The Future Is Calling Us

flying cadeuciiThe recent debate surrounding the American Board of Medical Specialties (ABMS) Maintenance of Certification (MOC) program is a microcosm for a transformation in medical practice that is long overdue. The profession of medicine is going through a fundamental shift from a traditional craft-based practice to a more sophisticated, data-driven profession-based practice.  The solo-based practice is dying. As the ABMS program suggests, the awareness and acceptance of this shift is already occurring at the national medical board level, but it is not happening as quickly at the individual physician level. It is time for all clinicians to consider a new, more effective and more empowering approach to clinical care.

Let’s take a look at the details. As you may know, the MOC program consists of six Core Competencies for Quality Patient Care that physicians must demonstrate to maintain certification.  These competencies are over and above the traditional board certification requirements. The core competencies are professionalism, patient care, medical knowledge, practiced-based learning and improvement, interpersonal and communication skills and systems-based practice. Descriptions of each competency can be found here. In addition to being a new requirement, the program encourages a new style of practice for physicians.

The MOC program has generated considerable friction, especially among physicians, some of whom argue that the requirements place an additional burden on their increasingly burdensome work experience. Others have joined the program and are fulfilling its requirements. As of May 2014, 150,000 physicians were enrolled in the program, but tens of thousands have also signed protest petitions.

As the debate over the value of MOC illustrates, transformational journeys are difficult. Those who believe it ought to be easy can often end up confused and frustrated. Those who embrace it, despite some painful realities, find opportunity. The friction of change, the challenges we encounter in life, the ebb and flow of the unexpected, work together to help us see the future and our role in it. Friction can wear us down or help us to see a powerful new reality.

Regulatory requirements like the MOC program are a burden when they are layered on top of an antiquated system. The requirements are much less of a burden when the work environment allows them to be satisfied as a byproduct of work.  In recognition of this reality, the ABMS has allowed 32 major health systems, including the Mayo Clinic and M.D. Anderson Cancer Center, to satisfy some MOC requirements for their physicians via their existing quality improvement projects and programs. 51 additional health organizations are applying to do the same. These organizations allow physicians to satisfy the MOC requirements as they deliver care.

Working in an improvement environment can be an exciting and energizing experience for involved clinicians because the reform debate suddenly shifts to what matters most to them and their patients — the value and outcomes of care. It also allows participating physicians to satisfy MOC requirements as a byproduct of their work. It is no longer an add-on. It is what they do. To date, the ABMS health system arrangement has produced 529 quality improvement projects and more than 3,250 physicians have received MOC Part IV credit for their participation.

In creating these arrangements with health systems, the ABMS is tacitly implying that organizations with effective, data-driven quality improvement programs integrated into their care environments are the future of care. They are correct. Increasingly, more physicians will seek such an environment, if for no other reason than to improve their professional lives. The good news is they will encounter a better way to practice clinical care when they do.

Care has simply become too complex not to go in a new direction. As I stated, the profession of medicine is going through a fundamental shift from a traditional craft-based practice to a more sophisticated, data-driven profession-based practice that is centered on continuous improvement. This new environment implies that clinicians are operating in a highly supportive and rational care delivery and improvement system that allows them to optimally manage care processes while collecting data to support continuous improvement and learning.

There are signs of this change everywhere, not only within the MOC requirements. Most patients already have multiple physicians and dozens of other caregivers involved in their care. Accountable care delivery systems are being formed. Care delivery environments are increasingly supported by advanced information technology, including electronic health records (EHRs), decision support systems and analytic systems. The number of reported data-driven care improvement projects is growing exponentially.

These and other signs point to the fact that these trends are real, inevitable and lasting.  It’s time for us to embrace them. We need to simplify the environment in which we work and create an environment that will allow us to be the best we can be. The sophistication of the structure to support such an environment may be complicated, but that does not mean that the environment in which clinicians work need be. We need an environment that helps us better manage complexity, not one that adds to it. That is possible and it is happening.

With every major transformation, people strive to escape an unpleasant existing reality. Some do so by denying and resisting; others search for a better way. The latter are the achievers. They strive to get the job done. They do not ask simply “How can I get by?” and remain mired in frustration. Rather, they ask, “How can I solve this?” With the vision inspired by this question, they set out in pursuit of solutions. This is not merely activity, but activity driven by a deep sense of purpose. They have a commitment to excellence. They do the best they can to solve the challenges confronting them. Increasingly, they will succeed and those around them will recognize them as champions and leaders.

Listen to these pioneers. Imagine a new reality. The future is calling.

John Haughom, MD, former senior vice president of clinical quality, safety and IT for PeaceHealth, is a senior advisor to Health Catalyst and the author of Healthcare: A Better Way. The New Era of Opportunity.”


63 replies »

  1. The trend in ACO leadership doesn’t surprise me, but the numbers do. I expected this would happen because as healthcare moves toward payment for value, it is inevitable. I just did not expect it this fast. Value in healthcare is high quality, safe care at a reasonable cost. One cannot achieve value in healthcare without effectively managing the process of care and only clinicians can do that effectively and well. Even 80% of costs in healthcare are driven by a physician’s pen (I.e., our decisions). To achieve this, however, we will need to relinquish some of our individual independence to collectively work together to achieve what is best for patients. Based on real experience, I can tell you this team approach is rewarding and enjoyable. You can also see this leadership trend in the rapid growth of Chief Medical Officer positions. Almost every serious healthcare delivery organization now has a CMO. That is a direct result of the drive toward value.

  2. I wouldn’t jump to conclusions too fast. I was pleasantly surprised by a recent study published in Health Affairs that showed physicians leading 50% of the emerging ACOs across the country and they co-lead in another 34%. Of course, being a physician does not necessarily mean you will be good at it, but I believe many will be. They understand and are likely to focus heavily on the process of care. Time will tell.

  3. “No doubt, we will see larger corporations delivering care in the future, but even they will not be successful in producing the outcomes we need without engaging clinicians in a responsible and meaningful manner. ”

    Unfortunately, we definitely agree on this.

  4. Barry… Thank you very much for sharing your thoughtful comments. We are in agreement on many important points.

    While I do not know most of the board members behind the MOC, I do know a couple and I know their intent is to encourage physicians to engage in continuous improvement. No doubt, one could argue whether the MOC will help accomplish this, but at least in these instances, I know the intent was an honest one.

    As I indicated in my post, I understand that the MOC is a burden for many physicians. However, I also stand by what I said about physician groups, hospitals and health systems that embrace continuous improvement as the core of how they deliver care. It is very much empowering for the involved clinicians and the MOC then becomes largely a byproduct of what they do every day. While I use a Mayo as an example, I do not believe you have to be a Mayo to do it. There are hundreds of other far less prominent and smaller organizations that are going down this road.

    The beauty of modern improvement techniques is that they allow clinicians to engage in what they care about the most — the quality of care they provide to the patients they serve — by standardizing the routine (making their lives easier) while allowing them to customize care whenever an individual patient’s situation requires it. Having observed it many times, I know it can be a very satisfying way to practice care because clinicians are in charge of what they were trained to do and what they know best — the process of care.

    The profession-based style of practice that I advocate for in “Healthcare: A Better Way” very much puts clinicians in charge where they belong. I believe very strongly that we will not solve the challenges facing our noble profession until clinicians engage and design the solutions at the ground level. The approach I advocate for does that and it is being used by a growing number of organizations. Healthcare will not change for the better until and unless we engage clinicians in this way and listen to their voice. My next blog post will make a strong case for this type of clinician involvement. I welcome your comments on what I say in that post.

    I agree that there is a change in the balance of power, but I also believe that this is because, as clinicians, we are allowing it to happen. The voice of clinicians can be profound, particularly if our sincere goal is improving care for patients. People will hear what we say. However, we need to focus on what we know best, the process of care, and always advocate for improving the quality and safety of care for those we serve. If we sincerely do that, our voice will be very hard to ignore. I view this less as a power move. Instead, it is clinician’s arguing for what they were trained to do — deliver the best possible care for patients. But, we need to do this in a sincere way and use data to prove we are right.

    I do not view this transition as one from craft-based care to corporate care. I view it as a transition from a craft-based care to a profession-based approach. No doubt, we will see larger corporations delivering care in the future, but even they will not be successful in producing the outcomes we need without engaging clinicians in a responsible and meaningful manner.

    Again, thank you for your comments.

  5. John,

    I feel your essay spans such a wide range of issues, and uses such overdetermined language, that the useful part of what you have to say is to a large extent overwhelmed.

    I found that the information about the integration of MOC into “learning organizations” and existing quality programs interesting and encouraging and far more forward thinking than I usually expect from the boards. (although it may be that the boards have realized they can extract more money from large organizations than individual doctors)

    Much of the pushback toward MOC has to do with the fact that the burden(cost) of MOC has been pushed on the physician as yet another unfunded mandate.

    As you point out this is a consequence of the change away from craft-based practice, but we are moving to something different but not necessarily better. Just as mass-production can lead to more uniform quality, moving from craft-based practice suggests more uniform, but not necessarily better healthcare. Change is monotonic, but progress is not.

    There has been a change in the balance of power in the medical profession from the doctor to the hospital, payer and other large aggregates. Advocates of change often tell us this is either a good thing, or inevitable. Many of us in the profession are (still) idealistic and disagree.

    If we look at other industries there is often a long period of decreased quality and trust in the transition from craft to corporation.

  6. The HealthCatalyst site is pretty revealing: another group of parasites scheming to divert health care dollars away from patients and physicians.

  7. John: Tell us a bit about your HealthCatalyst.com. Looking it over seems to indicate this is a company running down the federal tracks to implement “success” in EMR and other SCIP type programs for a profit. All about Data Acquisition-which means providing “big data” to prove god only knows what. What is the annual budget for HealthCatalyst.com? There are already so many such endeavors out there working for the Feds, why not just let the damn feds do it-after all they should be freeing up a huge computer system if we can shut down the telephone monitoring computers and put them to a good use. Just how does that differ from the ABMS who also is using regulatory capture to :make a buck”. your success stories seem to be larger institutions hell bent on capturing profits from the feds by giving them what they want. Much of american healthcare is a problem BECAUSE of the feds. Just look at the VA as prime example. How many corporations making a buck telling physicians how to “best practice” dictated by some corporate profit do we need, when bottom up is the answer? Most of us are NOT thrilled about buying and paying for data acquisition which does nothing for our patients, but provides primarily fertile grounds for the feds and insurers to “reject” payments (just like the 2% PQRS-MOC!) I believe it is all the overload with such “extranious industries” all sucking at the teat of real medical care.
    Go back to one patient and one doctor and toss all this corporate greed which produces NO medical care-the Big Data industry being one of the largest!

  8. Yes there is a board for Interventional Cardiology I believe. Just like for Allergy, GI, Rheum, Endocrine, etc.

  9. That may be true in IM, but in some surgical subspecialties it isn’t. Also what about the subspecialties?

    Are there boards for invasive cardiology, gynecological urology, etc?

  10. There’s a reason that subspecialists esp. in IM let their IM certification lapse and only recertify in their subspecialty.

  11. William… I use Word to write my responses and Word’s “auto-correct” feature sometimes defeats my best intentions. The word “disciples” above should be “discipline.”

  12. From a scientific standpoint, I definitely agree with you. We have made remarkable progress over the past several decades, and there is much more to come. Due to the confluence of many scientific disciples, there are amazing advances just over the horizon in a number of areas including minimally invasive surgery, drug delivery systems, monitoring sensors, organ assistance devices, stem cell technologies, genomics, imaging technologies, 3D printing, tissue and fluid bioengineering, nanotechnology, mobile computing, robotics, regenerative medicine, remote patient management systems, telehealth, wireless technologies and information technology systems, to name just a few. The list of healthcare innovations on the horizon is long and steadily growing.

    Where our current system falls down is in the area of consistent quality, unacceptable rates of harm, excessive waste and spiraling costs. Interestingly, this seems to have little to do with the type of insurance system. Every country in the developed world currently faces a similar challenge – the need to design and implement a well-resourced yet affordable system that efficiently provides high quality, safe and compassionate care consistently to those in need. The data here is overwhelming and cannot be ignored. As clinicians, ignoring these issues will be inappropriate and at our peril.

    I am familiar with the work you mention at UCSF. It is my alma mater and I keep pretty aware of the many exciting things they are doing.

    Thanks for the ongoing conversation.

  13. I think we are doing fine, scientifically, in health care. And it seems access is on the way to being solved. Do you agree, John? The only other thing that needs a real change is costs and prices. There is a comparative health care systems researcher at UCSF who says that all the advanced nations are all doing about the same thing in health care. About the same results. She says the only differences are that we are paying our docs much more and our administrations much more. How does your book see these? Are there other huge faults in our system besides these?

  14. “ I am not a big fan of criticism”

    Neither am I, but jumping at the unproven can make things worse. You know that as a physician.

    Healthcare might need a new vision, but as we have seen with the ACA these new visions don’t necessarily work as expected and don’t suddenly make all the bad disappear leaving us with goodness.

    Our discussion is not about any particular method or solution rather how a solution should be implemented. With coercion or without. That is where we differ and that is the essential difference between top down control and organic growth.

    Any physician can use your book as a good reference guide for many ways that can potentially aid him and a group of others to voluntarily try them out. I have no argument with any of the solutions you might offer as long as they are totally voluntary and without coercion.

    I am hoping you see my point and if you agree with my point regarding coercion then perhaps you would want to modify what you say so that those involved can look at them as solutions and choose between them or even the status quo. When a good solution is found competition will cause that solution to be voluntarily adopted by others for those with poor solutions eventually fail and disappear.

    Best to you as well, Allan

  15. Alan… I am not a big fan of criticism. Criticism alone rarely works, especially during major transition periods like the one healthcare is going through right now. What healthcare needs right now is a new vision. We need solutions. I encounter clinicians constantly who are looking for a new vision; one that offers them hope. One that captures their imagination. Thus, the book is heavily focused on solutions that will empower clinicians and offer them hope. It is easy to do a word search in a PDF document. Do a word search on “engagement,” “front-line clinicians,” or “smart cogs” (referring to front line clinicians). You will find that I repeatedly make the point that healthcare will not change until we effectively and constructively engage front line clinicians. This is a bottoms-up approach. Leading organizations are doing exactly that and they are enjoying the results that we all need to emulate. This solution is uniquely American and it promises to profoundly change healthcare for the better. We are not anywhere near a tipping point yet, but I believe we will be within 5 years. Clinicians are not the problem; they are the solution. However, as clinicians, we need to engage in solutions if we expect to make a difference. Best, John.

  16. John, we have scarce resources for many things and time is one of them. I have learned to scan just enough to see if I need continue. I don’t disagree with many of the methods used by others in a free marketplace and was quite familiar with most of what I read. The methods are not at issue. The issue revolves around change and how that change occurs. Will coercion be involved or not?

    That important aspect of change was left out of your treatise or at least the parts I read. Once coercion is used all sorts of bad things happen and all sorts of games begin to be played. If you can refer me to a paragraph in your book that explicitly states that coercion of any type should not be used or is dangerous then maybe I’ll take more of a look.

    I wait hopefully for such a paragraph.

  17. Thank you for your thoughtful comments. As you suggest, I suspect we share a common ground with respect to quality improvement, accountability, high quality care and effective use of data. I believe that is a common ground for most clinicians who I believe get up every day wanting to be the best they can be. We just need to get ever more effective at it. As a blog I just completed will argue, clinicians need to get into the game and focus the debate on what is best for patients – high quality, safe care. I appreciate your interest in the book.

  18. Allan… Sorry. I clicked “submit” before I meant. I appreciate your final comments. It is fine for us to disagree. The dialogue is what is important. We need more of it, especially among clinicians. I suspect I will have further posts. I will look forward to a continued exchange of ideas.

  19. Alkan… Rather than scanning the book, I would encourage you to read it. Healthcare faces serious challenges and it will take creative ideas to solve them. I certainly do not presume to have all the answers, but I have been fortunate to encounter many visionary healthcare leaders – mostly clinicians – who are being very innovative. Anyone is free to reject their ideas, but if they do, I would respectfully suggest that they are obligated to offer better solutions.

  20. Thank you for your response.
    One of the byproducts of Wal-Martization of care is neglect of rural communities like the one I am in. I just witnessed a large hospital system absolutely abandon several community clinics for lack of interest, funding, referrals or locality. What are those people supposed to do in a consolidation driven industry? Do without? Drive an hour for basic care?
    Telemedicine is not even close to there. So that ain’t the answer.
    If you deal in a carrot and stick model, like the board does, with a type of ultimate leverage being achieved by holding professionals hostage to their means of income, that is economic intimidation. AKA: sanctions. This does not encourage buy in. Sanctions are used to change behavior by threat. Your reference to compliance is simply showing the bludgeon is working.
    It is highly likely that we completely agree on QI, accountability, high quality care and efficient use of patient data. The board is not the source of any of these ideas. Physicians are worn out with the cha-cha line of organizations and consultants ready to pull wealth out of physicians in the name of quality or whatever. The board has been late to the game, focusing on cramming for tests, trick questions and frank arrogance.
    I just got done with a board review course. The tone was: cram for the exam, basic reading comprehension (which should have been addressed in grade school), and how to pick the least wrong answer. The MOC, which I also recently completed, was an exercise in foolishness. Testing me on: “Did I give the patient a flu shot or order a mammogram?” This is testing me on stuff that most docs have already protocoled because it does not take any intelligence to do in the first place. Testing on cookbook medicine is a waste of time. Testing on dead equations that don’t matter and I can google or app any time I need them. Worthless. Physicians are not going to waste time on occupying grey matter with trivia to satisfy a bunch of academics who barely work, and sit around on committees for 5 times my income. Have they heard of UpToDate?
    You have a reasonable agenda. You have the wrong organization to accomplish it. The board has not been interested and has continued to list in complacency. Their current efforts are poorly formed and redundant with most industry forces that have blown past them. An embarrassment.
    Physicians unfortunately have not had the organizational structure to accomplish what we likely mutually believe in. The AMA is completely irrelevant and the board is right behind them. Unless they completely reform, you will see plenty more resistance. I just got an arrogant email from the ABFM this week lecturing me about how they are not a membership organization and summarily dismissed the concerns being raised by physicians. They reframed the arguments as physician whining that could be easily refuted. I don’t have much hope that they will do much without real accountability from those who make up the profession of people who are actually caring for patients.
    On a positive note, I will check out your book.

  21. John, I actually went to your site and scanned over a bit in a few chapters. Scanning doesn’t permit me to draw definitive conclusions, but it certainly demonstrated to me that your treatise is advocating a change or as you put it a transformation of healthcare and comprehensively managing the health…

    Perhaps you believe it to be advice to others to think about while they grow organically. However, it certainly doesn’t sound that way. It sounds as if population groups need to be managed a certain way or else what? Coercion? From who? That is the big question.

    You also talk about innovation, but where does innovation come from? The consensus? No, the individual who frequently has to battle until his viewpoint becomes consensus. That innovation frequently does not successfully occur with top down thinking or micro-management. Instead that type of management generally inhibits innovation.

    I’ll watch and see what you have to say in the future. In the meantime thank you for providing your point of view even though it appears that there is wide disagreement between the two of us.

  22. John, you say you are advocating. Whether the techniques are modern or not doesn’t change the nature of the advocacy. You sound as if you are using a top down approach.

    That those methods from these other institutions improve anything in a different situation isn’t proven. In fact there are many techniques that differ from center to center. One technique that works in a high quality center might not work in another one.

    In the individual organizations such as Mayo physicians might be using the same methods, but from organization to organization those methods differ.

    I don’t know that one can create a Mayo in Topeka Kansas. You don’t either. Circumstances are different and people are different.

    Yes Mayo is a great place and their outcomes are quite good. Cardiac outcomes are excellent and people fly from all over the country to be operated there. However, people too sick to fly all over the country have to be operated where they are and add to the mortality rate.

    “It may sound like a top-down approach, but it is not.”

    You will have to define what you mean by top down for everything sounds as if you advocate a top down approach. A top down approach means some sort of coercion to do things a certain way. Of course we have a whole bunch of rules we all live by including Mayo, but you seem to be advocating coercion to duplicate individual systems approaches and that is top down.

    Of course if you believe others without coercion should choose to emulate these places and you believe they should develop their own systems where the system isn’t predefined then that would be a bottom up approach, but that would not lead to the rapid change in direction you might be looking for.

  23. I am advocating the use of modern improvement techniques. The physicians in those organizations are all using the same methods and tools and producing outcomes characterized by higher quality, safer and more cost-effective care. How they organize to achieve those goals does vary, but that can lead to innovative new approaches for others to emulate. It may sound like a top-down approach, but it is not. Clinicians who get engaged in this type of work are very empowered. I have seen it many, many times. Also, I don’t want to focus on just these organizations. There are hundreds of other health systems out there that are doing the same type of work and getting similar good outcomes. I believe that physicians and organizations that go down this road will thrive going forward. Others will either have to emulate them or come up with a better approach. Maintaining the status quo is not likely to be a winning strategy for most.

  24. Methods and process are similar in many respects. I said these leaders you mention have many different processes. I will add many different methods as well.

    ” It is the methods I am advocating”

    Methods differ in all of these different organizations. We all learn from the experience of others, but for the methods and processes to grow organically you have to leave things alone and let them develop in their own fashion. Mayo didn’t have top down control to create Mayo. By advocating the use of Mayo’s methods or the methods of others it sounds like you are using a top down approach. The blog sounds that way as well.

  25. I bet we’ve had a hundred ideas tossed at us-all telling us how to improve–since Obama declared our profession a disaster in 2009. Many are laughably contradictory: how can we have coordinated care up the gazoo in a medical home model and yet espouse hospitalists at the same time–who can barely remember the patient’s name? How can a movement not want big deductibles for HSA plans and yet bring in outrageously low actuarial value plans where cost sharing is enormous?…going so far as suggesting a copper plan with a 50% AV plan ( meaning 50% OOP). Apparently it’s ok to open the patient’s wallet after a course of treatment has begun but not before it has started. Also please reconcile the AOC concept with fee splitting and Stark’s Law. You are referring a patient to someone in your skimp-on-care club so that he and you will make a bonus. Wow.

    Some testosterone is called for to halt this whipsawing. First of all, no more ‘evidence-based for thee’ and not for me. Give us the cost/benefit for some of these notions floating out of government and academia and business.
    Wager with us on a futures market that your ideas will work. Put up some skin. Show us that MOC works somewhere and has a marginal benefit greater than its marginal cost. Shouldn’t there be a vote? Do the patients have a stake? Shouldn’t we get reimbursed if exam’s content is erroneous in five tears?

  26. When I advocate for healthcare’s smart cogs — clinicians — as the solution to the problem, I am arguing for a “bottoms up” solution. I am very familiar with organizations like Mayo and Intermountain. They are not top down. Their clinicians design the care that patients want and need. In my book, I argue that very healthcare organization (e.g., health system, physician group, or hospital) can emulate this, even if they are not a Mayo. It is the methods I am advocating, not the organizational structure. My point in highlighting these organizations is that they have demonstrated that the methods work.

  27. Since so many of the leaders like Mayo differ in so many different respects as to process and a whole bunch of other important things how does one follow the leader?

    The answer is from bottom up individually picking out those things most valuable to those at ground level. That means that collectives or organizations that tell others what to do (suggested in your blog) or think on the micro level are the ones that are inhibiting positive change.

  28. I certainly agree that the solution to the challenges facing healthcare is not top down. The beauty of modern improvement theory and methods is that it argues that the problems facing complex organizations can only be solved by its front line workers — so-called “smart cogs.” Healthcare and healthcare organizations certainly qualify as complex, and our “smart cogs” are clinicians. I believe healthcare has the most intelligent, well educated and committed workforce in the world. They are the solution, not the problem. However, in order to play this role, we need to collectively embrace new ideas and engage. A growing number of pioneering organizations like Mayo, Virginia Mason, Intermountain Healthcare and many others are showing the way, and empowering their clinicians in the process. We all need follow their lead. This is the central theme of my book. A couple of days ago, I drafted a blog post calling clinicians to action. I am hoping it will be posted on The Health Care Blog next week, but it will certainly be posted somewhere. I would welcome your comments on the opinions I express in it.

  29. I’m sure you are trying to help the profession, John, but this MOC idea is too forcing and top down, tries to cookie-cut our knowledge, necessarily leads to group-think, and is distracting everyone from his/her own interests. Besides, medicine is still half art and our true science is never settled enough for educational pronouncements from on high. It’s rather like requiring an artist or musician to be re-certified. This is a little hyperbolic, I admit, and I can see the need for docs to keep up on legal requirements and legislation, but you don’t want to negatively interfere with the pursuit of someone’s career when his own interests are his comparative advantage. This, of course, is economic foolery.

  30. Paul… I sincerely do a appreciate your passion. However, I think we are at a point where we have to agree to disagree. You are viewing the MOC program as a plot driven by corporate interests. I choose to view it as one of many manifestations of healthcare responding to the very real quality, safety and cost challenges confronting our noble profession. Health systems like the 32 that ABMS has partnered with basing their care model on continuous improvement and learning, and allowing physicians to meet MOC requirements while also improving care for patients. I believe that is the future. There is no right or wrong here. Just a disagreement over how we view change. I wish you well in all your endeavors.

  31. I just want to also add a thank you because I know sub specialists (and many physicians that restrict their practices) who are being tested in areas they never deal with and therefore are forced to spend less time studying their specific areas of interest where patients are involved in order to study areas of medicine they haven’t dealt with in years.

    The boards will eventually be little more than enforcers of government policy and we will have created a new medical industry that feeds off of supposedly protecting the public.

  32. John: I do not dismiss the “power movements” of healthcare. MOST are pushed by industries like pharma, computer-tech, imaging, etc, and NOT from Doctors who practice. The whole concept of patient responsibility is pushed onto doctors to do more, while non-physicians are increasingly allowed to practice medicine.
    It is time to PUSH BACK and take control of our profession from the carpetbaggers who wish to run medicine for their profit.
    The future IS calling us to take a stand and especially regarding MOC which has no outcome based evidence, but just a lot of “associations” published by ABMS corporate payrolled authors.
    ABIM’s changes to MOC barely quell unrest
    By: ALICIA AULT, Internal Medicine News Digital Network
    August 7, 2014


    The unrest is growing and the OSMA and membership should maintain opposition! See URL for full story!

    “Dr. Steven E. Weinberger, executive vice president and CEO of the ACP agrees that the ABIM’s timing was pretty poor. He said that there had been a “low to medium level of concern” about MOC for years, but the new requirements announced in January catalyzed the complaints and were “an important tipping point.” Added Dr. Weinberger, “To some extent, this was in part the straw that broke the camel’s back.”

    “It’s about a process that seems arbitrary, a little bit burdensome, and perhaps not achieving what we all want, which is the best care for our patients,” said Dr. Christopher White, professor and chairman of medicine, the Ochsner Medical Center, New Orleans, in an interview.
    Dr. White, who is a founding member of Physicians for Certification Change, has signed the Pledge of Non-Compliance. He is currently certified, and at age 63, wonders if it’s worth the time and effort to recertify in 2019, when he is next due. “It is a good idea that we continually educate physicians and that physicians have continuous improvement,” said Dr. White, but he said he questions whether the ABIM process is the best way. “There’s no evidence that this works, or there’s value,” he said.

  33. The evidence is very strong that hospital care is very expensive and we need to use it only when appropriate. There will always be a need for hospitals, and with our aging population, most of them will stay very busy. However, there are also some very exciting technology-enabled models of care that many organizations are currently studying in the US and Europe. These care models allow clinicians to be more proactive in their care, to be manage larger populations of patients efficiently and well, to empower patients and families (the largest untapped healthcare force in the country), and to lower costs, especially for chronic disease patients that account for 75% of patient care expenditures in the US. I briefly review some of this in chapter 8 of my book and will be discussing it in many future blogs. We are entering an era that will be very exciting and empowering for clinicians and patients. It will be very rewarding for clinicians, especially those that can see beyond the challenges and appreciate a new future.

  34. “We are also too hospital-centric and need to develop technology-enabled care models that are more ambulatory and patient centric. ”

    This, I see as a huge problem, and not likely to result in either better patient care or lower costs.

  35. I firmly believe that if good clinicians design the system, it will be focused on what is best for the patients we serve. If we honestly do that, it would be hard to go wrong. That means well coordinated, timely, high quality, safe, efficient, appropriate and timely care always delivered in the right venue. We may have honest debates about what this means. That is fine. It will still be vastly better than what a policymaker or politician can design. The problem is, because we are not collectively engaged, we are leaving these decisions to non-clinicians. Yesterday, I wrote another blog that will make this very argument. I welcome your comments and feedback on it when it is published.

    You are correct that we do not have adequate access to good primary care in this country. We are also too hospital-centric and need to develop technology-enabled care models that are more ambulatory and patient centric.

    These are all issues that I try to have a meaningful discussion about in the first couple of chapters of my book. The goal of the book is really to generate just this type of discussion. Thank you for your response.

  36. If you’re taking about coordinated care among diverse docs then that’s good, but the system that puts everything through the patient’s PCP (GP) has proven to work well. We don’t have a strong GP system here in U.S., it’s focused on specialty and pays that way as well.

  37. Well said. All the more reason for clinicians to get involved. As I said in a response that I posted to Peter1 moments ago, this challenge is too important to be left to politicians and policymakers. There is a need for clinicians to step up and get involved in designing a new future for healthcare. A growing number of clinicians are doing exactly that and it is an exciting process. However, we need to act collectively in designing a system that addresses the challenges facing healthcare. Simply resisting is not good enough.

  38. This is a wonderful question. In the final analysis, we are all patients and the answer to this question is what should really matter to physicians. The beauty of a profession-based practice is that the entire goal of physicians and other clinicians working collectively is to improve the quality, safety and cost of care for those we serve. Because clinicians are the experts about the process of care, having them focus on improving that process based on data does wonderful things for patients. In chapter 7 of my book, highlight a handful of examples, but there are literally thousands I could have used.

    Based on personal experience, I can tell you that every time a group of clinicians embarks on this quest, there is enormous energy in the room. This is because the reform debate has suddenly shifted to what matters most to both clinicians and patients: the value of care that patients are receiving.

    This challenge is too important to be left to politicians and policymakers. There is an urgent need for clinicians to step up, lead the debate and design a new future for health care. Placing professional responsibility for health outcomes in the hands of clinicians, rather than bureaucrats or insurance companies with vested interests, must be an ambition for all of us. We need to find the formula that meets the needs of the patients and communities we serve. A sincere collective effort by committed clinicians to design an effective system will lead to a health care system that has a democratic mandate and the appropriate focus on optimizing the outcomes patients and society need.

  39. As Paul Kempen will testify (greetings Paul!) I take a more middle road, but sway more towards the opposition camp.

    The information problem in medicine in the realm of quality, lends physicians to assessment by numerous third parties. It would be better for all, including the patient, not to be confused by the plethora of information that such a scenario might bring about. And ABMS could certainly bring about much sanity in such a plausible scenario.

  40. Paul, I truly appreciate your passion. We need the passionate involvement of good clinicians if healthcare is going to deal with the many challenges facing us. I would just encourage you to study the powerful movements currently unfolding in healthcare before you dismiss them. I wish you well.

  41. Thank you for your thoughtful comments. i appreciate them. Here are a couple of responses.

    The craft-based approach to practice has produced some amazing things over the past 100 years. We routinely achieve miracles on a daily basis providing clinical solutions to patients that simply did not exist in the past. However, as healthcare has become more complex, it is also producing inconsistent quality, an unacceptable rate of harm, tremendous waste and out of control costs. The evidence that this is true is overwhelming. As clinicians, we need to be at the center of designing solutions and we have the opportunity to do just that. This will require a more profession-based practice that allows physicians to collectively determine best practice.

    A profession-based practice consists of groups of clinical peers treating similar patients in a shared setting using carefully coordinated and standardized care delivery processes (i.e., evidence-based order sets, protocols) that individual clinicians can adapt based on specific patient characteristics or needs across the care pathways.

    This will in no way interfere with the important clinician-patient relationship. In fact, the experience of many clinicians is that it will enhance it.

    There is no question that the world of healthcare is changing. The clinicians that get involved will enjoy the experience more than those who do not.

  42. Hmmmm: John Houghoum stated:”Also, it does not surprise me that 53% of experienced physicians fail this. It is relatively new knowledge that many practicing physicians have not been exposed to. ”
    Or perhaps it is because there is so very much nonsense published that no one really believes, should believe, or even considers it to be worthwhile “knowledge” only subsequently subject to “medical reversal” and becoming today’s malpractice. This is especially true of ABMS/Certification nonsense that is paid, written and produced by the corporation for propaganda purposes! Publish or perish means more nonsense is produced than really useful “medical advancements”. Different specialties, nations,etc have very different guidelines that fit only “fair” to any patient. Remember mammograms, PSA, Yearly PAP smears and physicals, that are now “unnecessary” as they are not “cost effective”, until some senator turns up with cancer and sues some poor doctor!
    W.F. Miser, director of the Ohio State University family
    medicine residency program and vice-chair for the OSU
    biomedical institutional review board (IRB) wrote: “If physicians
    would read two articles per day out of the six million medical
    articles published annually, in one year, they would fall 82
    centuries behind in their reading!” (J Am Board Fam Pract
    1999;12(4):315-333. Reading everything does nothing because of the overwhelming volume of nonsense published for academic endeavor! Please, lets see the OUTCOME BASED DATA that proves MOC does anything-and PLEASE remember that ABMS has NO MARKETSHARE in Europe and they seem to have better, more cost efficient healthcare including longevity and newborn health! You can get anything published in medical journals, especially if your ABMS board owns, manages, publishes and pays the CEO to promote their business in THEIR OWN journals-and this includes the FSMB! Everyone needs to see through the BS of BC and MOC.

  43. Again, I appreciate your passion. You are definitely free to choose whether or not you read the book. However, it will be hard to portray it as a part of a “certification industrial complex” because the book portrays the knowledge I gained over a twenty year period learning from some very visionary clinicians who are definitely designing a better way to practice healthcare and I am giving it away for free. I make nothing from the book.

  44. Actually, two of the MOC requirements for “practice-based learning” and “system-based practice” have been proven to effectively address the quality, safety, cost and waste challenges facing healthcare. If you would like to read a more comprehensive, reasoned and referenced version of this, I invite you to download a free copy of my book, “Healthcare: A Better Way. The New Era of Opportunity.” (http://www.healthcatalyst.com/ebooks/healthcare-transformation-healthcare-a-better-way/ )

    Also, it does not surprise me that 53% of experienced physicians fail this. It is relatively new knowledge that many practicing physicians have not been exposed to. In 2004, the U.S. National Library of Medicine added almost 11,000 new articles per week to its online archives. That represented only about 40 percent of all articles published worldwide in biomedical and clinical journals. In 2009, it was estimated that this rate of production had grown to one article every 1.29 minutes. Furthermore, it has been estimated that approximately three to four years after board certification, general internist and internal medicine subspecialists begin to show “significant declines in medical knowledge.” He estimated that 15 years after initial board certification approximately 68 percent of internists would not pass the American Board of Internal Medicine certification exam. In order to maintain current knowledge, a general internist would need to read 20 articles a day, 365 days a year. Clearly, maintaining current knowledge has become a near impossible task for all clinicians. We need to find a better way to keep abreast of new knowledge.

  45. You gotta love it! Listen to another certification corporation for evidence published in THEIR journal or read MY book. Sounds like self fulfilling prophecies by members of the certification industrial complex-selling products and co-endorsing colleagues-but NO science:John Haughom says: August 7, 2014 at 8:25 am
    “Yes. They are routinely published in journals like the Joint Commission Journal on Quality and Patient Safety. In addition, if you would like to read a more comprehensive, reasoned and referenced version of my points above, I invite you to download a free copy of my book”

    I don’t know if you folks actually READ the references referred to but all of this is simply MORE hype. PRIME EXAMPLE:
    Sharp LK, Bashook PG, Lipsky MS, Horowitz SD, Miller SH. “Specialty Board certification and clinical outcomes: the missing link.” Academic Medicine 2002: 77(6) 534-542. and you will see that after decades of TRYING to prove Certification matters. After ATTEMPTING a meta-analysis from over 1000 papers, they produced this paper which PROVED that DATA was a MISSING LINK with only 13 papers included and only ONE having any prospective design. Of course this did NOT stop the ABMS who AUTHORED the paper from making a positive conclusion! Let’s ask :John Haughom to explain the difference from proof, associations and the significance of bias in the sort of publications actually USED to get this sort of trash published in “mainstream journals”! Anyone wishing a copy of this paper let me know!

  46. “As of May 2014, 150,000 physicians were enrolled in the program, but tens of thousands have also signed protest petitions.”

    There’s a reason many are signing up. Board Certification is a prerequisite or expected for admission to most hospital staffs, groups and insurance panels. In some ways docs are being “held hostage” by these requirements. I’ve never had a patient ask me if I’m board certified.
    On the other hand, I have to admit, I personally don’t find the MOC process particularly unwieldy. I am boarded in Family Medicine, but practice Occupational Medicine full time, so I am not constrained by night call, weekends and hospital rounds like most other Primary Care docs. Also, if I were to drop my certification status now, it probably wouldn’t have a huge effect on the remainder of my career as long as I don’t try to work somewhere else.
    I can very well see that MOC can be a burden for fully practicing primary care and even specialists who are spending time not only taking care of patients, but performing other inane activities required of them for “documentation”, quality assurance, EMR, etc, etc.
    What I find disturbing as well, is the push to advance NPs into a more advanced practice mode, without them having to do the same board certification and MOC process as physicians. On the one hand, we’re saying that they can do primary care without supervision, but all you physicians who have done a residency and 4 years of medical school have to continue to prove your abilities.
    And frankly, while I think we can gain a lot from technology and data, I don’t see what’s so awful about traditional craft based medicine. A doctor has face to face interaction with a patient and gains their trust and confidence, and uses his/her knowledge and intuition to treat the patient appropriately according to THAT patient’s needs. That is patient-centered medicine.

  47. Yes, there is published stuff.

    Some severe design issues with lot of intermediate metrics.

    Pharma/ device industry would probably not get away with that study design.

  48. Thank you for your thoughtful response. Allow me to respond to several of your points.

    • The statement that the solo-based practice is dying is not really a prediction. Instead, it is a statement of reality. There is a great deal of evidence that physicians are becoming part of bigger and bigger groups, and groups of physicians are becoming part of health systems.
    • This trend is an inevitable response to other trends that are the byproduct of healthcare’s attempt to address the quality, safety, waste and cost issues confronting it. This includes a long list of things including the need to implement electronic health records (EHRs) and respond to increasingly common pay for performance initiatives. A solo-based practice simply cannot deal with the complexity and costs of movements like this. This will only accelerate as healthcare moves more towards population management and payment for value. The good news is physicians who go in this direction encounter a better way to practice clinical care when they do.
    • This movement is not designed to control how physicians and other clinicians behave. Instead, it greatly empowers clinicians. They are healthcare’s front line experts and only they know how to manage the process of care.
    • While clinical care has always been “data-driven,” our historical way of practicing actually used quite primitive methods of managing data. There are far more powerful tools at our disposal now. If you want to see an example, I invite you to view my demonstration at this link. (http://www.healthcatalyst.com/webinar/the-deployment-system-creating-the-organizational-infrastructure-to-support-sustainable-change/ )
    • While thousands or physicians have protested, many more (over 150,000) have signed up for the program and are complying.

    Again, thank you for your comments. If you would like to read a more comprehensive, reasoned and referenced version of my points above, I invite you to download a free copy of my book, “Healthcare: A Better Way. The New Era of Opportunity.” (http://www.healthcatalyst.com/ebooks/healthcare-transformation-healthcare-a-better-way/ )

  49. If you go to the ABFM website they will enumerate the “evidence”. It consists of surveys, self-fulfilling prophecies, pre/post analysis, and validation that teaching to the test works. I hope you are not looking for science.

  50. link to some of the outcomes evidence please. I don’t believe you, but am willing to acknowledge my ignorance after you show me the published studies. They are published, right?

  51. If anyone wants to really think about the Certification Idustrial Complex including the ABMS, it is VERY important to know that the business ethics are just that and there is NO outcome based evidence to demonstrate that recertification matters in any way.
    Please take a look at today’s Medpagetoday article MOC: Dissecting the Issues at:

  52. Actually, the MOC process is not unproven. Over the past decade, there are dozens of health systems and thousands of physicians who have demonstrated that a profession-based, data-driven improvement system can produce better outcomes — care that is higher quality, safer, less wasteful and more cost effective. It is because of this growing evidence that the MOC requirements were created and it is on this evidence that they are based.

  53. Actually, the MOC requirements can support just what you suggest. However, when a physician is “following cues arising from their own practice” and “go outside the four walls of the profession,” they would be required to collect data and document to their peers that their approach is generating better outcomes. This is how a profession-based data-driven improvement environment works. One cannot say something is an improvement without reliable data that demonstrates that it really is.

  54. Follow the money. There is no way one can accept at face value something spoken by a physician who earns $800,000 a year simply for chairing one of the medical specialty boards. (not referring to the author of the article). Their salaries are obscene, funded by the physicians who must endure their unproven MOC process.

  55. The resistance has spoken loud and clear. So now it’s time for the unaccountable legacy structure to launch a propaganda campaign. It’s difficult to even know where to begin with this post. Solo practice is not dying, it is being intentionally killed. And yes it is facilitated by the national medical board. The ultimate goal is to control how physicians behave to enhance highly centralized self enriching entities, much like the board itself. Transformational journeys are not difficult. They are routine. They emerge naturally if allowed, frequently in spite of the central planning illuminati. Regulatory requirements, like the MOC, reinforce antiquated systems like standardized testing and distract from true quality improvement. Medicine has been “data driven” for a long time now. Please see ocean of journals for more details. The problem is that the data is frequently corrupted or just plain wrong. Many people have been harmed in the name of “continuous improvement”. Improvement is the entire basis of medicine and how it is sold. One can only hope that a physician will know when to deny and resist in the interest of the patient. I can assure you, they will not acquire those skills in the MOC process. Any time you witness physicians organizing by the tens of thousands and protesting, take note. It is a rare event, and usually a sign that something is extraordinarily wrong.

  56. I’m not sure that other people can direct your continual improvement better than you can, following cues arising from your own practice. The latter could be more relevant too. Besides, you want stragglers who go outside the four walls of the profession. An occasional doc veering into statistics or math or chemistry or physics or materials science and engineering–following his own inclination–could be a very fertile substrate for health care advancement. Rather than taking exams, wouldn’t having the re-certification require some teaching be a more bottom-up approach that could release more creativity in the applicant? E.g. “Show us that you have given some lectures in renal electrolyte manipulation or other renal physiology.” I would think that this would be better evidence of continued improvement and intellectual discipline than simply passing a few more exams. Besides, the accumulated knowledge from experience in the recertification applicants is likely more than those formulating/writing the examination… which will come from literature and texts, so who is going to learn from whom?