Tuesday, June 16, 2015

Pro-Con MOC articles in Radiology Journal-time to fight and notice the failure to declare conflicts of interest-rather supporting them as specialty Journal!

These two articles appeared in J Am Coll Radiol. This first one is quite on the mark but reserved in the stance against MOC:
2015 May;12(5):430-3. doi: 10.1016/j.jacr.2014.10.011. Epub 2015 Feb 26.Point: twin dogmas of maintenance of certification.Jha S.

A counterpoint followed on the next page.  I hope radiologists might take this to issue with the editor. The opposition piece was directly from the ABR and ABMS staff and playbook. Of course I wrote a letter to the editor and noticed the fact that there is no declaration of conflicts of interests about the ABR staff member (MJG) writing this piece (beyond his Email address at the ABR!)-pointing again that these specialty Journals are in Bed with the Boards big time.
(Disclaimer from the JACR):
"While the opinions offered in this article are the expression of the authors, the document was reviewed and is supported by the Board of Trustees of the American Board of Radiology.
Milton J. Guiberteau, MD, is from the Baylor College of Medicine, Houston, Texas. Gary J. Becker, MD, is from the American Board of Medical Specialties, Tucson, Arizona.
Milton J. Guiberteau, MD: Baylor College of Medicine, One Baylor Plaza, MS 360, Texas Medical Center, Houston, TX 77030; e-mail: guiberteau@theabr.org.
SSDD!
I will publish my submission here in a week unless I hear back from the Editor Bruce Hillman, MD
Editor in Chief. Here is the communications we have had to date:
-------------------------------Ms. No. JACR-D-15-00254
Important issues missed in the MOC debate-Point/Counter point.
The Journal of the American College of Radiology

Dear Dr. Paul Kempen,

I read your letter. Unfortunately, I found it to filled with unsupported assertions and accusatory language to consider it appropriate for publication.

I am sorry for this outcome, in part, because I am sympathetic with the thrust of your ideas. Thank you for giving us the opportunity to consider your work.

Regards,

Bruce Hillman, MD
Editor in Chief
The Journal of the American College of Radiology
My reply:
Dear Dr Hillman:
I am not sure you know my history or bothered to read either of my references (I have attached them for you here and the 2014 would clarify matters for you). I have been studying this MOC issue for 6 years intensely, am exquisitely informed of both pro and con opinions  and am happy to provide references for anything you feel needs to be referenced in such a letter, should you only let me know what needs such referencing (Given 500 words and typically 5 references for any letter-my limitations are quite obvious including the need to "get to the point" without flowers). I spent 10 years in Europe and there is NO ABMS MOC in Europe and yet excellence is clearly documented there!  As for the accusatory language (word count limits style) , it is fact that the ABIM paid for the "Gallop poll" (which was never published in any medical journal simply BECAUSE it is not any more scientific than a Pepsi or Coke "taste test") and this keeps popping up as ABIM and ABMS  references- as the starting point for supporting the whole MOC program.  Never is mentioned that State Medical, hospital Boards exist as physician led organizations and have actual authority to intervene in substandard care, while DEA, State, and local police, National data banks, FSMB, etc furthe "regulate doctors along with Tort lawyers.  
Certification/MOC are designed to be much more than minimum standards and  are not "voluntary" should you believe Dr Baron. It has become time to "call MOC" to the carpet and similarly the whole Certification industry and it's illusion-as is happening on the internet and now also Newsweek.  Yes, ABMS has admitted they "got it wrong" only after stark confrontation by physicians like myself threatened their machine-and please be aware that ABIM has been the driving force in this matter via ABMS, pushing through "sign up for MOC or lose the franchise" upon all 23 other boards. I do not think the Radiology boards are necessarily as radically pushing this, much like anesthesia was forced into this and now have,  along with the national societies (ASA) seen the income it generates- the $400 million a year to the ABMS boards is much less than the national societies are making!I will not go on further here, but hopefully await any editorial revision suggestions you might have to make this either acceptable for publication as a letter or otherwise. If you are interested, yes, "the Boards" have an army of people publishing yearly "updates", grandfather attestations and other programs to sell MOC, typically including free advertisements in journals they and national societies own, without providing "equal time" for counterpoint. You can read in depth about this at: http://www.jpands.org/vol19no3/kempen.pdf . and read more examples of this in this supplement financed to the tune of $50k by ABMS (as per the editor himself in personal conversations) to promote the ABMS programs: . Nora LM. Professionalism, career-long assessment, and the American Board of Medical Specialties’ Maintenance of Certification: An introduction to this special supplement. J Contin Educ Health Prof 2013;33(S1):S5–S6. 
 Also find attached the newest information regarding ABA's own problem with declaring corporate products "Insuring clear declaration of corporate conflicts of interest in all medical journals: the highest priority". I admire your publication of Dr Jha's article and yet wonder why you were unable to select someone who is NOT from the boards to provide an unbiased counterpoint and without the repeated use of corporate products (gallop poll)  as "evidence". Why should any journal continue to provide free advertising to a corporate entity-this would not be done for any pharmaceutical or medical device company, yet alone the extreme extent provided the boards.I look forward to your response.

Paul Kempen, MD, PhD
ABA Board Certified Anesthesiologist 1989, 2005 and never again.

Kempen PM: Maintenance of Certification and Licensure: Regulatory Capture of Medicine. Anesth Analg. 2014 Jun;118(6):1378-86.

P Kempen:  Maintenance of Certification: Ethics and Conflicts of Interest  Journal of American Physicians and Surgeons Volume 19 Number 2 Summer 2014 http://www.jpands.org/vol19no3/kempen.pdf

Kempen PM. Insuring clear declaration of corporate conflicts of interest in all medical journals: the highest priority.  J Clin Anesth. 2015 Aug;27(5):434-5. 
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Friday, June 12, 2015

JAMA issue 5/12/15: Professionalism and Governance: Pure BS

I tried to rebut the propaganda published here and the editors again reject as damage control:
The JAMA issue from May 12, 2015, was a theme issue entitled: Professionalism and Governance,  proclaiming to be a “series of Viewpoints by scholars and academic leaders “.(1) The issue appears to be a clear attempt at damage control, in the face of mounting physician dissatisfaction with “top down” imposition of corporate certification and regulation agendas upon practicing physicians and patients- and now mainstream media reporting of this ordeal in Newsweek. Overwhelmingly representatives from multiple“ legacy” non-profit corporations,  who together built these intertwined industries (including the AMA as “Stakeholders”) with multimillion corporate annual incomes,  again opined how to “fix” education, certification, regulation, etc, of the medical profession to meet their needs as private interest groups,(earning from impositions on practicing physicians and pushing their corporate agendas and outdated testing programs). (2) While both ABMS and ABIM have repeatedly found opportunity to publish their message in multiple journals and internet sites (often owned by the boards) and at times after buying complete “supplements” in medical journals for this purpose and hiding the significant conflicts of interest involved, JAMA now felt obligated to endorse them with yet another free opportunity to facilitate this regulatory capture of medicine.( 3) Opposition has successfully availed social media in grassroots fashion and against overwhelming odds, in spite of limited consideration by the JAMA or the AMA-even from within. Over 17 state medical societies have repeatedly passed resolutions along with the Young physician’s AMA component mounting resolutions at the annual AMA meetings in recent years. Yet respected and authoritative practicing physician opponents of regulatory capture  are remarkable by their absence in this “balanced presentation” of JAMA, including and to name only a few-Drs Wes Fisher (http://drwes.blogspot.com/ ), Ron Benbassat (http://www.changeboardrecert.com/ ),  Charles Cutler (PA Medical Society debate-http://www.pamedsoc.org/MainMenuCategories/Education/MOC/Video-MOC-Debate.html ), Richard Amerling (AAPS lawsuit against ABMShttp://www.aapsonline.org/index.php/site/article/aaps_takes_moc_to_court/ ) and William Carbone (CEO of the certification agency ABPS http://www.abpsus.org/.
Practicing physicians have become the weakest component driving healthcare policy, with government, pharmacy, university, insurance, computer-EMR, hospital, medical devices and many ancillary industries and professionals dictating practice parameters often over patient prerogatives using their multimillion corporate profits. Physicians increasingly become mere “employees” or are replaced by non-physicians as less educated “providers”-physicians being controlled, not controlling medicine.  This may specifically be the demise of the trust patients extend to physicians. We are losing self-regulation to numerous corporate and government entities and agendas! (4)
MOC and Board Certification are both apparently imposed without relevant data or proof of value, the costs are now forced upon physicians removed from the clinical care and their families, to do whatever outside private interest corporations and government decide must be performed for compliance. (5) Compliance is NOT education!  Past failures serve as anecdotal  opportunity,  to evoke emotion via press reports of serial murder (Dr. Harold Shipman) or hospital mismanagement (Bristol, England)  to facilitate regulatory corporate program growth appeasing political needs-while not addressing any specific problem with recertification. (6)
We only need ONE oversight organization with teeth (state medical boards), which licenses practitioners as physician led organizations and without corporate profit incentives, not the current multitude of independent and profiteering corporations with self- enriching intentions.(1) EJ Emmanuel summarized the problem in this sentence: “ The threat of money to the ideals of medicine is not new.” It is time to cut waste by eliminating the multiple redundant “non-profit corporations” reaching into the medical pocketbook (providing six and seven figure incomes to their CEOS) and specifically providing NO improvement in care. We need to expand Ronald Reagan’s greatest fear “I am from the government and am here to help!”  to include these armies of the non-productive “non-profit organizations” and now stand up for medicine as practicing  professionals.
If medical care is a “right”,  then medical education should be provided by the government at no cost-to reach everyone and without corporate funding influence or  repeated “unfunded mandates”. The negative commercial influence of medical industries as CME sponsors is thus renounced.  Currently,  the intrinsic earnings and conflicts of interests of “accreditation industry giants” (ABMS, FSMB, ACCME, ACGME) are completely ignored as if they were benevolent or producing some unidentified improvement in care. (3) There really is no difference in profit vs non-profit corporations or hospitals, when the price is high and staff earnings so outrageous! To see the CEO of the Pediatrics board earing $1.3 million a year,  while the board itself earns $2 million,  raises significant questions regarding the legality of  “non-profit” status and inappropriate  inurement to select individuals.  The NBPAS is emerging as a real competitor to ABMS,  with no salaries for their executive leaders!
Dr Nisson correctly stated private practice physicians are at disadvantage from universities-they have no universal access to medical literature on any computer. (7) Legislation forcing medical  information  become freely publicly available for anything listed in PubMED/the US National Library of Medicine after 6-12 months is appropriate. Let everyone read the whole articled and not just the excerpt, thus enabling a complete understanding of published “science”,  which only in this way becomes possible,  rather than hidden behind an often self-serving  “conclusion” of the author disseminated as fact in the excerpt. Break the corporate bonds of information dissemination and reduce the number of private profit publishers producing mountains of hubris. The internet makes information readily available, while requiring payment of $25-50 for a single article view (of material already typically privately funded and submitted for free to the publisher),  sight unseen (or based on authors biased excerpt conclusions),  does not!
Finally, let all CME providers,  including MOC products,  compete on an even playing field (possible only with the return to universal lifelong certification as is found in every other industry and was originally intended) with physicians choosing what they deem meaningful learning to them and for their patients and practice. Let competition provide for growth of quality-the good old American way.  It is completely germane to apply the “choosing Wisely” approach of the ABIM to board certification and MOC and recognize this as one of the most wasteful tests of all-false positive “failures”  limiting practice, by pushing good physicians from practice at a time of shortage-and profiting only the ABIM and their affiliates. This hypocrisy of the ABIM to continue with their recertification  program is unbearable.  Eliminate the multiple oversight corporations earning millions via regulatory capture of medicine. (4) Electronic databases mandated by the federal government should increasingly allow for widespread evaluation of practice-make that work…. not physicians doing ever more useless and non-clinical busywork at such wasteful cost. It is time to abandon the certification industry of the past century and move forward using the extremely expensive EMR and insurance based analysis,  also being increasingly imposed at this time. Let all doctors treat patients with their valuable time and let those bureaucrats  demanding the evidence,  find and prove their programs with outcome based data first-the gold standard of medical science!


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Sunday, September 28, 2014

HIDING IN PLAIN SIGHT: THE DETERIORATION OF MEDICINE-a disgusted physician tells the real story

 
HIDING IN PLAIN SIGHT:
THE DETERIORATION OF MEDICINE

by John Tedeschi, MD

(Robbinsville, NJ) – It’s happening so gradually you hardly notice it at first.  It’s a slow and deliberate erosion, targeting your family doctor, someone who will soon become a thing of the past. 

Thanks to politics, insurance companies, special interest groups and other organizations, medicine is changing:  the way it’s provided; who it’s provided to; exactly who the providers are and their qualifications; how much it costs and, literally, “who lives and who dies.”  The old saying “follow the money” has never been truer than today. 

On the surface, the bureaucrats are pretending to have the best interest of the patient in mind when it comes to medical coverage and healthcare.  One wonders, though, when the architect of the Affordable Care Act questions the quest for life after 75.


In reality, Ezekiel Emanuel says it’s a matter of saving money – and where the money IS ultimately spent, it’s directed to special interest, profit-making organizations.  Benefit to the patient is secondary.

It’s all carefully choreographed -- better than a Broadway musical.

As a result, physicians around the country are up in arms over unsafe and unethical insurance and federal regulating policies.  These policies remove the trusted, precious and irreplaceable ‘doctor/patient relationship’ in favor of healthcare “rationing’ that is based on previously established Third World standards.  And physicians have nowhere to turn for help.  The AMA (the American Medical Association), long the advocate for the nation’s doctors, abandoned the needs of the physician years ago and has its own agenda.  Today, only 14% of the nearly 400,000 licensed physicians are still members.

Doctoring just isn’t the same.  The practice of medicine, its costs and medical policies, are now dictated and controlled by groups that don’t know the first thing about medicine, nor the people it serves.  At one time, the practice of medicine in America was the envy of the world.  Unfortunately, it has now been radically segmented.

The individual human rights and patient care needs are completely eroded and purposefully ignored.  And more and more great doctors and educators, whose hands are tied, are simply giving up or leaving the country altogether.

It’s a national disgrace. 
  
Getting a flu shot at Wal-Mart or CVS, for instance.  Do these walk-in-off-the-street retail stores even know -- or care -- about the history of the patient and whether or not it’s safe to administer medicine of any kind?  Flu shots are not for everyone, but they have no way of knowing.  You find yourself in the hands of pharmacists who’ve just recently received a ‘crash course’ in how to immunize, a process mandated by the companies for which they work.

And even TV producers are realizing it’s a joke.  In a recent episode of one sitcom, a son asks his father, “Hey, where have you been?”  The father replies, “I got a flu shot at the pharmacy, because who better to administer medical care than the guy who puts price tags on flip-flops?”

Did I already use the words “national disgrace?”  

Then, there are the rapidly emerging, drive-thru urgent care centers.  Do you see a real doctor, or are you treated by a nurse practitioner or physician assistant who ‘looks and acts’ like a doctor?  Plus, it’s an uncontrolled data collection center of your personal information.

Regardless of issue, doctors are now told how much time we can spend with each patient; 
what tests we can and cannot request.  We are now forced to re-certify more frequently and answer questions, in many cases, unethically, just to serve their financial needs. 

We are told what kind of treatment can be provided to older patients, a type of  “too old to treat” approach because of the life expectancy of the patient and the cost to the federal government.  Even prescription medications that will effectively help the patient are routinely rejected by insurance companies and Medicare in favor of less expensive, ‘generic’ drugs that are archaic and simply don’t do the job. And we are aware, of course, of the conflict of interest of insurance companies having stock in the drugs that they do approve.  It’s really sad.

The entire emphasis is not just based on saving money, but also ‘making money’ at the expense of human life and quality care.

We saw what happened to the VA under government control.  Now the government wants to administer and control all of healthcare, nationwide? 

The Affordable Care Act, neither ‘affordable’ nor ‘caring.’  Not a political statement; a fact.  Ask any ‘real’ doctor.

The so-called “watchdogs” are not watching.  The government agencies established to “protect American citizens” from these abuses are not doing their job.  Where are our protectors?  Where is today’s Paul Revere who can set out to “warn us.”

Why does society accept this?  Are we ignorant, naïve, apathetic?  Probably.  One thing’s for sure:  We’re on our own.

Think about that.  But not for too long; you’ll give yourself a headache.”

-0-

Doctor John Tedeschi is a primary care-family doctor in Robbinsville, New Jersey, who has been practicing medicine for more than 30 years. He lives in Morrisville, Pennsylvania.
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Monday, September 22, 2014

How To Discourage a Doctor from doing the right thing

This is one of the most informative pieces I have read in years as to how the medical profession is being tied by the ankles:
“Though physician compensation accounts for only about 8% of healthcare spending, decisions that physicians strongly influence or make directly – such as what medication to prescribe, whether to perform surgery, and when to admit and discharge a patient from the hospital – have been estimated to account for as much as 80% of the nation’s healthcare budget. To maintain a favorable balance sheet, hospital executives need to gain control of their physicians. Most hospitals have already taken an important step in this direction by employing a growing proportion of their medical staff..............
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Tuesday, September 16, 2014

NBCRNA IRS 990s and the exponential growth of profits in this non-profit!

Gross receipts $3,292,415

Gross receipts $8,001,719

Gross receipts $16,570,001
So you see an exponential growth in income at this NBCRNA and there is certainly NOT an exponential growth in that profession in these 3 years! ALl information is on file at Guidestar.com, or as a NON-profit they  are REQUIRED to provide this information on request-and I wonder what they will charge you for that!
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Tuesday, August 12, 2014

MOC the Pablum for the masses of the ABMS

MOC is all just Pablum for the masses and there is no better analogy: see: 
http://www.babypost.com/babies/infant-developme... 
ANother invention that SEEMED a good idea which is NOT!

Is Pablum Necessary? New recommendations on what baby's first foods should be (hint: it doesn't include infant cereal) 
by Teresa Pitman 
In the 1920s, many babies were being fed with homemade formulas that consisted primarily of sweetened cow’s milk and water. Doctors at Toronto’s Hospital for Sick Children wanted to find a baby food that could supplement this formula, as many babies of the time showed signs of vitamin deficiencies and malnourishment. 
In 1931, they invented Pablum, a powder that could be mixed with water or milk and spoon-fed to even quite young babies. The original ingredients included: ground wheat, oatmeal, cornmeal, wheat germ, bone meal, brewer’s yeast and alfalfa plus added vitamins and minerals. It was the first infant cereal, and it quickly became the standard first food for babies. 
Over time, many companies began producing their own variations. Because of concerns about allergic reactions, most now use just a single grain (such as oats or rice). 
But times have changed. As more babies are once again being breastfed, and the quality of formulas available to parents has improved, recommendations about adding complementary foods have also changed. The Canadian Pediatric Society and the World Health Organization now both recommend that babies be exclusively breastfed for six months, and then continue breastfeeding with added solid foods for two years and beyond. 
When a baby starts on solid foods at six months or later, there’s no need for a highly processed, semi-liquid food like Pablum or another infant cereal. These babies are ready for REAL food! In fact, the World Health Organization recommends that babies be offered the foods that are part of the family’s usual healthy diet. 
- See more at: http://www.babypost.com/babies/infant-developme...
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Saturday, August 9, 2014

Putting Quality on the Global Health Agenda-NEJM & IOM crap



I read the article praising Institute of medicine political statements from the NEJM and wrote the following (naturally not accepted for publication). I used real definitions to define the problem, not politically motivated ones:
Placing the “mea culpa” in real terms regarding "quality healthcare".
The recent perspective on quality in healthcare continues to miss many essential realities. Quality is also defined as:”A measure of excellence or a state of being free from defects, deficiencies and significant variations.”
Rehashing the Institute in Medicine’s particular brand of definition, emphasizing: “it is safe, effective, patient-centered, efficient, timely, and equitable” simply does NOT describe modern medical care:
Safe: The very nature of healthcare (surgery, drug administration, anesthesia and procedures) is extremely dangerous, while this fact is typically minimized in expectations and when obtaining informed consent.
Effective: Typically the patient’s ability for self-healing is only promoted by treatment, typically introducing drugs and procedure related specific known dangers in the process-often as dangerous as the disease itself.
Patient centered: Increasingly emphasis decries utility of preventive care including PSA, mammograms, pelvic and even routine yearly physical exams-emphasizing cost effectiveness over patient centricity.
Efficient and timely: would require maintenance and preventive care-currently not emphasized-see above.
Equitable: you cannot purchase health, only health care. Poverty and lifestyle remains after healthcare, as a causative factor.

By failing to recognize that quality healthcare starts with having health and maintenance, whereby the patient is the primary source of health, we will never get past placing blame on physicians and health care systems for inadequate quality. Physicians cannot consistently replace that, which is already lost. The continued emphasis on “adverse outcomes” blaming heathcare systems, ignores the many patient centered causes of sickness including poverty, handguns, rampant drug, tobacco and alcohol abuse, obesity and multiple other life style choices including “extreme” and professional sports-which are not typically terminated by the patient, even after problems are treated and causality confronted. Adverse outcome continues to be defined as anything less than an optimal desired (advertised) outcome typically=restitutio ad integrum! This “failure” is not equal to malpractice, deficient or even inadequate care. Patients come to hospitals, when problems become severe and baseline health is marginal, increasing the risks from receiving care.
The example of the inability to decrease maternal mortality by financing all deliveries in hospitals is not surprising, as provision of care introduces specific risks (a la Semmelwiess or modern expected risks): I.e. failure to provide adequate pre and postpartum care, C/section rate risks are certainly as, or even more important, than delivery in a hospital vs home . We need to quite blindly accepting corporate definitions from the IOM or elsewhere and accepting all blame for complications.

As an anesthesiologist and for example, where the expectation is to provide general anesthesia (versus no anesthesia needed) for a MRI scan, in the most extremely hostile physical environment known, to merely “take a picture”, expected complications will always prevail and provide “adverse outcomes”. It is time to capture all inherent/statistical/expected risks and start tabulating adverse outcomes based in the real world.

This is the article available at: http://www.nejm.org/doi/pdf/10.1056/NEJMp1402157
Putting Quality on the Global Health Agenda
Kirstin W. Scott, M.Phil., and Ashish K. Jha, M.D., M.P.H.
n engl j med 371;1 nejm.org july 3, 2014
PERSPECTIVE
3
Thoughts?
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