Saturday, July 11, 2015

Bob Wachter on the American Board of Internal Medicine

The deafening silence from Bob Wachter on the concerns swirling around the ABIM was finally broken in a recent post titled The ABIM Controversy: Where the Critics are Right, Where They’re Wrong, and Why I Feel the Need to Speak Out. Well, I have to take issue with Bob right off the bat. There is no controversy about what's happened at the ABIM. The discussion has been overwhelmingly one sided. No one (well, at least not until Bob's post) has offered much of a defense or counter argument; not that people haven't been given the chance.

But indeed he did need to speak out. Though Bob has been a booster of the ABIM we look to him to provide healthy skepticism. After all he describes his blog as a series of “Lively and iconoclastic ruminations..” But his post is hardly iconoclastic concerning the ABIM. From the post:

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

I haven't seen much in the way of personal attacks on Dr. Baron and will accept Bob's statement that he's a great guy. The focus of the outrage has been, as it should be, about where the ABIM has gone wrong and the consequences to practicing physicians and, ultimately, patients.

There's a lot to unpack from Bob's next paragraph:

Here’s what’s at stake: we physicians are granted an extraordinary amount of autonomy by the public and the government.

An extraordinary amount of autonomy? Really Bob? Decades ago maybe but not the last time I checked. He goes on:

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

Well, society has already done just that. And apparently Bob has no problem with some of the baggage imposed on medicine by politically driven initiatives not well informed by science, as evidenced, for example, by his repeated praise of the IOM's egregious spin on patient safety (you know, the one about how medical errors result in patient deaths equivalent to a jumbo jet crash a day). I, for one, do have a problem with such grandstanding and have seen more negative consequences from the IOM report than benefits, but I digress. What's really telling in that paragraph is the strongly implied premise that resuscitation of the Board will help protect patients against an out of control, incompetent medical profession. That's apparently why, in his view, this particular fight matters. There's no evidence, of course, that the MOC program helps patients at all. To be clear, I wouldn't demand evidence were it not for all the negative consequences. After all, there is not, and probably never will be, good evidence concerning regular CME. But the negative consequences of the MOC program, as it has recently existed, abound.

Much of the rest of Bob's post was more thoughtful and nuanced, though I partially disagree with his ideas on the demonstration of competence. His attempt to offer a defense, point by point, against the various accusations was unconvincing to me, though it is clear Bob believes passionately in the Board.

He makes the point that regulation should come from within the profession, which was part of the Board's original mission, with which I heartily agree (that's why I am a tad concerned that he said they are about to add non-physician members to their governance structure). And I can't make an argument against doctors having to take a test now and again (though I remain displeased that the Board recently told grandfathered diplomats, in effect, concerning that requirement, Sorry, we lied).

Bob points out changes that are being made to the process. I, like many physicians in the community, am skeptical as to whether this will be enough. I am even skeptical as to whether trust can be restored at all. The reputation of the ABIM is on a downward trajectory like a freight train rolling down hill. It is largely, though probably not entirely, of their own making. I find this unfortunate because I used to have a good feeling about the Board. Bob concludes with a valid concern. If the Board meets its demise something worse may emerge to fill a perceived vacuum.

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