation with other willing stakeholders, that would be completed on a regular basis as determined by the individual medical specialty, to ensure lifelong learning
(Directive to Take Action); and be it further
RESOLVED, That our AMA reaffirm Policies H-275.924 and D-275.954 (Reaffirm HOD Policy);
and be it further
RESOLVED, That the AMA voice this policy directly to the ABMS and other certifying organizations (Directive to Take Action); and be it further
RESOLVED, That there be a report back to the AMA HOD by the 2017 Annual Meeting. (Directive to Take Action)

Awesome, right? Well, as soon as the committee got ahold of it, they butchered into

RESOLVED, That our American Medical Association call for the immediate end of any mandatory, recertifying examination by continue to work with the American Board of Medical Specialties (ABMS) to encourage the development by and the sharing between specialty boards of alternative ways to assess medical knowledge other than by a secure exam or other certifying organizations as part of the recertification process (Directive to Take Action);
and be it further
RESOLVED, That our AMA support a recertification process based on high quality, appropriate CME material directed by the AMA recognized specialty societies covering the physician’s practice area, in cooperation with other willing stakeholders, that would be completed on a regular basis as determined by the individual medical specialty, to ensure lifelong learning
(Directive to Take Action); and be it further
RESOLVED, That our AMA reaffirm Policies H-275.924 and D-275.954 (Reaffirm HOD Policy);
and be it further
RESOLVED, That the AMA voice this policy directly to the ABMS and other certifying organizations (Directive to Take Action); and be it further
RESOLVED, That there be a report back to the AMA HOD by the 2017 Annual Meeting. (Directive to Take Action)

Funny how that works.  The resolution was dead. Gutted.

But between testimony in Reference Committee C on Sunday, and final voting on Wednesday, the Pennsylvania Medical Society melted the meeting down with a blistering two hour exposé on the abuses of the ABIM and the boards in general.  It was standing room only, with Dr. Wesby Fisher and Charles Kroll presenting their financial data, Dr. Bonnie Weiner discussing NBPAS, and Dr. Scott Shapiro announcing the PA Medical Society’s vote of “no confidence” in the ABIM and plans to pursue legal action against the boards.  Full report on the meeting and PowerPoint presentations can be found here.

With a much needed boost in morale and the data to support strong action, the full house convened on Wednesday and the delegates soundly rejected the Committee’s butchering of the resolution, extracted it to a full vote on the house floor, and restored the strong language of the first resolved.  It passed easily.

RESOLVED,That our American Medical Association call for the immediate end of any mandatory, secured recertifying examination by the American Board of Medical Specialties (ABMS) or other certifying organizations as part of the recertification process for all those specialties that still require a secure, high-stakes recertification examination.

Boom. This is amazing!  So why isn’t the AMA announcing this from the rooftops? Why is this hiding in hundreds of pages of resolution verbiage, only accessible via secure login?

Because they’re hoping you don’t know. If you don’t know, then they can ignore this policy exists and they won’t have to fight their friends at the ABMS on your behalf.  But now you do know. You know that your colleagues from Florida, California, Georgia, Pennsylvania, Washington, New York, & Virginia wrote a strong resolution and fought it to the end. Now their resolution is policy. Bravo to Texas and Michigan standing strong as well.

Obviously, I’m not good at keeping secrets, and I hope the rest of my physician colleagues spread this secret policy far and wide. While I’m not yet ready to jump on the AMA bandwagon, I am warming to the realization that the AMA is made up of individual doctors. If we fill the AMA with the right physician delegates who will fight for us, we might actually win a few battles.

UPDATE: 6/17/16 ABMS Responds to AMA MOC Resolution. Still no mention of the MOC resolution from the AMA.

Full annotated report of Ref Com C, along with members of the committee here.
Link to the AMA HOD Reports here, AMA membership not required, just create a login.
Photo by (cup)cake_eater

The American Board of Medical Specialties says “board certification is a voluntary process, and one that is very different from medical licensure.” This is echoed by my board, the American Board of Pediatrics, who says “Board certification is a voluntary process that goes above and beyond state licensing requirements for practicing medicine.”

Over the past few years, the definition of “board certified” has changed from a one-time test to an ongoing series of tests, hoops, and fees to maintain certification through the MOC program. Not participating in any portion of the convoluted and expensive MOC program results in loss of board certification, but so what? Board certification, either as initial certification or 20 years into maintaining certification is voluntary, so what’s the big deal?

Well, it turns out, not complying with MOC is a big deal. Not only has the definition of “board certified” changed, apparently so has the definition of “voluntary”.

On December 17, with the blessing of my partners, I decided to test how “voluntary” board certification is.  Over the past 13 years, I’ve passed my board examination twice, completed multiple proprietary online tests, and completed three ABP research projects on my patients. But when the American Board of Pediatrics threatened to revoke my certification and nullify 13 years of testing and research projects if I didn’t pay $1300 to “maintain certification”, I had enough. I didn’t pay, and voluntarily gave up my board certification.

I wrote a letter explaining why, so there wouldn’t be any confusion. To date, that letter has been read 100,000 times. Clearly, I hit a nerve among my colleagues. But what would happen to me professionally? What happens to doctors who stop doing MOC?

First off, after many threatening emails, the American Board of Pediatrics erases the name of any doctor who fails to complete any of the four parts of MOC from their website. Erases.

December 17, there I am.

And now, I don’t exist.

Grandfathered doctors, like ABP president David Nichols,  are listed as “Board certified, not participating in MOC”, but those of us who have passed multiple board exams and a decade of MOC? Erased.

Obviously, they have the technical ability to list us as “Board certified, not participating in MOC”, but they don’t. They erase our names, as if we’d never passed our boards to begin with. The only way to find out that I’ve passed two board exams is to write the ABP and pay $40 for a release of information. Why would they do such a thing, why make this so difficult for us? Because their website has the power to destroy our careers, that’s why.

Four weeks after my Open Letter to the American Board of Pediatrics was published, my name was erased from the ABP website and the threats began. On an insanely busy Friday afternoon in February, I was called by Blue Cross Blue Shield of Michigan/Blue Care Network, and informed that I had to immediately cease from seeing any of my BCBS/BCN patients. Immediately. They checked the ABP website, my name was no longer listed and I was therefore no longer allowed to see my patients.

I asked if I could have a colleague co-sign my notes, and that was not allowed. I asked it I could see my patients and not be paid. They said I was forbidden from seeing my patients. I submitted my board certification through the National Board of Physicians and Surgeons, and was told only ABMS boards were allowed. I asked if I asked if I could see the credentialing policy I was being held to, and was told “it was proprietary”. All this stress and harassment in Michigan,  because I didn’t pay $1300 to the American Board of Pediatrics, a multi-million certification corporation out of North Carolina. Unbelievable.

I pushed back and asked for a departicipation notice in writing, and they backed off. I now have until December 31, 2016 to comply and pay the American Board of Pediatrics $1500 (with the added $200 late fee, of course), or I will be banned from seeing my patients at that point.

Next up were the hospitals. My hospital privileges were due for renewal this month, and imagine my surprise when I had to sign a contract confirming that I would enroll in ABP MOC! This was nowhere to be found in my med staff requirements, which only requires me to have initial board certification. When I asked the hospital credentialers, they assured me this was a glitch. No one knew how this language made its way on to the computer-generated contract or how to change it.  After much anxiety, I signed the contract as there was no alternate way to get my privileges renewed. Time will tell if I lose my hospital privileges over a computer “glitch”.

So far, six months after dropping my board certification, I’m still standing, but not without a ridiculous amount of harassment and bullying. My scenario repeats itself thousands and thousands of times across the country. Usually, most doctors back down and pay the money, they stop doing CME of their own choosing and complete the education modules decreed by the boards, they stop doing their own novel medical research and instead complete the  busywork research for the boards, they give up family time to travel to review courses, they shut down their offices to take secure examinations.  Doctors do this out of fear. The ABMS has long banked on fear and intimidation as a business model.

That model is coming into question as more and more doctors fight back. Rather than fear, I’m banking on the strength of my fellow physicians to return board certification to its rightful place as a voluntary process: one that is not tied to licensure, hospital privileges, insurance participation. Oklahoma has shown us this is possible.

This morning,  Michigan will take the first step towards freeing our doctors from overreach of the ABMS, as House Bills 5090 and 5091 finally go to testimony before the House Health Policy Committee.  I will be there testifying, alongside an incredibly diverse group of physicians finding common ground on this issue.  The powerful insurance and hospital lobbies will oppose us, as anticipated. Maybe the ABMS will send someone to plead their case.

I remain optimistic that Michigan lawmakers will see MOC for the money-making sham it is, and act on behalf of Michigan doctors and our right to care for our patients without interference by these unaccountable outside board certifying corporations. My hope is that this will be the beginning for other states to follow in our footsteps and return board certification and MOC to a voluntary process, free of fear and intimidation.

Wow. For those who think MOC isn’t a big deal, my Open Letter to the American Board of Pediatrics just hit 70,000 views.  That’s stunning.

For those commending my bravery,  realize efforts like this are not done in isolation. I am not alone. I have the most amazing partners. I can’t even express how blessed I am to work with the ten doctors in our private practice. Not only do we share a common faith, we share a fierce independence.  They know that in the end, I may lose my MOC battle even on the way to winning the war. Blue Cross Blue Shield of Michigan may force me to be certified through the ABP, and rather than lose access to care for my patients, I will pay $1300 plus a $200 late fee to the ABP to regain my certification. But I certainly won’t lose quietly.

I have the support of my state medical society.  Michigan State Medical Society has the strongest state policy on MOC in the country: MOC should not be tied to licensure, hospital privileges or insurance participation and it should not be the monopoly of one organization. It helps knowing there’s a 15,000 member society on my side. And they’re doing the impossible. But more on that in another post.

I have the support of thousands of Sermo doctors, over 5,000 signatures on our pediatric MOC petition and now 70,000 views on the letter without one single doctor opposing my stand.  I am not alone. Numbers are clearly on our side.

Since writing my original letter, my inbox has been flooded with hundreds of heartbreaking stories. Physicians with cancer, on chemotherapy and immunosuppressed, are denied waivers to delay testing in the public facilities, losing their certification and their jobs. Parents of children with cancer are denied waivers while their children are undergoing treatment, losing their certification and threatened with job loss. Physicians are retiring early to avoid another costly and demeaning cycle of MOC. Physicians are feeling isolated and embarrassed after failing their re-certification and are falling into depression and suicide.

My eyes are wide open now, and I realize this is more than mere annoyance or financial inconvenience.  MOC is a toxic stress that is literally killing doctors. The worst part is the boards have heard our voices, yet they keep pressing forward. Their unflagging defense of MOC in the face of what they know it’s doing to our colleagues is not a simple error of knowledge, this is a breach of morality. This is something we cannot participate in.

It appears we’ve come to the divide in the road.  If you’ve had enough and are ready for a revolution in MOC, there are some very simple things you can do. This applies to all ABMS specialties, but I speak directly to my pediatric colleagues here.

1.) If you really don’t need MOC to practice medicine, please stop participating.  Continuing to financially support the ABP harms your colleagues, and it harms children as experienced doctors retire early.  Paying fees to the ABP harms more than just pediatricians,  as the ABP turns around and gives $837,000/yr to the American Board of Medical Specialties Foundation which develops MOC programs to inflict upon your colleagues in other specialties. When you give up your certification, send a letter to the ABP explaining exactly why.

The ABP has threatened to sue any doctor who calls themselves “board certified” in print or on the web if they don’t do MOC, so getting certified through the National Board of Physicians and Surgeons is probably a wise move if you still want to call yourself “board certified.” Note that you can still keep the “FAAP” in your title, even if you don’t do MOC, as the AAP only requires initial board certification to be a fellow.

2.) If you think you need MOC to practice, please make sure. Check your insurance contracts. Check your hospital privileges. We had a local pediatrician harassed by the children’s hospital when he didn’t participate in MOC.  Turns out, our staff bylaws only require initial board certification. The harassment was completely unfounded.

3.) If MOC is required for your job, insurance contracts, or hospital privileges…this is where the fun starts and is going to require more information than I can give in this post. It’s going to require politics, organized medicine, and some hard work.  I will post soon on exactly how this is done, but for now, if you’re really forced into MOC just start by asking questions. Call up your state medical society to see if they have written policy opposing MOC and resources to help. Find a few colleagues, and ask if hospital policy or office policy can be changed to either only require initial board certification or NBPAS as an alternative.  You might be surprised by how much support comes out of the woodwork.

And finally a word to those who are “grandfathered” and exempt from MOC. I harbor no bitterness toward my grandfathered colleagues. Indeed, the requirements enjoyed by grandfathered pediatricians should be the standard for all.  But to those grandfathered doctors who now know what is happening to your younger colleagues, yet turn your backs on us or even worse, enforce MOC requirements for our employment but not yours, I do hold you accountable.

There is a reason the “grandfathered” class exists. Established in your careers, and trained in an era that encouraged oppositional defiance, MOC wouldn’t have lasted 2 months if you were included. You would have fought and shamed the ABP into immediate apology and retraction.  Instead they targeted younger doctors facing significant education loans, newly employed with young families, just trying to make partner and not interested in making waves.

We all want to leave medicine better than we found it and this is the chance for our grandfathered doctors to step up in your circle of influence. It is likely you or your contemporaries are in hospital administration and on medical society boards.  You or your contemporaries are the ones making employment guidelines for your university department or private practice. Rather than breathe a sigh of relief that you’re exempt or nearing retirement, fight for us. Don’t show solidarity with us by voluntarily participating in MOC, show leadership by fighting for our right to self-education without coercion. Use your hard-earned status and influence to end MOC employment requirements for all pediatricians.

It’s no wonder the ABP has been successful at pushing us so far, yet listening so little. Pediatricians are a tolerant lot.  We have nearly unending patience. We can tune out incredible distractions to get our job done. We are literally pooped on every day, yet we show up day after day, with white coat pockets full of Star Wars stickers and love our jobs.

It’s because we’re viewed as such tolerant happy doctors that I started to worry what my patients would think if they read my letter as it was spreading quickly on social media.  A friend forwarded a comment one of my patients made on the article, something I wasn’t intended to see.  The mom said, “A doctor that fights this hard, will fight for us if we need her to.”

See, that’s what the American Board of Pediatrics forgot.  Pediatricians have devoted our lives to fighting tirelessly for the little guy. And this time, we’re the little guy.  If we can give even a fraction of that passion, tenacity, and love fighting for our fellow pediatricians, the ABP better hold on. They’re in for one bumpy ride.

Photo by anjan58