The American Board of Internal Medicine (ABIM) is describing a March 10 Newsweek column on its controversial maintenance of certification (MOC) program as inaccurate and misleading.
The piece, titled "The Ugly Civil War in American Medicine," was written by Newsweek columnist and best-selling author Kurt Eichenwald, an investigative journalist who twice won the prestigious George Polk Award for business reporting. A former reporter for the New York Times and a two-time finalist for the Pulitzer Prize, Eichenwald has dug into corporate scandals ranging from Enron to HCA Healthcare.
In an email to its specialty board and exam committee members, the ABIM said it would ask the magazine to either correct or remove the "highly critical" column from its web site. However, the article is still there, bearing only one very minor correction: Eichenwald erroneously had suggested that the ABIM certifies anesthesiologists. "Dumb mistake," Eichenwald told Medscape Medical News.
ABIM President and Chief Executive Officer Richard Baron, MD, confirmed that his group did contact Newsweek. "We shared with them the same kind of concerns that we shared in our statement," Dr Baron said in an interview with Medscape Medical News. "We have substantial concerns about the accuracy of the story."
In his Newsweek piece, Eichenwald reported that "tens of thousands of internists, cardiologists, kidney specialists and the like...say the ABIM has forced them to do busywork that serves no purpose other than to fatten the board's bloated coffers." Exercising a columnist's license for hyperbole, he added that the "ABIM went from being a genial organization celebrated by the medical profession to something more akin to a protection racket." What is being protected are admitting privileges at many hospitals that require internists and internal medicine subspecialists to be ABIM-certified.
Although the ABIM contests his reporting, Eichenwald's headline may ring true for many physicians: There is a civil war, at least in internal medicine, and it is ugly. As chronicled in Medscape Medical News for the last 12 months, a large swathe of internists and internal medicine subspecialists is rebelling against the ABIM's increasingly complex MOC program, which they call burdensome and irrelevant. At issue are recent requirements for physicians who are certified for 10 years to earn credits for lifelong learning and self-assessment, testing, and practice improvement every 2 years, which is a faster pace than before.
Almost 23,000 physicians have signed a petition demanding that the ABIM base its board recertification merely on an exam taken every 10 years. The House of Delegates of the American Medical Association has chimed in, urging the ABIM to make the process more physician-friendly.
MOC dissidents have taken matters into their own hands by recently forming the National Board of Physicians and Surgeons (NBPAS), a rival to the American Board of Medical Specialties, to which the ABIM belongs. All about simplicity, the new group makes recertification contingent, among other things, on prior certification by an American Board of Medical Specialties member board and traditional continuing medical education. (Full disclosure: Eric Topol, MD, editor-in-chief of Medscape, is a member of the NBPAS advisory board, an unpaid position.)
During the past year of controversy, the ABIM has defended its MOC program as a way for physicians to prove to hospitals, insurers, and patients that they are keeping up with their profession and improving their performance. However, the organization also has said repeatedly that it is listening to its detractors and attempting to fine-tune MOC.
In its latest good-will gesture, the ABIM apologized for its MOC program in a February 3 letter to its diplomates and vowed to make changes. "We launched programs that weren't ready and we didn't deliver a MOC program that physicians found meaningful," wrote Dr Baron.
ABIM Objections, Author Responses
Dr Baron's apology letter of February 3 was followed by a storm. On March 10, Newsweek published Eichenwald's column. It summarized familiar complaints about MOC, the ABIM, and its related ABIM Foundation, created, in its own words, to advance medical professionalism (it is probably best known for launching the Choosing Wisely campaign in 2012).
The column offered a few eye-opening MOC war stories. Eichenwald quoted endocrinologists who said they were forced to answer questions about pediatric endocrinology even though they treated only adults. Exam preparation instructors told physicians they would never see a particular condition in their practice, "but they needed to review it because it would be on the test."
In a news release the next day, the ABIM said Eichenwald's column "contains numerous and serious misstatements, selective omissions, inaccurate information and erroneous reporting."
Medscape Medical News asked the ABIM to elaborate on key areas of disagreement in the news release, and asked Eichenwald to comment on them as well.
Are Exams Harder?
The ABIM said it is untrue, as Eichenwald asserted, that it has made recertification exams harder so as to fail more physicians and collect more in fees when they retake the test. Dr Baron told Medscape Medical News that when he took the internal medicine exam himself in 2013, he found it no harder than the 2007 exam.
He also rebutted Eichenwald's statistical argument. Eichenwald wrote that the percentage of first-time takers of the internal medicine exam who passed fell from 88% in 2010 to 80% in 2014. True, said Dr Baron, but there was an uptick from 78% in 2013 to 80% in 2014 that Eichenwald did not mention. Plus, the percentage had been as low as 79% in 2006. And do not dismiss the fact that physicians who flunk retake the test, Dr Baron said. When they are counted, the ultimate pass rate increases to 96%, he noted.
Eichenwald counters that the first-time pass rate trend from 2010 to 2014 still holds up, notwithstanding the stats from 2013 and 2006. "You can always find a blip," he told Medscape Medical News.
The March 11 statement also said Eichenwald was wrong in characterizing ABIM as exercising a monopoly on certifying internists, who actually have a choice of boards. In his interview with Medscape Medical News, Dr Baron identified these alternatives as the brand-new NBPAS and the American Board of Physician Specialties. The latter, a rival to the American Board of Medical Specialties, was incorporated in 1952 as the certifying body of an osteopathic surgery association. Branching out to include allopathic physicians as well, it certified its first candidate in 1960. An American Board of Physician Specialties spokesperson declined to say how many current diplomates the group has, but said that it has certified a total of 5000 physicians.
Eichenwald told Medscape Medical News that the NBPAS and American Board of Physician Specialties are "not on the same level" as the ABIM. A monopoly is not defined by the absence of competitors, he added, but by market control, and that is what the ABIM possesses. Without ABIM certification, "you are certainly shut out of the vast majority of certification-accepting organizations [such as hospitals]", he said. At the same time, Eichenwald said the ABIM seemed to be calling the NBPAS "a legitimate competitor."
Rolling in Money?
Eichenwald based some of his reporting on tax returns — Form 990s for tax-exempt 501(c)(3) organizations — filed by both the ABIM and the ABIM Foundation. In its rebuttal statement, the ABIM said Eichenwald "presents an untrue and misleading interpretation" of Form 990 data.
When asked to provide examples of this misreporting, the ABIM cited Eichenwald's assertion that in tax year 2012, which ended June 30, 2013, the ABIM Foundation earned $20 million in investment income from $74 million in net assets ("this organization is loaded," he wrote). Eichenwald's figure for investment income is literally what line 10 on page one of the tax return says. However, the ABIM points to another section of the return listing $12.4 million in unrealized investment losses, which meant the foundation held on to investments that had dropped in value.
For Internal Revenue Service tax purposes, these unrealized losses of $12.4 million are not subtracted from realized gains of $20 million, but they are subtracted when it comes to a consolidated financial statement for the ABIM and the ABIM Foundation covering tax year 2012, the ABIM said. In that statement, based on generally accepted accounting principles, net investment income for the combined organizations that year comes to only $7.3 million, a figure that reflects almost entirely gains and losses for the wealthier ABIM Foundation. So the foundation is not as well off as Eichenwald says, according to the ABIM.
Eichenwald told Medscape Medical News that "when you talk about a 501(c)(3), $20 million is the relevant number."
"You are allowing them to change the terms of the discussion," he said, adding that he has seen accounting "games" like this before in his 35 years as a financial reporter. The ABIM may prefer that he write about a different number, but "it's not how the reporting of 501(c)(3)s is done."
The ABIM also objected to Eichenwald's reporting that the foundation's operating expenses in tax year 2012 were $5.2 million — again, the figure on the tax return — when in fact almost $1.8 million of that amount represented pass-through payments from a research grant to grantees. In other words, the foundation's real operating expenses amounted to only $3.4 million. However, this fine-print explanation does not appear on the tax form itself.
What Eichenwald did not address in his column was why investment income for the ABIM Foundation jumped from $2.3 million in tax year 2011 to $20 million the next. The ABIM told Medscape Medical News that in December 2012, the foundation liquidated investments with Vanguard and transferred them to TIFF, a fund for foundations. This transaction forced the ABIM Foundation to recognize investment gains achieved during the Vanguard years.
Conflict of Interest?
The final ABIM criticism of Eichenwald's article was that "the author failed to disclose that his wife is an internist."
"As physicians, we get used to disclosing the perception of any potential conflict," the ABIM's Dr Baron told Medscape Medical News. "I have no idea what her views are. The issue isn't about her. It's about whether he disclosed something that might have been relevant to readers."
Eichenwald disagrees that he had a conflict to disclose. "The argument is akin to saying that I can't write about politics because I voted," he said, adding, "Shouldn't being married to an internist make me pro-ABIM?" He asked that his wife not be identified.
Of all the criticisms of his article, Eichenwald said, the one that got under his skin was the one involving his wife and making her part of the story.
"It was despicable," he said, "[and] a sign of people who had nothing to say in response to the substance of the article.
"I don't react to bullies well. When they're bullying my family, I hit back."
"Hard to Square That With Reality"
Since the ABIM issued its rebuttal of his article on March 11, Eichenwald has indeed hit back on Twitter.
On March 14, he tweeted, "If ABIM would stop bullying critics & instead justify their pay checks by conducting studies proving MOC has benefits, MDs would support them."
He turned up the heat with another tweet on March 18: "I have written about scams for decades. MOC is most obscene, inter-related abuse of monopolistic control to rip ppl off that Ive ever seen."
Asked to respond to the last tweet, the ABIM's Dr Baron sounded flabbergasted.
"It's hard to square that with reality," Dr Baron said. "I can't speak to what his experience has been in terms of what scams he's covered and why he would think this is a scam.
"This is a completely above-board organization with leaders of the profession working together, and substantial pedigree.
"I find that a surprising statement," Dr Baron said.
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Cite this: ABIM Says Newsweek 'Civil War in Medicine' Story Inaccurate - Medscape - Mar 25, 2015.