MOC

Dear American Board of Pediatrics:

On December 17 2015, at 3:01 in the middle of my busy day seeing patients, I voluntarily gave up my American Board of Pediatrics certification. I thought I should write this letter, hopefully preempting any more threatening emails warning me that I must pay up or lose my certification. This was not mere oversight on my part. This was purposeful.

The reason I am no longer ABP certified has nothing to do with my education or skill. Indeed, I’ve easily passed my board examination twice. Like a compliant pediatrician, I enrolled in MOC in 2010, paid my $1000 and completed all my educational requirements.  I participated and completed all my MOC requirements again in 2013 and 2015.

I have disrupted my office flow to ask patients to rate me on my hand washing and I’ve sent that data to the ABP.  Twice.  I have disrupted my office flow to ask patients to rate me on my ability to give them flu shots and I’ve sent that data to the ABP.  I have dutifully completed your proprietary CME modules. I have submitted to and passed two secure examinations where I was treated as a near-criminal. Up until December 17 at 3:00, I did everything you asked.

But when I was threatened with loss of certification if I didn’t give another $1300, I finally had enough. The fact that the ABP can completely strip qualified and competent pediatricians of board certification for not paying more money is further evidence that MOC is all about the money.

A quick glance at your tax records makes it abundantly clear that this IS all about the money.  It’s about the president earning $1.3 million, but not doing MOC himself. It’s about first class airfare for board members and their spouses and $1.2 million spent on board meetings and conferences. It’s about $102 million in total assets in 2013, skyrocketing up from $65 million just 4 years earlier. It’s about an elite group living lavishly while front-line pediatricians slave away complying with never-ending hoops and ever-increasing fees.

And that’s why I didn’t pay.  I can’t continue to fund this type of coercion.  Those funds are used to change MOC rules on a whim and to threaten pediatricians into compliance.  While the ABP board was enjoying holiday preparations with their families, thousands of pediatricians were scrambling desperately to complete their MOC by Dec. 17.  Social media groups and message boards were full of physician moms and grandmothers looking for support as ABM MOC was pulling them away from family events to take tests, run reports on patient charts, and then cough up $1300 out of fear. This breaks my heart. The ABP should be ashamed of themselves and what they’re doing to our colleagues. The ABP board should be ashamed of what they’ve done to the reputation of the ABP.

On one hand, I am sad about giving up my ABP certification. I remember the elation I felt when I passed my boards after residency. I really felt like I had accomplished something and that my certificate represented my professional  educational commitment to pediatric medicine. Now, after seeing the monster that board certification has ballooned into, I’m very happy to be off the MOC hamster wheel and no longer supporting a corrupt system that punishes very good doctors and pushes our most experienced pediatricians into early retirement.

As it stands, something with American Board of Pediatrics MOC must change. As pediatricians, we’ve joined the rest of our physician colleagues across all specialties pleading for MOC to end. It must return to a one time examination after residency, maintained by holding an unrestricted state medical license and completing CME hours of our choosing. Ongoing secure examinations must end, limitation to ABP and AAP proprietary CME must end, the outrageous fees must end, and the time-consuming busywork of “Part 4 Practice Improvement Modules” must end. MOC must be egalitarian for all pediatricians, without exemptions or lowered fees for favored groups.

These are not just my isolated musings, this is what 4000 of my pediatric colleagues have requested in petition at peds4mocreform.org . This is what 23,000 physicians have signed under Dr. Paul Tierstein’s petition.

If past behavior of the ABP is any indication, I’m sure there will be more board meetings, work-groups, and pilot programs to tinker with MOC, to make it more “integrated” with our practices. Dr. David Nichols will write another blog post letting us know you are listening and have tinkered some more.

It’s all this flailing around and tinkering that makes me realize you don’t get it. We aren’t asking you to tinker and integrate MOC, we’re asking you to stop. The ABP keeps arbitrarily changing rules, and will continue to control us with these never-ending changes.

I really don’t think the ABP will be able to end MOC until we are allowed to stop participating. In order for us to stop participating, we have to conquer the one thing that keeps us in compliance: fear.

So in 2016, while the ABP meets and tinkers, I will focus on ending the fear. I will focus on freeing pediatricians from MOC requirements for hospital privileges and insurance credentialing, so MOC is truly voluntary. I will focus on educating my colleagues about alternative board certification options that treat us fairly and professionally like the National Board of Physicians and Surgeons, so there is choice.

In the end, I truly hope the ABP regains some measure of credibility and respect among practicing pediatricians. That will only come by respecting us as the professionals and colleagues we are, and not siding with the many other forces that are piling never-ending requirements, regulations, fees, and abuses upon us in the pursuit of power and financial gain.

Sincerely,

Megan M. Edison MD

Photo by lukas.b0

Sign the Petition to End Pediatric MOC Here.

Contact the ABP here.

My inbox has been flooded lately with emails from fellow pediatricians begging for help fighting the American Board of Pediatrics MOC program. These are doctors with decades in the care of children, now threatened with complete loss of their ability to practice because of the onerous ABP MOC process.  In trying to help my colleagues, I visited the ABP website today and was amused to see announcements of three awards given to fellow pediatricians for their exemplary contributions to the care of children.  The celebrated doctors were indeed inspiring. But that’s not all they share in common.

Former ABP board chair, Dr. Catherine DeAngelis was awarded the 2015 Howland Award. She “has led virtually every national pediatric organization…authored more than 200 peer-reviewed publications and a dozen books. She was editor-in-chief of JAMA from 2000-2011… three decades on numerous ABP committees andsubboards, and ultimately chairing the ABP Board of Directors in 1996.” Former ABP president James A. Stockman (yes, the one with the $1.2 million salary) gushed: “Cathy DeAngelis’ career not only mirrored the future of pediatrics as it was evolving, but she single-handedly created a good deal of that future.”

But you know what? Catherine DeAngelis is not meeting MOC requirements.

Dr. Calvin Sia was awarded the Starfield Primary Care Leadership Award as the grandfather of the medical home concept. He served as Hawaii AAP chapter, President of Hawaii Medical Association, AAP Committees on School Health &Pediatric Emergency Medicine, Immediate Past chairperson of the AAP Delegation to the AMA chairperson of the Section Council on Pediatrics, on and on, all while in private pediatric practice.

But you know what? Dr. Calvin Sia is not meeting MOC requirements.

Dr. Barry S. Zuckerman was awarded the Joseph W. St. Geme, Jr. Leadership Award. He is professor and chair emeritus of the Department of Pediatrics at Boston University School of Medicine and professor of Public Health at Boston University School of Public Health. From 1993-2012, he served as the chair of the Department of Pediatrics at the Boston University and chief of pediatrics at Boston Medical Center from 1993-2012. He has authored 250 publications, more than 130 of them peer-reviewed, and edited 12 books.

But you know what? Dr. Barry Zuckerman is not meeting MOC requirements.

It is wildly hypocritical that the ABP would highlight and award these “deficient” doctors. The ABP has successfully lobbied Congress, hospitals, and insurance corporations into believing MOC is the only measure of competency, yet they applaud these “incompetent” doctors.

Even though the ABP would define Drs. DeAngelis, Sia, and Zuckerman as incompetent to practice medicine for not meeting MOC requirements, I do not. I happen to believe that passing the pediatric boards once, and then maintaining an active license and the CME requirements of your state is more than enough to demonstrate competency and life-long learning. (Apparently, so do 1400 of my pediatric colleagues who have signed the Pediatric MOC Reform Petition, not to mention the thousands who have stopped participating in MOC and are board certified through NBPAS instead.)

I look at what these three doctors accomplished over their careers, and it is a testimony to the self-motivation of American pediatricians without MOC. No ABP nanny is necessary for us to advance the field and care of children.

On the flip side, I wonder if these pediatricians would have accomplished all they did, if they had to comply with MOC in the middle of the careers like thousands of their colleagues do now.  Would solo practitioner, Dr. Sia, have the time to creating his medical home model while taking weeks away from the office to attend another board review course followed by yet another secure examination? Would Dr. DeAngelis have enough patient base in her academic career to complete a Part 4 module? Would Dr. Zuckerman have been able to follow his passion of environmental impacts on childhood development if he had to stop research to review charts to send in for Part 4 credit on a completely unrelated and irrelevant issue?

We may never see leadership and research like we have in the past. The reasons are many, but MOC ranks high. It also ranks bitterly, because this is being done to us by our “colleagues”, not some faceless bureaucrat in DC.

How many pediatricians today are not pursuing research pertinent to their community because of MOC? How many are retiring early? By a glance at my inbox, we’re talking about hundreds if not thousands.

The American Board of Pediatrics needs to afford all diplomates the same career opportunities, free of MOC coercion and distraction, as Drs. DeAngelis, Sia, and Zuckerman experienced. Time-limited certificates must end, as well as the stranglehold the American Board of Pediatrics has over practicing pediatricians and our care of children.

On February 25, 2015 the American Board of Pediatrics published their “long-awaited” response to the growing physician outcry against the “Maintenance of Certification” scheme. I started writing a full response to their blog article, but I can’t even get past the graphic posted at the top of the page. Read their graphic carefully.

Bottom Line: The ABP believes that accountability to the public, continuous improvement of our operations, and transparency are important core values for the board.

Yeah, I know. Not a single mention of actual pediatricians, their diplomates, who are working daily in the care of children.

There are currently over 200 moderated comments allowed on the blog, I’ve read every one. 100% are negative, not a single comment in support of MOC. But it doesn’t matter what pediatricians think, because board president David Nichols started out with their Bottom Line: They don’t care about pediatricians.

They are accountable, not to pediatricians, but to the “public”. I honestly have no idea who the public is, because patients are not demanding board certification, let alone MOC.  I’ve never, ever, had a family ask if I was board certified. My guess is that “the public” is pure imagination.

They are not focused on continuous improvement of MOC for pediatricians, they are focused on continuous improvement of their operations for themselves. MOC is an incredible revenue source. All the physician opposition to MOC revolves around three main concerns: Useless Part 4 “Performance in Practice” modules, never-ending and irrelevant secure examinations, and exorbitant costs. But because their focus is on their operations, ie. revenue, there’s no way they can respond and improve MOC for pediatricians when their revenue depends upon those issues opposed by their diplomates.

They claim transparency, but refuse to be transparent. They post silly grade school graphics of their budget and projected revenue, but refuse to release real numbers. They post data that makes it look like they’re $1/2 million in the red, poor guys, just barely making ends meet on $28 million dollars in revenue! Maybe posting data on board member salaries would help explain the $1/2 million shortfall.  Previous ABP president James Stockman took home a cool $1.3 million annual salary, but David Nichols refuses to post his and other board member’s salaries. That’s the real transparency we want. But then again, they’re not accountable to us, remember?

But there is a way out of this mess, and I thank David Nichols for advertising it to my fellow pediatricians:

In the midst of debate around MOC, a different model has emerged. The National Board of Physicians and Surgeons (NBPAS) now offers a certificate for individuals with a valid license, a history of initial board certification, and evidence of at least 50 hours of CME credit. The reliance on CME for maintaining certification mirrors the requirements for renewal of licensure.

The National Board of Physician and Surgeons (NBPAS) is a new certification board open to pediatricians, recently created by practicing physicians in direct response to the failure of our boards to listen and adapt to diplomate concerns about MOC. The pediatric board member of NBPAS is none other than David John Driscoll, M.D., Professor of Pediatrics, Mayo Clinic College of Medicine. Take a look down the list of board members, it’s a veritable who’s who of medicine. No wonder the ABP is worried.

NBPAS certification standards are straightforward, egalitarian, inexpensive, and physician-focused: Pass a board examination once, hold an active unrestricted state medical license, demonstrate commitment to ongoing education through 50 hours of CME every 2 years.  Seeing how the ABP has made it abundantly clear in their “Bottom Line” that they do not care about practicing pediatricians, it’s time we stop supporting a corporation that doesn’t support us and pursue certification through a physician-minded organization that does.

The ever-changing ABP rules say my certification expires December 2015, at which point I’ll breathe easy knowing my certification will no longer be at the whim of a board that doesn’t care about me. Instead, I’ll be a proud diplomate of the National Board of Physicians and Surgeons only.

“For the most part, doctors and civil servants simply did their jobs. Some merely followed orders, others worked for the glory of science.”
— Dr. John Heller, Director of the Public Health Service’s Division of Venereal Diseases

The first time I complied with the American Board of Pediatrics Maintenance of Certification system, the choices for “Part 4 Practice Improvement Module” credit were limited so early in the program. I asked around, and the least painful exercise was the “hand washing module”. It involved self-reporting on my hand washing technique, watching a video, and then self-reporting my improvement.  It was lame, but could be completed quickly without disrupting patients during their office visits or requiring my staff to pull charts for review.

This time around, the Part 4 options have exploded and are far more complex.  There are currently over 400 research projects being done on children without patient consent under the auspices of the American Board of Pediatrics “Practice Improvement Module”.  Large hospital systems and institutions have created research projects that are approved for Part 4 credit. This serves two purposes for the institutions: their doctors can get MOC done within the usual research being done by the hospital and that research is exempt from patient consent because it’s “Quality Improvement” and not “research”.

It’s a bureaucratic line, to be sure. If a major research hospital does a “quality improvement study” and changes the way they care for patients, then publishes that study to show patient outcomes, it sure sounds like research to me. As a patient or a parent of a child enrolled in the study, I’d sure like to know if the study was why I had to pay for extra follow-up, extra testing, or why my child was denied care.

The American Board of Pediatrics disagrees and defends these studies, lack of consent and publishes the results with pride.  The most recent example is an asthma study published this summer in Pediatrics,  Effectiveness of an Asthma Quality Improvement Program Designed for Maintenance of Certification.

In exchange for Part 4 MOC credits, 56 physicians conscripted 594 patients to participate in the asthma study without consent. In addition to being a crummy study with questionable outcomes, there was no disclosure on how patients paid for the extra visits, extra time, medications and extra testing required in this study or if they ever found out they were part of a study.

When the Pediatrics Editorial Board was questioned on the ethics of “paying” doctors with MOC credit for studies done on children without consent, this was their response:

The issues that you raised about human subjects protection and quality improvement have been previously addressed by the US Department of Health and Human Services. Based on this federal guidance, there has been no ethical breach and no reason to consider retraction of this work. Please refer to: http://answers.hhs.gov/ohrp/search/results?category_id=1569

Sincerely,

Alex R. Kemper, MD, MPH, MS
Deputy Editor, PEDIATRICS

In other words, it’s ethical because the government says it is. Sad that the nation’s leaders in pediatric research have no higher ethics than government sanction.  Equally sad is that the pressure of fulfilling MOC apparently seduces good physicians to neglect human research subject’s and fundamental patient’s rights.  The American Board of Pediatrics needs to come clean on these studies, allowing patients full informed consent to participate. Anything less regresses medical ethics to the time of Dr. John Heller.

The Tuskegee Experiments were sanctioned by the government as well. Out of Tuskegee came various laws, commissions and Institutional Review Boards to protect patients and require informed consent. Now, simply renaming research as “Quality Improvement” allows complete disregard for the safeguards of IRB and informed consent that came out of Tuskegee. Returning to the Tuskegee standards for patient rights doesn’t sound like Quality or Improvement to me.

Photo by throgers

Up until 1988, being board certified in pediatrics was a voluntary process of passing the board exam once in a career. The American Board of Pediatrics apparently realized this process didn’t make them much money, so in 1989, they abruptly ended “Lifetime Certification” and required an open book test and the associated fee every seven years.  I was in pediatric residency during this MOC stage, the mandate was an annoying and costly change from lifetime certification, but an open book test seemed manageable for a busy pediatrician to complete.  I watched my attendings work on their open book tests over the lunch hour.  It was collegial and almost fun.

The ABP apparently realized this process didn’t make them enough money either, because in 2003, they abruptly required a secure exam every seven years. This was a bigger deal, requiring participation in expensive $1000 board review courses, offered conveniently by the same academic doctors who established this new requirement. Secure exams, in addition to costing more to administer and prepare for, also require taking time away from the office and patient care for the actual test.

Then out of the blue, just seven years later, the rules changed yet again.  Passing the boards once in a career wasn’t enough, an open book exam every seven years wasn’t enough, a secure exam every seven years wasn’t enough: pediatricians needed to remit $990 and enroll in a “continuous MOC program”.  Because pediatricians are a compliant lot, I did as I was told.

So what is Continuous MOC? In addition to now costing $1200, it’s an incredibly convoluted, continual process of complying with the boards and financially supporting their friends.  It requires a secure examination every 10 years, an utterly humiliating process where practicing physicians are treated like criminals. I was subjected to a body scan, I had to lift my pants above my knees and show my bare arms to the proctor. For administering this humiliation, Prometric received $1.7 million from the ABP in 2013.  Every 5 years it also requires 40 points of “Approved Part 2 Activities” and 40 points of “Approved Part 4 Activities” and then another 20 points of either Part 2 or Part 4 Activities.  But the 10 year test may not coincide with the 5 year MOC requirements. Confused yet?

“Approved Part 2 Activities” are incredibly difficult online questions that are largely designed for pediatric subspecialists.  “Approved Part 4 Activities” are purportedly “practice improvement modules” that take 2-4 months to complete. Part 4 Activities involve pulling charts, enrolling patients into study groups without their consent, doing the study and reporting the data to the boards.  Currently, there are nearly 400 research projects being done on children through Part 4 MOC. Not only is performing research on children without consent immoral, it is costly in both time and money for the patient.  In an effort to show “improved care”, the physician is compelled to order testing that may not be necessary for the individual child and ask for more frequent office visits than is necessary. One has to question the validity of any practice improvement module that a physician is participating in upon threat of losing their hospital privileges or insurance participation.

So when will this end? What will the next iteration of MOC bring? It’s my aim to never find out, because I’m no longer part of the “compliant lot”. I look at ABP president James Stockman’s $1.3 million salary and realize they will not voluntarily stop forcing us to participate in their testing and their research projects.  The outrage against MOC and this clear overstep and monopoly by our boards is rising. State medical societies are passing resolutions to end MOC, it’s only a matter of time before the AMA has to listen to us. State legislatures are taking steps to protect physicians from these unaccountable outside corporations. A federal lawsuit against the ABMS by the Association of American Physicians and Surgeons is moving forward. Physicians are connecting together nationally through the network of changeboardrecert.com.

The history of war shows “mission creep” and the hubris it reflects invariably results in catastrophic failure and retreat by the offending force. December 17, 2015 is the day the American Board of Pediatrics will finally retreat from my career and my care of patients.  My next cycle of MOC starts on that day, and my answer is “I will not comply.”